A Fall in Ventricular Fibrillation Just after Skin Incision in a Hemodialysis-patient

We report intraoperative cardiac arrest in a patient who was medicated by antiarrhythmic drugs. A 70-year-old male was scheduled for amputation of necrotic digiti pedeis due to arteriosclerosis obliterans. He takes daily pirmenol for premature ventricular contractions (PVC), and undergoes hemodialysis three days a week. Anesthesia was induced with thiamylal, fentanyl, and vecuronium and maintained with nitrous oxide (60%), oxygen (40%) and sevoflurane (1-3%). After inducing of anesthesia, his serum potassium level was 2.4mEq•l-1. Five minutes after the start of surgery, several PVC appeared and there was a drop in ventricular fibrillation (Vf). After immediate cardiopulmonary resuscitation and countershock, sinus rhythm was restored within approximately five minutes. In this case, triggered activity, a factor in life-threatening arrhythmia, was induced by interaction with pirmenol and hypokalemia, and additively an insufficient depth of anesthesia brought PVC to Vf. It was considered that the class Ia antiarrhythmic drug should be reduced before surgery under general anesthesia for the hemodialysis patient, and that hypokalemia should be avoided.