Cardiac arrest during induction of anaesthesia in a child on long-term amphetamine therapy
Lausanne, Switzerland
* E-mail: christophe.perruchoud{at}chuv.ch
Editor—The number of children on chronic amphetamine treatment for attention deficit hyperactivity disorder (ADHD) has dramatically increased during the last decade. Although several previous case reports1 have described serious adverse reactions during general anaesthesia in adult patients on chronic amphetamine, very little is known about perioperative problems with paediatric patients. We report a case in which a 10-yr-old child on long-term methyphenidate (MPH) therapy presented a cardiac arrest during induction of general anaesthesia.
A 10-yr-old male child was undergoing an ambulatory laser therapy of a haemangioma on the face. The patient had been taking MPH daily for 4 yr because of ADHD. Anaesthesia was induced by mask with sevoflurane. Arterial pressure and heart rate remained stable and oxygen saturation was 100%. After i.v. access was established, propofol 2 mg kg–1 and alfentanil 10 µg kg–1 were administered. Immediately after, the child developed a severe bradycardia followed by asystole. I.V. atropine 0.5 mg was given twice and external chest massage was performed. Normal cardiac rhythm with correct haemodynamic measures was restored 30 s after the start of the cardiopulmonary resuscitation. The planned operation was continued. Operation and emergence were uneventful. The patient was taken to the post-anaesthesia care unit where his heart rate remained stable at 90 beats min–1. He was discharged home on the same day.
Amphetamines are indirect sympathetic amines with powerful central nervous system stimulation activity and peripheral 
and β actions. Chronic administration can result in depletion of norepinephrine and dopamine storage. This decreased reserve of endogenous catecholamine can contribute to a blunted sympathetic response which can lead to bradycardia and refractory hypotension during anaesthesia. In our case, the patient did not take his medication on the morning of surgery, but it has been shown that intraneuronal catecholamine levels may not return to normal for days to weeks after cessation of amphetamine use.2
Perioperative cardiac arrest in children has multiple causations.3 Propofol has been associated with bradycardia and asystole4 and the decrease in heart rate is more pronounced when propofol is combined with alfentanil.5
We found in the patient's medical files several previous uneventful general anaesthetics for the same procedure, before the patient was on amphetamine therapy. However, a severe bradycardia responding to atropine was noted during induction of a general anaesthesia several months earlier when the child was on amphetamine treatment. We believe that a blunted sympathetic response due to a chronic amphetamine exposition associated to the cardiac effects of propofol and alfentanil may have transformed a trivial bradycardia in a life-threatening asystole.
Therefore, the management of children on chronic amphetamine therapy should include avoidance or careful titration of cardiac depressor anaesthetic drugs. Direct acting vasopressors such as epinephrine or phenylephrine are preferable because of possible cross-tolerance to other indirect vasopressors such as ephedrine.6 Premedication or pre-treatment with atropine may also be useful.
In conclusion, we have observed a severe cardiovascular complication during induction of anaesthesia, possibly in relation to chronic amphetamine treatment. In view of the increasing number of children on such treatment, further studies on the anaesthetic implications of this are required to determine if a specialized anaesthetic approach is appropriate in this group.
References
1 Samuels SI, Maze A, Albright G. Cardiac arrest during caesarean section in a chronic amphetamine abuser. Anesth Analg (1979) 58:528–30.
2 Healzer JM, Fischer SP, Brook MW, Brock-Utne JG. General anesthesia in a patient on long-term amphetamine therapy: is there cause for concern? Anesth Analg (2000) 91:759–9.
3 Flick RP, Sprung J, Harrison TE, et al. Perioperative cardiac arrests in children between 1988 and 2005 at a tertiary referral center: a study of 92,881 patients. Anesthesiology (2007) 106:226–37.[CrossRef][Web of Science][Medline]
4 Tramer MR, Moore RA, McQuay HJ. Propofol and bradycardia: causation, frequency and severity. Br J Anaesth (1997) 78:642–51.
5 Hiller A, Saarnivaara L. Injection pain, cardiovascular changes and recovery following induction of anaesthesia with propofol in combination with alfentanil or lignocaine in children. Acta Anaesthes Scand (1992) 36:564–8.[Web of Science][Medline]
6 Johnston RR, Way WL, Miller RD. Alteration of anesthetic requirements by amphetamine. Anesthesiology (1972) 36:357–63.[CrossRef][Web of Science][Medline]
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