Persistent ventricular bigeminy during anesthesia in pediatric patients: a case report of an 11-year-old child.

An 11-year-old male child with fractures in both bones in his left forearm presented for open reduction and internal fixation. The pre-anesthetic check-up and investigations did not reveal any pre-existing underlying cardio-respiratory disease. The patient had an uneventful peri-operative period during the operation and was comfortable without any anxiety or restlessness. After an uneventful induction and intubation as per routine protocol, the patient received 600 mg of amoxicillin+clavunate intravenously as an antibiotic. After 3 min, the patient developed persistent ventricular bigeminy with intermittent sinus rhythm, which returned to normal after 20 min. Open reduction and internal fixation of the fractures in both bones were done. Extubation and the post-op course were uneventful. To rule out the cause of arrhythmia, ECG, 2D-ECHO and serum electrolyte evaluation were done, however the results came back as normal. Many days later, the patient fell again on the same arm and revisited the ortho operation theatre for revision surgery. As the child was very cooperative and calm, he was given a supraclavicular block after proper counseling. Thirty minutes before tourniquet inflation as a routine method, 600 mg of amoxicillin+clavunate was administered. After 5 min, the patient developed persistent ventricular bigeminy. After 1 h, the child complained of chest pain and had redness of eyes and was restless. This was managed with 100% oxygen and an injection of 150 mg amiodarone intravenously. Surgery was postponed for further stabilization and optimization. Serum electrolytes were normal. The child was observed in the surgical intensive care unit with continuous ECG monitoring. Ventricular bigeminy with intermittent sinus rhythm persisted for 3 days. This was managed with metoprolol 12.5 mg BD and amiodarone 100 mg OD tablets. The opinion of a pediatric cardiologist was obtained and repeated 2D-ECHO results revealed no abnormality. After 5 days, the patient was discharged and surgery was rescheduled for 2 weeks later with continuation of metaprolol and amiodarone tablets. On the fourth occasion we avoided the injection of amoxicillin+clavunate and all anesthetic drugs, which might contribute to cardiac arrhythmia. The peri-operative period was uneventful. An in-depth discussion of the case and ventricular dysrhythmias in the pediatric population is emphasized in this case report.