Intraoperative Cardiac Arrest Due to the Oculocardiac Reflex and Subsequent Death in a Child with Occult Epstein-Barr Virus Myocarditis

(Fayon) Fellow in Critical Care Medicine.(Gauthier) Associate Professor of Pediatrics; Medical Director, Pediatric Intensive Care Unit, Hopital Sainte-Justine.(Blanc) Associate Professor of Anesthesiology.(Ahronheim) Clinical Associate Professor of Microbiology.(Michaud) Professor of Pathology.Received from the Departments of Pediatrics, Anesthesia, Microbiology, and Pathology, Hopital Sainte-Justine, Montreal, Canada, and Universite de Montreal, Montreal, Canada. Submitted for publication December 29, 1994. Accepted for publication April 29, 1995.Address correspondence to Dr. Gauthier: Department of Pediatrics, Sainte-Justine Hospital, 3175 Cote Ste-Catherine, Montreal, Quebec, Canada, H3T 1C5.Key words: Complications: cardiac arrest. Heart, myocarditis: Epstein-Barr virus. Ophthalmologic: oculocardiac reflex.FATAL cardiac arrest due to the oculocardiac reflex (OCR) is uncommon. [1]Myocarditis is also an infrequent, although well known, cause of sudden death. [2-4]This entity may go unrecognized in patients whose illness may resolve spontaneously, thus the true prevalence of myocarditis in the general population is unknown. In several major textbooks [5-8]and in studies on the risks of anesthesia, [9-11]myocarditis is not mentioned as a cause of either morbidity or mortality related to anesthesia. We describe the case of a boy who died after OCR-induced cardiac arrest during strabismus surgery and who was found to have Epstein-Barr virus (EBV) myocarditis.A 5-yr-old, 18.8-kg boy was taken to surgery for elective correction of right-sided strabismus. He had undergone two similar surgical procedures uneventfully when he was 17 and 48 months old. His medical history was otherwise unremarkable, with no known allergies. Two weeks before surgery, he had symptoms of an upper respiratory tract infection but was asymptomatic and afebrile afterward. There was no family history of sudden death, cardiac dysrhythmia, or other cardiac disease.On arrival in the operating room, the child was anxious. His systolic blood pressure was 100 mmHg, and his heart rate was 120 beats/min. Anesthesia was induced using a Bain circuit with halothane, nitrous oxide, and 40% Oxygen2by mask. After 0.01 mg/kg intravenous atropine and 1 mg/kg promethazine, tracheal intubation was performed without the use of muscle relaxants, under 3.0% inspired halothane in oxygen. Anesthesia was maintained with 1.5% inspired halothane in a mixture of nitrous oxide and oxygen (FIO20.33) using mechanical ventilation (tidal volume 180 ml, respiratory rate 12 breaths/min, fresh gas flow 3.0 l/min, and peak inflation pressure 20 cmH2O). The child initially remained hemodynamically stable after induction (SpO298-99%, systolic blood pressure 95-100 mmHg, and heart rate 140-150 beats/min). Fifteen minutes after induction, gentle traction was exerted on the right lateral rectus muscle, at which time the heart rate suddenly decreased to 70 beats/min. The surgeon relieved the rectus traction, and 0.01 mg/kg intravenous atropine was given immediately. However, within the next few seconds, the pulse oximeter failed to detect a reliable signal. Peripheral cyanosis was observed within 1 min, at which time femoral pulses were no longer palpable. The electrocardiogram (ECG) showed wide ventricular complexes at a rate of 60/min. Manual ventilation with 100% Oxygen2and closed chest massage were instituted, epinephrine (total dose 14 micro gram/kg) and 1 mEq/kg sodium bicarbonate were administered intravenously. Direct laryngoscopy confirmed that the trachea was correctly intubated; nevertheless, because of a moderate air leak, a new endotracheal tube was inserted orally.After 4 min of cardiac resuscitation, there was a return of the heart rate and blood pressure to previous values. The ECG showed sinus rhythm, an SpO2of 100% was recorded, and peripheral perfusion was improved. Analysis of an arterial blood gas drawn immediately after sinus rhythm was restored, while the FIO2was 1.0, revealed pH 7.30, carbon dioxide tension 23 mmHg, oxygen tension 524 mmHg, and bicarbonate 11.3 mmol/l. An additional dose of 0.5 mEq/kg intravenous sodium bicarbonate was given. The rectal temperature was 35.8 degrees Celsius. Pupils were mildly constricted and reacted to light; fundi were normal with a venous pulse. Under 1.0% inspired halothane in a mixture of nitrous oxide and oxygen (FIO20.50), surgery was resumed and completed 25 min later with no new incident.The immediate postoperative laboratory tests showed the following results: glucose 9.5 mmol/l, Sodium 138 mmol/l, Potassium 4.7 mmol/l, Chlorine 102 mmol/l; arterial pH 7.36, PaCO240 mmHg, Pa sub O358mmHg; hemoglobin 116 g/l, hematocrit 0.343, leukocyte count 12.1 x 109/l (23% neutrophils and 71% lymphocytes, including many