Anesthetic Management in a patient with Wolff-Parkinson-White Syndrome undergoing

Laparoscopic Cholecystectomy: A Case Report

CASE
This is a case of K.K, 43 years old, male, Korean came in with a chief complaint of RUQ pain with
a pain score of 10/10 radiating to the back and was posted for laparoscopic cholecystectomy due
to calculus cholecystitis. While the patient claims to be asymptomatic during examination, he
gave a history of occasional palpitation during strenuous exercises which gets spontaneously
remitted after rest.

The general and systemic examination was within normal limits with a regular heart rate of
83bpm and bp of 120/80mmHg. His 12 lead ECG was suggestive of Wolff Parkinson White
Syndrome with shortened PR interval and presence of delta waves (figure 1). 2D echo was done
which showed normal left ventricular geometry with adequate left ventricular function, dilated
left atrium and ejection fraction of 67%. Treadmill Exercise Stress Test was done which showed
Normal Stress Test at 12.6 Mets.

Figure 1.
The goal during perioperative management of anesthesia was to avoid any factor that increases
sympathetic activity such as pain, anxiety, fear, stress response of intubation/extubation, lighter
plane of anesthesia, hypovolemia, and avoiding premedication with anticholinergic drugs.

Patient was adequately counseled and reassured. Premedication with Omeprazole 40mg ivtt was
given early morning of surgery.

In the OR theatre, patient was attached to Standard ASA monitors. Drugs which were kept ready
included Adenosine, Esmolol, Amiodarone, Lidocaine; and defibrillator was made readily
available in case the need arises.
Preoperatively, Midazolam 1mg and Fentanyl 25mcg were given. Once patient was noted to be
comfortable and relaxed, preoxygenation with 100% oxygen was done. Induction was done with
the following medications: Midazolam 1mg, Fentanyl 50mcg, Propofol 100mg. After induction,
anesthetic depth was maintained by adding Sevoflurane, Remifentanil TCI and muscle relaxant
of Rocuronium 50mg. 5 minutes after induction, intubation was done with noted minimal
changes in HR and BP.

The case proceeded uneventfully and after completion of surgery, residual carbon dioxide in the
peritoneal cavity was carefully removed by the surgeon. While the patient was still under
anesthesia and paralysis, gentle suctioning under direct vision was done and residual
neuromuscular blockage was reversed with Sugammadex 200mg. After the return of
consciousness with ability to follow verbal commands and generation of adequate tidal volume
patient was extubated. Prophylaxis against PONV was taken intraoperatively and patient was
sent to recovery room for monitoring of vitals. Patient was successfully managed at PACU and
was then transferred to PCU. On the 2nd day post-op, patient was discharged improved.