Post induction arrhythmia in a renal patient: an unexpected risk factor

A 44 year-old woman was anaesthetised for a transplant nephrectomy. About 10 min after induction of anaesthesia she had several runs of ventricular tachycardia followed by ventricular fibrillation requiring 30 s of cardiopulmonary resuscitation, after which she reverted to sinus rhythm. Review of her chest X-ray, suggested that the haemodialysis catheter (Permcath) position may have precipitated this event. However, subsequent investigation found that she had toxic serum levels of sotalol, with a prolonged corrected QT interval on the electrocardiogram. She was started on sotalol while her renal graft was functioning well but it was not reviewed when the graft started to fail and she had to commence haemodialysis. This led to the accumulation of sotalol and explains her serum sotalol value of 7.1 mg x l(-1) on the day of the event. Concentrations greater than 2.5 mg x l(-1) are generally considered toxic.