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Table of Contents
LETTER TO EDITOR
Year : 2021  |  Volume : 37  |  Issue : 2  |  Page : 311-312

Diagnosis and practical implications of ECG lead reversal: Anesthesiologist perspective


Department of Anaesthesiology and Critical Care, JIPMER, Dhanvantari Nagar, Puducherry, India

Date of Submission08-Dec-2018
Date of Decision09-Apr-2019
Date of Acceptance11-Jul-2019
Date of Web Publication15-Jul-2021

Correspondence Address:
Dr. Lenin B Elakkumanan
Department of Anaesthesiology and Critical Care, JIPMER, Dhanvantari Nagar, Puducherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacp.JOACP_363_18

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How to cite this article:
Ravi R, Aravind C, Sundararajan V, Elakkumanan LB. Diagnosis and practical implications of ECG lead reversal: Anesthesiologist perspective. J Anaesthesiol Clin Pharmacol 2021;37:311-2

How to cite this URL:
Ravi R, Aravind C, Sundararajan V, Elakkumanan LB. Diagnosis and practical implications of ECG lead reversal: Anesthesiologist perspective. J Anaesthesiol Clin Pharmacol [serial online] 2021 [cited 2022 Sep 30];37:311-2. Available from: https://www.joacp.org/text.asp?2021/37/2/311/321412

Dear Editor,

Most electrocardiographic (ECG) abnormalities during the perioperative period are diagnosed and managed appropriately by the anesthesiologist. Abnormal ECG owing to the reversal of limb lead could also happen either by manual error or faulty equipment.[1] Here, we report a case of ECG lead reversal and discuss the important relevant points for practicing anesthesiologists.

A 24–year-old female patient was planned for puerperal sterilization. During preoperative evaluation by an experienced anesthesiologist, she was found to have a pulse rate of 116 bpm with regular rhythm and blood pressure of 124/82 mmHg. Other clinical examination including cardiovascular system was unremarkable. Her hemoglobin level was 10.2 g/dl.Considering the differential diagnosis of anxiety, hyperthyroidism, and cardiac abnormalities, an ECG was asked for further evaluation of tachycardia.

The ECG showed heart rate of 103 bpm, with right axis deviation, aVR uptake, ST depression in V3, V4, V5, V6, and T wave inversions in V1–V4 [Figure 1]a. Although the automatic ECG machine (MAC 1200ST series, GE medical systems) interpretation was "suspect arm lead reversal," these findings were suggestive of non ST-elevation myocardial infarction (NSTEMI), which warrants further investigations.[2],[3] In addition, the clinical features were not correlating, and the ECG was repeated and found to be normal [Figure 1]b.Our case strongly emphasizes the fact that an ECG should always be correlated clinically.
Figure 1: (a) ECG with lead reversal and suspected NSTEMI. (b): Normal ECG

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If ECG findings of NSTEMI had been present with non-specific cardiac symptoms, any anesthesiologists would have asked for further cardiac evaluation. On the first look, we could not have diagnosed the lead reversal. Only after reading the ECG machine interpretation, we could diagnose the ECG limb lead reversal [Table 1]. This was simulated in the various anesthesia workstations, and we noticed that surprisingly none of the perioperative multiparametric monitor (equipped with arrhythmia analysis) used in the perioperative period gives alarm for limb lead reversal. On several occasions, the ECG monitoring is disconnected and reconnected especially during the change of position (eg., supine to prone) in operating room. In those situations, sudden change in the ECG is a serious cause of concern for anesthesiologist.
Table 1: Alterations observed in ECG caused by common leads misplacement in normal ECG

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Therefore, we suggest the manufacturers to incorporate the lead reversal alarm in the arrhythmia analysis of ECG monitoring. In addition, every anesthesiologist should be aware of the diagnostic criteria for ECG limb lead reversal.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Velagapudi P, Turagam MK, Ritter S, Dohrmann ML. Left arm/left leg lead reversals at the cable junction box: A cause for an epidemic of errors. J Electrocardiol 2017;50:111-4.  Back to cited text no. 1
    
2.
Peberdy MA, Ornato JP. Recognition of electrocardiographic lead misplacements. Am J Emerg Med 1993;11:403-5.  Back to cited text no. 2
    
3.
Heden B. Electrocardiographic lead reversal. Am J Cardiol 2001;87:126-7.  Back to cited text no. 3
    


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