good morning 20 august 2002. anesthetic considerations in patients with cardiac arrhythmias...
TRANSCRIPT
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Good Morning
20 August 2002
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Anesthetic Considerations in Patients With Cardiac Arrhythmias
麻醉科 林子富
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Perioperative Cardiac Arrhythmias Incidence:
Overall: 70.2% > 90% in cardiac surgery
Majority (90.7%): ASA 1 and 2 Without preexisting cardiac dz. or noncardiac surgery: benign
and short-lived 18% to 30% (conventional intermittent EKG) vs. 60% to
80% (continuous Holter) Common factors:
Tracheal intubation, extubation & known heart dz. More frequently observed in neurologic, thoracic and he
ad and neck procedures.
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Causes of Perioperative Cardiac Arrhythmias
Abnormalities of cardiac impulse formation (sma
ll portion): In normal automaticity:
Bradycardia and escape beats with high dose narcotics In abnormal automaticity:
A less negative diastolic potential In triggered automaticity:
Etopic beat activated by preceding action potential “Early afterdepolarization” during phase 3 “Delayed afterdepolarization” during phase 4
Abnormalities of impulse conduction: Re-entry excitation (most common mechanism underlying premature
beasts and tachyarrhythmias)
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Physiologic ImpactTachyarrhythmias:
Reduce diastolic ventricular filling Decrease cardiac output and BP Coronary perfusion suffers Myocardial ischemia
Significant bradyarrhythmias also decrease cardiac output
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Anesthsia and ArrhythmiaHigher incidence
Anesthetic agents altering cardiac impulse generation and conduction
Volatile agents causing AV dissociation
Perioperative ischemia and elevated catecholamine level
Light anesthetic levels Hypoxemia Hypercarbia Exogenous epinephrine and aminophylline
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Sinus Node Dysfunction
Transient Autonomic implication
Neuraxial blockade, laryngoscopy, endotracheal instrumentation
B1 agonist Atropine Cardiac pacing
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Paroxysmal Supraventricular Tachycardia
Onset and termination are usually abrupt. Higher incidence in major vascular, cancer, and orthopedic surg
ery Death rate in non-cardiac surgery remains high: 50% Causes of PSVT:
AV node and accessory pathways re-entry: 85% to 90% SA node and intra-atrial re-entry: casual mechanism
Narrow-QRS PSVT With WPW syndrome: Vagal maneuver, adenosine, B-bloker, and cardiov
ersion Without WPW syndrome: Vagal maneuver, adenosine, Ca++ channel blo
cker followed by cardioversion Wide-QRS PSVT
IV procainamide and amiodarone and cardioversion
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Atrial Fibrilattion
>90% of SVTs in the post-op setting Etiology:
Cardiac cause Systemic process Electrolyte imbalance
If ventricular rate increases in an acute fashion perioperatively leading to significant hemodynamic perturbation, treatment should be prompt. Verapamil, esmolol, digoxin DC cardioversion
Acute onset ( <1year) LA diameter < 45mm No ventricular enlargement Prior anticoagulation for arrhythmias older than 4 to 5 days
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Atrial Flutter
Less frequently encountered Same etiological factors as AF Not typically responsive to antiarrhythmic dr
ugs Pacing Catheter ablation
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Ventricular Arrhythmias
Benign Ventricular premature beats and nonsustained v
entricular tachycardia 6.3% incidence of VPBs, only 0.62% severe adverse o
utcomes Structurally normal hearts Reduction of VPBs and NSVT in GA
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Ventricular Arrhythmias
Potentially malignant Sustained monomorphic ventricular tachycardia
>90% previous infarction leading to LV dysfunction Antiarrhythmic effects of volatile agents (animal study) Lidocaine, procainamide, amiodarone High-energy cardioversion
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Ventricular Arrhythmias Malignant
Polymorphic ventricular tachycardias Mostly due to torsades de points or acute ischemia Significant prolongation of the Q-T interval Correction of ischemia Asynchronous DC cardioversion Repletion of K+ and Mg++ Atropine and isoproterenol ( not in ischemia ) V-pacing Lidocaine or phenytoin
Ventricular fibrillation High-energy shock Drugs only for prevention of recurrence
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Summary Common but most are transient and benign Greater implications in the presence if significant ca
rdiac structural abnormality Special challenges of the operative setting
Hypo- and hyper-tension, low-flow rate, volume overload, high catecholamine state, hypoxia, hypercarbia, temperature alterations, and pericardial tamponade…
Antiarrhythmics with their proarrhythmic potential Devices for cardioversion, defibrillation, and pacing
and familiarity with their use..
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References
1. Anesthetic Considerations in Patients With Cardiac Arrhythmias, Pacemakers, and AICDs. International Anesthesiology Clinics 39(4):21-42,2001 Fall
2. Perioperative Cardiac Dysrhythmias diagnosis and management. Anesthesiology 1997;86:1397-424
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Have A Nice Day