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Peri-op Cardiac Arrhythmias, cause, recognition and treatment.

Peri-op Cardiac Arrhythmias, cause, recognition and treatment. . Presented by R1 林至芃 2000.5.04. Case presentation. 77 y/o female, DM poor control, HTN….. Necrotizing pneumonia with respiratory failure s/p intubation and ventilator support

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Peri-op Cardiac Arrhythmias, cause, recognition and treatment.

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  1. Peri-op Cardiac Arrhythmias, cause, recognition and treatment. • Presented by R1林至芃 2000.5.04

  2. Case presentation • 77y/o female, DM poor control, HTN….. • Necrotizing pneumonia with respiratory failure s/p intubation and ventilator support • hemopneumothorax, poor chest tube function came to OR for VATS. • PSVT with hemodynamic compromisesuccessfully stopped by esmolol+phenylnephrine Af with RVR after PSVT stopped.

  3. Peri-op Cardiac Arrhythmias • High incidence (15%-85%) • healthy individuals • supraventricular, ventricular, short run VT • from infant to eighties. • Less than 1% are life-threatening.

  4. Peri-op Cardiac Arrhythmias • Physiology:1.Action potential. 2.Pace maker cells. 3.Conduction system. • Electrophysiology of arrhythmia. • Anti-arrhythmic drugs. • Management of perioperative arrhythmia.

  5. Action potential of myocardiumphase 0,1,2 => absolute refractoryphase late3, 4=>relative refractory

  6. Pacemaker cells and myocardium

  7. Classification of arrhythmia • Bradyarrhythmia: sinus bradycardiaAV block- 10degree, 20 degree (Mobitz type I , Mobitz type II) 30 (complete) • Premature complexes:PACs, PJCs, PVCs.

  8. Classification of arrhythmia • Tachycardia:A. Narrow complex tachycardia 1.Sinus tachycardia 2.Atrial tachycardia 3.AV junctional tachycardia 4.AVNRT 5.AVRT 6. W-P-W syndrome 7.Atrial fibrillation 8.Atrial flutterB. Wide complex tachycardia 1.SVT with aberration 2.In WPW 3.AIVR 4.VT 5.VF 6.Torsades de pointes.

  9. Sinus bradycardia • PR<60/min • increased vagal tone, antiarrhythmic drugs effect, ischemia, primary sinus node disease • 0.2-2 mg atropine, pacing.

  10. AV block • 10AV block: PR>200ms, conduction delay in AV node • 20 -Mobitz type I, delay within AV node, inferior or posterior ischemia • 20 -Mobitz type II, His-Purkinje system, anterior distribution. • 30 -complete heart block, congenital, infarction or ischemia, drug, idiopathic degeneration.

  11. Premature complexes-PVCs • most common arrhythmia • occur with and without heart disease • adult males, 60 percent. • up to 80 percent previous MI, if frequent (>10/h) or/and complex (couplets)=>increased mortality. • wide (usually >0.14 s), bizarre QRS complexes no preceding P waves

  12. Premature complexes-PVCs • No cardiac dz: isolated asymptomatic VPCs, regardless of configuration and frequency, need no treatment. • Beta- blockers (daytime or under stressful situations,MVP, thyrotoxicosis. • In AMI, first 24 h Temporary prophylactic antiarrhythmic therapy with lidocaine or procainamide.

  13. Narrow QRS tachycardia • Sinus tachycardia: Tx targeted at underlying • Atrial tachycardia: pulmonary dz => MAT, theophyllinedigitalis toxicity=> PAT with 20 AV-block => lidocaine, beta-blocker • AVNRT: most common PSVT • orthodromic AV reciprocating tachycardia

  14. Narrow QRS tachycardia • WPW syndrome: preexcitation, delta wave. Af with WPW=>VF • Af: most common sustained tachycardia (10% of older than 75y/o)acute Af with RVR, unstable=> DC shockchronic AF, for RVR control=> Ca blocker, beta blocker are rapid and effective digoxin for LV dysfunction. • A flutter: sawtooth pattern baseline, esp II, III, aVF

  15. Wide QRS tachycardia • SVT with aberration • AIVR: terminal purkinje, myocardium. Acute MI, inflammatory process 60-130/min, atropine, overdrive pace • VT: most common life-threatening form. CAD, CM, other inflammatory process D/D: SVT with aberration. Tx: synchronized DC shock procainamide, lidocaine, amiodarone

  16. Wide QRS tachycardia • VF: immediate unsynchonized DC shock • Torsades de Pointes: polymorphic VT. Tx: magnesium sulfate.

  17. Electrolyte Imbalance and pH • Low Potassium (acute/severe) => ventricular arrhythmia • Sodium => not significant • Magnesium => low ->interfere Na-K pump produce primarily SVT =>2 gm despite actual Mg level to reduce post-CPB SVT • arrhythmias are not major seguela of acute pH change.

  18. Anesthesia • Most anesthetics are calcium antagonistic => anti-arrhythmic • halothane sensitize heart to circulating or exogenous catecholamines. • Potentiate myocardial suppression effect of antiarrhythmic agent.

  19. Classic anti-arrhythmic drugs • I: membrane stabilizer, block fast Na channelsIa: quinidine, procanamide => not available!!Ib:lidocaine=>useful for all ventricular arrhythmia SVT with aberration=> harmless! 2% lidocaine, 100mg/amp 20mg/ml a.post-defib VT/VF 1.5mg/kg b.Stable VT, undetermined wide QRS tachycardia 1-1.5 mg/kg 5-10 min 1/2 dose repeat x 2-3c.post DC or post-MI 的警示性VPC (>6/min, R-on-T, couplets or short-run, polymorphic) 0.5mg/kg (may repeat x3)

  20. Classic anti-arrhythmic drugs • II: beta-blocker effective in all tachycardic arrhythmia even in LV dysfunction when RVR superimposed • III: prolong repolorization, effective in all arrhythmia, including bupivacaine induced arrhythmiaamiodarone (150mg/3ml/amp) for refractory, repetitive VT/VF Loading 150mg over 10 min than 1mg/min Cx: hypotension, QT-prolong!

  21. Classic anti-arrhythmic drugs • IV: calcium channel blocker effective in SVT, Af, AF. Contraindicated in narrow QRS Af with known WPW! Ineffective at ventricular arrhythmia!!Verapamil (Isoptin 5mg/ml/amp) a. systolic >90 mmHg b. AF, Af, MAT:effectively decrease ventricular resoponse!(esp diltiazem, less myocardium suppression )c. 2.5-5mg slowly push for 2 min, 15-30 min repeat, Max 30mg, may pre-treat CaCl2

  22. Other anti-arrhythmic drugs • Adenosine(6mg/2ml/vial)for PSVT (I) 6mg -> 12mg rapid push!!transient bradycardia, even asystole (max15 sec) • Digoxin(0.25mg/1ml/amp)AF, Af, PSVT : ventricular rate control0.25-0.5 mg slow push for loadingonset 5-30 min, peaking 1.5-3 hrbe careful: HypoK

  23. Other anti-arrhythmic drugs • MgSO4: (2gm/20ml/amp)a. Torsade de Pointes or refractory VF/VTb. Post-CPB SVTc. post-MI ventricular arrhythmia d. 1-2 g solwly pushe. hyperMg, decrease DTR, hypotension, resp muscle paralysis, f. antidote:CaCl2

  24. What we forget?! • Defibrillator • TCP • Bradycardia • Call for help!?

  25. Thanks for your attention!

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