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Atrial Fibrillation Post-Anesthetic Induction: Managing Unexpected Events

Explore the case of a 57-year-old woman with atrial fibrillation after undergoing anesthetic induction, leading to unexpected events during surgery and recovery. Learn about the management strategies employed for this scenario.

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Atrial Fibrillation Post-Anesthetic Induction: Managing Unexpected Events

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  1. CASE PRESENTATION A 57-Year-Old Women with Atrial Fibrillation after Anesthetic Induction Presented by Ri 郭錦輯 楊素廷 指導老師 劉漢平醫師 7/1/2002

  2. 謝曾OO • A 57-year-old female Admission date: 91.06.23 • Chief Complaint: Left hip pain for half a year

  3. Brief History • No any other underlying systemic diseases • Bilateral hip OA s/p bil. THR about 10 years ago. • Mild progressive left hip pain since 6 months ago. • Progressive limited ROM was also noted. • Under the impression of left THR loosening, she was admitted for THR revision. • Family history : non-contributary

  4. Phyical Examination • 134/88mmHg, T/P/R: 37.1/84/20 • No murmur on heart auscultation • Lungs were clear • Abdomen was soft & flat • Limited ROM of low extremities • ECG showed normal sinus rhythm.

  5. 1. CBC-DC: RBC: 4.46 Hb: 13.4 Hct: 39.9 MCV: 89.5 MCHC: 33.6 Plt: 353 WBC: 8.01 CRP: 0.28 2. BCS: Bil.(t): 1.02 AST:18.0 BUN: 13.2 Cre.:0.59 Na: 138.7 K: 4.13 Cl: 106, Glucose AC: 101 Lab Data 6/23

  6. 1st Operative day on 6/24 • General anesthesia was performed. • Bp 134/77 with pulse rate of 107 bpm • 97% of SaO2. • At 3 pm after induction drugs were given • Atropine(0.5 mg) • Fentanyl(2 ml) • Pentothol(10 ml) • Esmeron(20 mg) • 2% Xylocaine(6 ml) • Codaron 3 Amp in 50c.c IV drip

  7. Unexpected Events • Atrial Fibrillation suddenly developed • Rapid ventricular rate of 129 to 150 beats/min. • Blood pressure remains stable (120/70mmHg). • After or Before Endotracheal Intubation? • Invasive monitor including CVP & A-line

  8. Maintenance • From 3pm ~ 5:20pm • Sevoflurane was used • A fib still persisted through this stage • HR:140~150 ; BP: 110/60 • Operation was canceled • Transfer to Recovery Room.

  9. Recovery Room • 5:25pm to Recovery Room • Consult CV man for A-Fib • HR: 130+ bpm ; BP:110/70 • Decided to DC cardioversion 200J at 6:45 pm

  10. After DC Cardioversion • Around 6:47pm, A-Fib was converting to NSR • Cordaron IV drip 5c.c./hr. • BP 110+/70+ ; PR 86 bpm • After condition stabilized, transferred back to 11B ward!

  11. Next Day • Re-evaluate the surgical cardiovascular risk • CV man defined this case was relative low risk • Keep Amiodarone for maintenance • Perform THR revision next day!

  12. 2nd Operation on 6/26 • This time, the Combination Tech was used. • Continuous Regional (spinal and epidural) Anesthesia + Light General Anesthesia(Laryngeal mask airway)

  13. 2nd Operation on 6/26 • Agents we used during induction • Plain(Tetracaine) • 2% xylocaine(5 ml) • Propofol(3 ml, 30 ml/h) • Demerol(25 mg) • Vitacal(2 amp) • GA gas: N2O/O2

  14. 2nd Operation on 6/26 • Invasive monitor: CVP & A-line • Operation went smoothly through whole process • HR: 86 bpm ; BP: 110+/70+ • After 5+ hr. Op and 2+hr. RR stay, she was transferred back to 11B ward for continuing care.

  15. Discussion

  16. What is A-fib? • One of commonest • Large gradient across age categories • Multiple reentrant atrial wavelet curcuits • Loss synchronization • Irregular ventricular response Hurst “ THE HEART” 10th edition p824

  17. Lone A-fib Asymptomatic v.s. severe symptomatic Advanced structural diseases. MS AS Restrictive cardiomyopathy Advanced LV dysfunction A-fib Clinical pectrum

  18. ECG Features • Irregular irregularity • Absence of P wave • Fib waves

  19. Clinical Expression of A-fib • Paroxysmal Short-lasting (< 1hr.) Long-lasting (>1; ,48hr.) • Persistent [ 2days to weeks] • Chronic [Months/ Years]

  20. Consequence of A-fib • Symptoms • Hemodynamic compromise Loss of atrial kick & Reduced ventricular filling time! • Increased risk of thromboembolism

  21. A-fib & Anesthesia A-fib may be seen coincidentally in many patients presenting for both elective and emergency anesthesia. Nathanson and Gajraj. Anesthesia 1998, 53: p665-676

  22. Why Atrial Fibrillation after induction? Etiologies of A-fib • Myocardial ischemia (the most common). • Acid-base disturbances. • Electrolyte abnormalities: hypokalemia, hypomagnesemia. • Pneumonia, post-pneumonectomy, pulmonary embolism, pleural effusion,pericardial disease, pre-excitation syndromes(e.g. WPW syndrome)

  23. Why A-fib ? (2) Etiologies • Alcohol intoxication, ASD, atrial or pericardial manipulation during cardiac surgery, atrial myxoma, bronchial arcinaoma. • Cardiomyopathy, central venous catheters, electroconvulsive therapy • Hypertension, hypovolemia, hypoxia, rheumatic HD, sick-sinus syndrome, thyrotoxicosis.

  24. This event related/associated to Anesthetic procedures?

  25. What We Do? • Administrated induction drugs • Intubation • Invasive monitor including CVP & A-line

  26. Side Effect of Atropine A. Rebound tachycardia B. Paradoxical bradycardia (if low dose atropine used) D. Paradoxical rate slowing: 1. Type II Second degree AV block 2. Third degree AV block E. Arrhythmia (especially in coronary artery disease) 1. Ventricular fibrillation 2. Ventricular tachycardia F. Anticholinergic toxicity with overdosage G. Decreased sweating and secreations

  27. Side Effects of Pentothal • hypotension • decreased cardiac index • shivering • dysrhythmias • bronchospasm; laryngospasm severe cardiovascular depression when toxic

  28. Side Effects of Xylocaine A. Myocardial depression of conduction and contractility 1. Concurrent antiarrhythmic therapy 2. Sick sinus syndrome 3. Left ventricular dysfunction B. Circulatory depression C. Overdosage 1. Third degree AV Heart Block 2. Altered AV conduction 3. Sinus node automaticity depressed

  29. Side Effects of Fentanyl Many ones but almost “Not” related to CV system

  30. Side Effects of Esmeron 1. Cardiovascular: arrhythmia, abnormal ECG, tachycardia 2. Respiratory: asthma ( bronchospasm, wheezing or ronchi), hiccup

  31. Our Drug Committed that Crime • Seems Innocent • No strong evidence support their relationship • How about GA procedures?

  32. Endotracheal Intubation • Powerful noxious stimulation • May have deleterious respiratory, neurologic, cardiovascular effects. • Deeper levels of anesthesia are required! Yakaitis R.W. Anesthesiology 47:386 1977 & 50:59 1979 Miller Anesthesia 5th edition p.1432

  33. What CV Effect Intubation Induced? • Not clear! • But may be due to Vagal and Sympathetic stimulation!

  34. Central Venous Catherization Complications • Pneumothorax • Arrhythmias (!!!) • Hematoma • Many others Miller Anesthesia 5th edition p.1150

  35. Why CVC induced Arrythmias? • Gire wire tips is the killer! • LBBB and ventricular tachycardia were ever reported! Eissa NT Anesthesiology 73:772, 1990 Kasten GW Anesthesiology 62: 185,1985

  36. Who made the A-fib?

  37. God!!

  38. Further investigation and Tx of A-Fib • Newly diagnosed • Not associated with known precipitating factors! • Warrants full investigation! Nathanson and Gajraj. Anesthesia 1998, 53, p665-676

  39. Investigations • Full Hx and examination • 12 lead ECG • Echocardiography • Serum chemistry screen including thyroid function tests • Exercise ECG • EPS

  40. Perioperative Management ofA-fib

  41. Management Strategies • Management of acute-onset atrial fibrillation • Maintenance of sinus rhythm • Control of ventricular rate • Prevention of thromboembolism

  42. Management of acute-onset atrial fibrillation (1) DC cardioversion is the treatment of choice. Indication: • Atrial fibrillation a/w hypotension • Congestive cardiac failure • Active ischemia or acute infarction • Severe aortic stenosis, MS, and hypertropic cardiomyopathy A-fib Mx in flux. Chest.1992;101:1095-103

  43. Management of acute-onset atrial fibrillation (2) Contraindications • Digoxin toxicity • A history of bradycardia or sick-sinus syndrome • Inadequately treated precipitating cause • A-fib Duration is more than 48 h without at least 3 weeks of anticoagulation

  44. Management of acute-onset atrial fibrillation (3) Pharmacological cardioversion • The role is not clear in Acute A-Fib • Not been studied its role in the peri-op • Class Ia: procainamide, quinidine, disopyramide • Class Ic: flecainide, propafenone • Class III: amiodarone, sotalol

  45. Maintenance of Sinus Rhythm Prophylactic Tx 50-70% effective Class Ia: quinidine, disopyramide Class Ic: flecainide, propafenone Class III: amiodarone, sotalol SE: Pro-arrhymias

  46. Control of ventricular rate Optimum ventricular in chronic atrial fib. Pt. Is 90 bpm Class II (-adrenoceptor blockers): esmolol, propranolol Class IV (calcium channel blockers): verapamil, diltiazem Cardiac glycosides: digoxin

  47. Prevention of thrombo-embolism • Atiral stasis → promote clot formation • Thromboembolic stroke: 5% in chronic A-fib pt. • Oral anticoagulation: Warfarin • If A-fib present ≧ 48 h, cardioversion should be delayed to allow 3-4 wks of oral anticoagulation. • Stroke rate from 5% to 1% • Continued for at least 4 wks after cardioversion.

  48. Conclusion • Our knowledge gained from non-anesthesia med! • The acute precipitating factors, must be borne in mind and dealt with. • Simple algorithms and knowledge of a relatively small number of drugs and DC cardioversion make us manage atrial fibrillation safely and effectively

  49. Behind the Story

  50. 6/29 Patient Visit • She told me that after 1st OP GA induction, her consciousness still remained clear! • She felt very painful when intubation but can’t resist! • What happened? • Intubation induced? • The anesthetic depth not enough!?

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