Perioperative case of arrhythmias

1. •PERIOPERATIVE
CASE OF
ARRYTHMIAS
DR ZIKRULLAH

2. PERIOPERATIVE
ECG
ABNORMALITIES
ARRYTHMIAS
ISCHEMIC
CHANGES

3. CARDIAC ARRHYTHMIAS ARE THE
MOST FREQUENT PERIOPERATIVE
CARDIOVASCULAR ABNORMALITIES

4. PATHOGENESIS
• RE-ENTRY
• AUTOMATICITY
• MUTATIONS IN ION CHANNELS
• ECTOPIC FOCI/ IRRITABLE FOCI

5. FACTORS AND CAUSES
• PATIENT RELATED FACTORS
• ANAESTHESIA RELATED FACTORS
• SURGERY RELATED FACTORS

6. PATIENT RELATED FACTORS
• PREEXISTING CARDIAC DISEASE
• CENTRAL NERVOUS SYSTEM DISEASE –RAISED ICT
• OLD AGE - DEGENERATIVE CHANGE IN ANATOMY

7. ANAESTHESIA RELATED FACTORS
• INDUCTION – INTUBATION
• LIGHT PLANE, HYPOXAEMIA, HYPERCARBIA
• DRUGS
• ELECTROLYTE IMBALANCE
• CENTRAL VENOUS CANNULATION

8. SURGERY RELATED FACTORS
• CARDIAC SURGERY
• VAGAL STIMULATION ?
• DENTAL SURGERY CAUSES PROFOUND
STIMULATION OF ANS

9. ARRYTHMIAS WITH
PULSE
TACHYARRYTHMIAS
NARROW COMPLEX WIDE COMPLEX
BRADYARRYTHMIAS
SINUS BRADYCARDIA
SINUS ARRYTHMIA
AV BLOCKS
REGULAR
SINUS
TACHYCARDIA
ATRIAL
FLUTTER
SVT
JUNCTIONAL
TACHY
IRREGULAR
ATRIAL
FIBRILATION
REGULAR
MONOMORPHIC
VT
IRREGULAR
VF
POLYMORHMIC VT
FIRST DEGREE
SECOND DEGREE
THIRD DEGREE

10. GENERAL MEASURES IN ALL
ARRYTHMIAS

13. UNSTABLE TACHYCARDIA WITH PULSE
UNSTABLE IF CAUSING:
HYPOTENSION
SIGNS TISSUE HYPOPERFUSION
ALTERED MENTAL STATUS
ISCHEMIC CHEST PAIN
ACUTE CHF
NARROW WIDE
REGULAR
ADENOSINE
50-100 J
(MONOPHASIC/
BIPHASIC)
SYNC CARDIOVERSION
IRREGULAR
BIPHASIC : 120 J(UPTO 200J)
MONOPHASIC : 200 J (UP TO 360J)
REGULAR
100 J
(MONOPHASIC/
BIPHASIC)
IRREGULAR
DEFIBRILATION
(NO SYNC)
CONSIDER SEDATION
1. PROPOFOL
2. MIDAZ + FENTA
3. ETOMIDATE+FENTA

14. TACHYCARDIA WITH PULSE
STABLE
NARROW WIDE
REGULAR
VAGAL MANUEVER
ADENOSINE
NOT REVERT
RATE CONTROL
EXPERT CONSULTATION
DRUGS
IRREGULAR
REGULAR AND
MONOMORPHIC
ADENOSINE
NOT REVERT
IRREGULAR
AMIODARONE

15. DRUGS
• ATROPINE 0.5mg ---3-5 mins---max 3mg
• DOPAMINE INFUSION 2-10mcg/kg/min
• EPINEPHRINE INFUSION 2-10mcg/min
• ADENOSINE 6mg rapid(3mg cvp)---12mg
• DILTIAZEM rule of 15
• ESMOLOL 0.5mg/kg----0.3mg/kg/min
• SOTALOL 1.5mg/kg
• AMIODARONE 150mgslow---1mg/kg/hr*6hr---.5mg/kg/hrfor18hr
• LIGNOCAINE 1.5 mg/kg load----1.5mg/kg/hr

16. EXERCISE

17. ISCHEMIC ECG CHANGES
SEQUENCE OF ECG DURING PERSISTENT ISCHEMIA
LARGE PEAKED T WAVES (OR HYPERACUTE T WAVES)
ST ELEVATION/DEPRESSION
NEGATIVE T WAVES
PATHOLOGIC Q WAVES

18. ST ELEVATION
NEW ST ELEVATION AT THE J-POINT IN TWO
CONTIGUOUS LEADS :
≥0.2 MV IN MEN OR ≥ 0.15 MV IN WOMEN
IN LEADS V2–V3
AND/OR
≥ 0.1 MV IN OTHER LEADS.

19. ST DEPRESSION AND T-WAVE
CHANGES
NEW HORIZONTAL OR DOWN-SLOPING ST
DEPRESSION >0.05 MV IN TWO CONTIGUOUS
LEADS;
AND/OR
T INVERSION ≥0.1 MV IN TWO CONTIGUOUS
LEADS WITH PROMINENT R-WAVE OR R/S
RATIO ≥ 1