POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT
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Hemodynamic instability commonly occurs in the postoperative period and can present as hypertension, hypotension, tachycardia, bradycardia, or cardiac dysrhythmias. The document outlines the various causes and management strategies for each type of hemodynamic instability. Hypertension is often caused by pain, emergence excitement, or residual effects of drugs and can be treated with analgesics, sedation, ventilation, or antihypertensive medications. Hypotension can be hypovolemic, cardiogenic, or distributive in nature and requires fluid resuscitation, vasopressors, or inotropes depending on the cause. Tachycardia and bradycardia also have multiple potential causes that must
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POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT
- 1. POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT
- 2. Professor Department of Anaesthesiology & Intensive Care Adesh Institute of Medical Sciences and Research (AIMSR) Bathinda, Punjab, India Prof. Minnu M. Panditrao Previously Consultant Department of Anesthesiology and Intensive Care Rand Memorial Hospital Freeport Commonwealth of Bahamas
- 3. Presented as a Faculty lecture on 29th December 2014:
- 4. Introduction continuation of intraoperative Process new occurrence in the postoperative period Hemodynamic instability (HDI) in Postoperative Period a very common phenomenon !
- 5. Introduction Care of patient with HDI in the early post-op. period Shifting of patient from OR RR/ HDU/ ICU Continuation of same level of (Intra- operative) monitoring and support Accompany the patient during shifting
- 6. Introduction Hypertension Hypotension Tachycardia Bradycardia Cardiac Dysrhythmias HDI in post-op. period can occur in the form of Post-operative tachycardia and systemic hypertension are more predictive of adverse outcome than hypotension and bradycardia.
- 7. Hypertension More common after G.A. Occurs within 30 minutes, in up to 35% pts. common causes are • Preexisting essential hypertension • Post-operative pain • Emergence excitement • Hypoventilation (Hypercarbia, Hypoxemia) • Residual effect of sympathomimetic/anticholinergic drugs, ketamine etc. • Rebound hypertension after withdrawal of hypotensive agents • Distension of viscera esp. urinary bladder
- 8. Hypertension Other likely causes are • Hypervolemia • Intracranial surgeries, raised ICP • PONV, Shivering • Elderly age, h/o cigarette smoking, renal disease etc. • Substance withdrawal • Hyperthyroidism, malignant hyperpyrexia etc. Hypertension
- 9. Hypertension Management • treat the cause • adequate analgesia/sedation • adequate ventilation/oxygenation • Labetalol • Esmolol, metoprolol • Hydralazine • Glyceryl trinitrite • Nifedipine Hypertension
- 10. Hypotension Common occurrence after trauma/emergency surgeries in critically ill patients & neuraxial blocks Incidence: post spinal in C.S.- 50-80% Three types : • Hypovolemic • Cardiogenic • Distributive
- 11. Hypotension Hypovolemic • Inadequate intra op. fluid/blood replacement or ongoing losses • Sympathetic blockade—residual effect of spinal/epidural, relative hypovolemia • Management: treat the cause, head down position, oxygen supplementation, rapid boluses (250-500 mls.) of IV fluids (crystalloid/colloids), replace blood • Vasopressors: Ephedrine, Phenylephrine, Mephentermine, Metaraminol • Management of ongoing blood loss – surgical, clotting enhancing agents Hypotension
- 12. • Myocardial ischemia, myocardial infarction, CHF • Cardiomyopathies, valvular heart disease, pericardial disease • Cardiac dysrhythmias • Drug induced (β blockers, calcium channel blockers ) • Electrolyte disturbances, acidosis, sepsis • Cardiac tamponade, pulmonary embolus, tension pneumothorax Cardiogenic - decreased cardiac outputHypotension
- 13. Cardiogenic - Management • CVP, Surface and Trans E.E., pulmonary artery catheter monitoring • nitrates, opioids, β blockers and anticoagulants • supportive treatment, optimizing the preload, diuretics, inotropic and vasodilator therapy • Correction of electrolyte imbalance and acidosis, antiarrhythmics • For cardiac tamponade and tension pneumothorax, appropriate surgical intervention Hypotension
- 14. Distributive - decreased afterload • Iatrogenic sympathectomy due to neuraxial blockade • Allergic reactions: anaphylactic/anaphylactoid • Sepsis • Critically ill patients rely on exaggerated sympathetic tone to maintain systemic blood pressure and heart rate. In these patients even low doses of inhaled anesthetic agents/opioids/sedatives may decrease the sympathetic tone to produce marked hypotension. Hypotension
- 15. Distributive - Management • Vasopressors, atropine/glycopyrrolate, rapid IV fluids, supportive Tt. • Epinephrine, Steroids and supportive treatment • Fluid resuscitation, Nor-adrenaline, Phenylephrine, Vasopressin Hypotension
- 16. Tachycardia Pulse rate > 100 or an increase of > 20% of baseline P.R. More common after G. A. • Pain • Hypovolemia • Anemia • Pyrexia • Hypoxia/Hypercarbia • Sympathomimetic drugs, ketamine • Anticholinergic drugs • Hypothermia/shivering • Presence of endotracheal/other tubes/catheters
- 17. Tachycardia • Cardiogenic/septic shock • Pulmonary embolism • Substance withdrawal • Hyperthyroidism • Malignant hyperpyrexia Management: • Treat the cause • B blockers Tachycardia
- 18. Bradycardia Pulse rate < 60 BPM More common after spinal up to 60% • Often iatrogenic - β blockers, opioids, anticholinesterases, dexmedetomidine etc. • Bowel distension, increased ICP/IOP • High spinal/epidural block • Cardiac origin
- 19. Management • Moderate degree of bradycardia (PR of 45-50) may be allowed if the blood pressure is in the normal/high range • Symptomatic bradycardia - anticholinergic agents • Atropine IV 0.3mg boluses, Up to 3 mg • Glycopyrrolate IV 0.1 -0.4 mg to get the desired effect • Inotropes like dopamine/dobutamine • Aminophylline IV may be given in refractory β blocked patients • Pacing • Supportive Tt. Bradycardia
- 20. Cardiac dysrhythmias May be atrial or ventricular Hypoxemia/Hypercarbia hyperthermia Pain/agitation myocardial ischemia/infarction Hypovolemia/anemia electrolyte abnormalities/acidosis Volume shifts/fluid overload hypertension Endogenous/exogenous catecholamines digitalis intoxication Anticholinesterases/anticholinergics substance withdrawal Hypothermia pre-operative cardiac dysrhythmias
- 21. Atrial dysrhythmias In up to 10% pts. after non-cardiac major surgeries, higher incidence after cardiac and thoracic surgeries • Supraventricular tachycardia and Atrial fibrillation are common Management: Treat the cause, Control of ventricular rate • Prompt electrical cardioversion • Adenosine 6 mg IV push, plus another 12 mg IV push if required • Diltiazam 15-20 mg IV over 2 minutes followed by 5-15 mg/hour SVTs. • For atrial fibrillation Esmolol (rapid onset and short duration) • Amiodarone, if β- blockers are contraindicated Cardiac dysrhythmias
- 22. Ventricular dysrhythmias Pre-mature ventricular contractions (PVCS) and bigemini - common True ventricular tachycardia may indicate cardiac pathology Management: treat the cause • occasional PVCs without any fall in blood pressure - just observe • Significant numbers/runs of ectopics producing hypotension - IV Lidocaine 50-100 mg bolus, infusion 1-4 mg/minute • Amiodarone 150mg over 10minutes, 1mg/min for 6 hours, 0.5 mg/min for 18 hours • Ventricular tachycardia (rare), can progress to ventricular fibrillation, treat immediately with IV Lidocaine (blood pressure stable) • If hypotension, DC cardioversion Cardiac dysrhythmias
- 23. HDI Tachycardia Bradycardia Dysrythmias Hypotension Hypertension Hypotension Hypertension I/V fluid boluses + ve Response - ve Response Correct Blood/ fluid loss CVP monitoring Peripheral perfusion CVP/PCWP monitoring To rule out Cardiac pathology & specific treatment Analgesia & sedation Still hypertensive β Blockers α adr. Agonists Vasodilators Ca++ channel blockers diuretics Monitor Urine output Anti-cholinergics IV Fluids Vasoconstrictors Inotropes pacing Sympathetic blockade Cardiac pathology analgesia sedation Diuretics Ventilation Control of ICP atrial Ventricular SVT AF A fib. PVCs. V tach V fib. Cardio version Adeno sine Diltia zam Beta block ers Amiod arone Digi talis Obser vation IV Ligno caine Amiod arone IV Ligno caine Cardio versionOxygenation/ventilation CVP/IBP/ABG monitoring Normothermia Intake/output/ electrolytes
- 24. Conclusion Hemodynamic instability is one of the most frequently encountered complication in the early post-operative period If diagnosed early and managed promptly and decisively, significant amount of morbidity and mortality can be prevented.
- 25. THANK YOU!!