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Its a review of prophylactic strategies and management of arrhythmias after non cardiac thoracic surgeries.
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ARRHYTHMIAS AFTER THORACIC SURGERIES: REVIEW OF PROPHYLAXIS AND MANAGEMENT
Dr. Abhijit S. NairDr. G. Muthuswamy Consultant Anesthesiologist, Citizens Hospital, Serilingampally, Hyderabad, INDIA.
WHY IMPORTANT?
Increased LOS High cost of treatment Morbidity/ mortality Thrombo embolism Specific recommendations do not exist
PRESENTATION
Syncope Dizziness Hypotension Respiratory distress
INCIDENCE
3.8-37%: Non cardiac thoracic surgery 10.3-29.4%: Pneumonectomy
RISK FACTORS Male Elderly Magnitude of lung resection Duration CCF
RISK FACTORS CONT.
COPD Previous AF Pericardial & atrial dissection Bronchoscopy
AGE??
Degenerative & inflammatory changes in atrial myocardium
Alteration in electrical properties of atria, SA, AV node
Prolonged SA & AV node conduction time and shorter atrial refractoriness
Atrial tachyarrhythmias : causes
alteration in electrical & structural properties due to REMODELLING
MEDICAL CONDITIONS ASSOCIATED
Hyperthyroidism PE Pneumonia Pericarditis Dyslipidemia
POSSIBLE ETIOLOGIES BASELINE TACHYCARDIA! Hypoxia Hypovolemia Decreased vagal tone
ETIOLOGY CONT
Sepsis Electrolytes Increased afterload Handling Mediastinal dissection
PAIN RELIEF & ARRHYTHMIAS?
VAS > 6 Triggers tachycardia Pain: autonomic imbalance, increased
sympathetic activity Epidural- sympatholysis, less
arrhythmia
NON SIGNIFICANT FACTORS
PHARMACOLOGICAL PROPHYLAXIS
DRUGS Recommendation
Level of evidence
Beta blockers ( continuation)
Class I B
Diltiazem Class IIa B
Amiodarone Class IIa B
Magnesium Class IIa B
Digitalis Class III A
STUDIES/ TRIALS?
1980-2003: 11 RCTs CCB, β blockers, Amiodarone,
Flecainide, Magnesium explored Β blockers, CCB reasonably effective Amiodarone, Flecainide: not established Magnesium: needs further evaluation
DIGITALIS ? NO!
AMIODARONE?
Acute pulmonary toxicity Causes: High FiO2, dose, COPD Post pneumonectomy?
FLECAINIDE??
Contraindicated in: CAD Valvular HD Systolic dysfunction LVH
JUSTIFICATION OF PROPHYLAXIS
Costs involved in hospital stay, treatment
Morbidity/ mortality Can justify using prophylaxis if adverse
effects minimal
POSTOP AF?
POSTOPERATIVE AF
Indication Management Recommendation
Level of evidence
Hemodynamic instability
DCCV Class I C
Stable but symptomatic
Chemical Class I C
Stable, asymptomatic
Rate control Class I B
Stable but recurrent AF after rate control
Chemical Class II a C
Resistant AF DCCV Class II b C
CHOICE OF RATE CONTROL DRUGS
Agent Indication Recommendation
Level of evidence
Beta blockers Moderate COPD I B
Diltiazem Moderate-severe COPD
I B
Digitalis In combination with agents
III A
RHYTHM CONTROL
Beta blockers Diltiazem Amiodarone
DURATION OF ANTI- ARRHYTHMICS?
Variable Minimum 1 week At least upto 6 weeks
ANTICOAGULATION AFTER POST OP AF?? > 75 yr age Long standing hypertension LV dysfunction
Class II,
LOE A
Previous stroke/ TIA
NEWER DRUGS??
Dronedarone Budiodarone Celivarone Vernakalant Adenosine A1 receptor antagonists
IVABRADINE
WHAT DO WE DO?
We continue β blockers/ CCBs Magnesium in OT Dexmedetomidine infusion in OT : rate
control & central sympatholysis Epidural analgesia 12 lead ECG post op
CONT
Fluid/ analgesia for tachycardia Electrolyte optimization Rule out SIRS/ sepsis Ivabradine ‘ SOS ’ Amiodarone ( if not contraindicated ) in
AF Cardiology consult in unstable patients