case presentation

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

謝曾 OO A 57-year-old female

Admission date: 91.06.23

Chief Complaint:

Left hip pain for half a year

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

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.

Lab Data 6/23

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

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

Unexpected Events

Atrial Fibrillation suddenly developed Rapid ventricular rate of 129 to 150 beat

s/min. Blood pressure remains stable (120/70mm

Hg). After or Before Endotracheal Intubation? Invasive monitor including CVP & A-line

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.

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

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!

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!

2nd Operation on 6/26

This time, the Combination Tech was used.

Continuous Regional (spinal and epidural) Anesthesia + Light General Anesthesia(Laryngeal mask airway)

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

2nd Operation on 6/26

Invasive monitor: CVP & A-line Operation went smoothly through whole pr

ocess HR: 86 bpm ; BP: 110+/70+ After 5+ hr. Op and 2+hr. RR stay, she wa

s transferred back to 11B ward for continuing care.

DiscussionDiscussion

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

A-fib Clinical pectrum

Lone A-fib

Asymptomatic v.s. severe symptomatic

Advanced structural diseases.

1. MS

2. AS

3. Restrictive cardiomyopathy

4. Advanced LV dysfunction

ECG Features

Irregular irregularity Absence of P wave Fib waves

Clinical Expression of A-fib

Paroxysmal

Short-lasting (< 1hr.)

Long-lasting (>1; ,48hr.) Persistent [ 2days to weeks] Chronic [Months/ Years]

Consequence of A-fib

Symptoms Hemodynamic compromise

Loss of atrial kick & Reduced ventricular filling time!

Increased risk of thromboembolism

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

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)

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.

This event This event related/associated to related/associated to

Anesthetic procedures? Anesthetic procedures?

What We Do?

Administrated induction drugs Intubation Invasive monitor including CVP & A-line

Side Effect of Atropine

A. Rebound tachycardiaB. 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

Side Effects of Pentothal

hypotension decreased cardiac index shivering dysrhythmias bronchospasm; laryngospasm

severe cardiovascular depression when toxic

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

Side Effects of Fentanyl

Many ones but almost

“Not” related to CV system

Side Effects of Esmeron

1. Cardiovascular:

arrhythmia, abnormal ECG, tachycardia

2. Respiratory:

asthma ( bronchospasm, wheezing or ronchi), hiccup

Our Drug Committed that Crime

Seems Innocent No strong evidence support their

relationship How about GA procedures?

Endotracheal Intubation

Powerful noxious stimulation May have deleterious respiratory, neurolog

ic, cardiovascular effects. Deeper levels of anesthesia are required!

Yakaitis R.W. Anesthesiology 47:386 1977 & 50:59 1979

Miller Anesthesia 5th edition p.1432

What CV Effect Intubation Induced?

Not clear! But may be due to Vagal and Sympathetic

stimulation!

Central Venous Catherization

Complications1. Pneumothorax

2. Arrhythmias (!!!)

3. Hematoma

4. Many others

Miller Anesthesia 5th edition p.1150

Why CVC induced Arrythmias?

Gire wire tips is the killer! LBBB and ventricular tachycardia were ev

er reported!Eissa NT Anesthesiology 73:772, 1990

Kasten GW Anesthesiology 62: 185,1985

Who made the A-fib?Who made the A-fib?

God!!God!!

Further investigation and Tx of A-Fib

Newly diagnosed Not associated with known precipitating fa

ctors! Warrants full investigation!

Nathanson and Gajraj. Anesthesia 1998, 53, p665-676

Investigations

Full Hx and examination 12 lead ECG Echocardiography Serum chemistry screen including thyroid f

unction tests Exercise ECG EPS

Perioperative ManagePerioperative Management ofment ofA-fibA-fib

Management Strategies

1. Management of acute-onset atrial fibrillation

2. Maintenance of sinus rhythm

3. Control of ventricular rate

4. Prevention of thromboembolism

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

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

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

Maintenance of Sinus Rhythm

Prophylactic Tx

50-70% effective

Class Ia: quinidine, disopyramide

Class Ic: flecainide, propafenone

Class III: amiodarone, sotalol

SE: Pro-arrhymias

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

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.

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

Behind the StoryBehind the Story

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!?

1st v.s. 2nd Anesthesia Induction

1st GA Induction drugs Intubation (+) CVP (+) A-line (+) GA gas: sevoflurane

2nd

RA drugs Intubation (-) [Mask] CVP (+) A-line (+) Light GA gas Premedication: Amio

darone!

Thanks ComingThanks Coming