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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: - PowerPoint PPT PresentationTRANSCRIPT
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