1. 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

2.  謝曾 OO  A 57-year-old female Admission date: 91.06.23  Chief Complaint: Left hip pain for half a year

3. 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

4. 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.

5. 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

6. 1 st 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

7. Unexpected Events  Atrial Fibrillation suddenly developed  Rapid ventricular rate of 129 to 150 beats/min.  Blood pressure remains stable (120/70mmHg).  After or Before Endotracheal Intubation?  Invasive monitor including CVP & A-line

8. 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.

9. 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

10. 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!

11. 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!

12. 2 nd Operation on 6/26  This time, the Combination Tech was used.  Continuous Regional (spinal and epidural) Anesthesia + Light General Anesthesia(Laryngeal mask airway)

13. 2 nd 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: N 2 O/O 2

14. 2 nd Operation on 6/26  Invasive monitor: CVP & A-line  Operation went smoothly through whole process  HR: 86 bpm ; BP: 110+/70+  After 5+ hr. Op and 2+hr. RR stay, she was transferred back to 11B ward for continuing care.

15. Discussion

16. 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” 10 th edition p824

17. 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

18. ECG Features  Irregular irregularity  Absence of P wave  Fib waves

19. Clinical Expression of A-fib  Paroxysmal Short-lasting (< 1hr.) Long-lasting (>1;,48hr.)  Persistent [ 2days to weeks]  Chronic [Months/ Years]

20. Consequence of A-fib  Symptoms  Hemodynamic compromise Loss of atrial kick & Reduced ventricular filling time!  Increased risk of thromboembolism

21. 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

22. 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)

23. 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.

24. This event related/associated to Anesthetic procedures?

25. What We Do?  Administrated induction drugs  Intubation  Invasive monitor including CVP & A-line

26. Side Effect of Atropine A. Rebound tachycardia B. 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

27. Side Effects of Pentothal  hypotension  decreased cardiac index  shivering  dysrhythmias  bronchospasm; laryngospasm severe cardiovascular depression when toxic

28. 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

29. Side Effects of Fentanyl Many ones but almost “Not” related to CV system

30. Side Effects of Esmeron 1. Cardiovascular: arrhythmia, abnormal ECG, tachycardia 2. Respiratory: asthma ( bronchospasm, wheezing or ronchi), hiccup

31. Our Drug Committed that Crime  Seems Innocent  No strong evidence support their relationship  How about GA procedures?

32. Endotracheal Intubation  Powerful noxious stimulation  May have deleterious respiratory, neurologic, cardiovascular effects.  Deeper levels of anesthesia are required! Yakaitis R.W. Anesthesiology 47:386 1977 & 50:59 1979 Miller Anesthesia 5 th edition p.1432

33. What CV Effect Intubation Induced?  Not clear!  But may be due to Vagal and Sympathetic stimulation!

34. Central Venous Catherization Complications 1.Pneumothorax 2.Arrhythmias (!!!) 3.Hematoma 4.Many others Miller Anesthesia 5 th edition p.1150

35. Why CVC induced Arrythmias?  Gire wire tips is the killer!  LBBB and ventricular tachycardia were ever reported! Eissa NT Anesthesiology 73:772, 1990 Kasten GW Anesthesiology 62: 185,1985

36. Who made the A-fib?

37. God!!

38. Further investigation and Tx of A-Fib  Newly diagnosed  Not associated with known precipitating factors!  Warrants full investigation! Nathanson and Gajraj. Anesthesia 1998, 53, p665-676

39. Investigations  Full Hx and examination  12 lead ECG  Echocardiography  Serum chemistry screen including thyroid function tests  Exercise ECG  EPS

40. Perioperative Management of A-fib

41. Management Strategies 1.Management of acute-onset atrial fibrillation 2.Maintenance of sinus rhythm 3.Control of ventricular rate 4.Prevention of thromboembolism

42. 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

43. 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

44. 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

45. Maintenance of Sinus Rhythm Prophylactic Tx 50-70% effective Class Ia: quinidine, disopyramide Class Ic: flecainide, propafenone Class III: amiodarone, sotalol SE: Pro-arrhymias

46. 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

47. 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.

48. 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

49. Behind the Story

50. 6/29 Patient Visit  She told me that after 1 st 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!?

51. 1 st v.s. 2 nd Anesthesia Induction 1 st  GA Induction drugs  Intubation (+)  CVP (+)  A-line (+)  GA gas: sevoflurane 2 nd  RA drugs  Intubation (-) [Mask]  CVP (+)  A-line (+)  Light GA gas  Premedication: Amiodarone!

52. Thanks Coming