Presentation on theme: "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."— Presentation transcript:
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.
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
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
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!
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)
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
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.
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
This event related/associated to Anesthetic procedures?
What We Do? Administrated induction drugs Intubation Invasive monitor including CVP & A-line
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
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, 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
What CV Effect Intubation Induced? Not clear! But may be due to Vagal and Sympathetic stimulation!
Central Venous Catherization Complications 1.Pneumothorax 2.Arrhythmias (!!!) 3.Hematoma 4.Many others Miller Anesthesia 5 th edition p.1150
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
Who made the A-fib?
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
Investigations Full Hx and examination 12 lead ECG Echocardiography Serum chemistry screen including thyroid function tests Exercise ECG EPS
Perioperative Management of A-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 Story
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!?
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!