Arrhythmias after lung surgeries: Review of prophylaxis and management
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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.
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WHY IMPORTANT?
Increased LOS High cost of treatment Morbidity/ mortality Thrombo embolism Specific recommendations do not exist
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PRESENTATION
Syncope Dizziness Hypotension Respiratory distress
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INCIDENCE
3.8-37%: Non cardiac thoracic surgery 10.3-29.4%: Pneumonectomy
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RISK FACTORS Male Elderly Magnitude of lung resection Duration CCF
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RISK FACTORS CONT.
COPD Previous AF Pericardial & atrial dissection Bronchoscopy
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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
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MEDICAL CONDITIONS ASSOCIATED
Hyperthyroidism PE Pneumonia Pericarditis Dyslipidemia
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POSSIBLE ETIOLOGIES BASELINE TACHYCARDIA! Hypoxia Hypovolemia Decreased vagal tone
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ETIOLOGY CONT
Sepsis Electrolytes Increased afterload Handling Mediastinal dissection
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PAIN RELIEF & ARRHYTHMIAS?
VAS > 6 Triggers tachycardia Pain: autonomic imbalance, increased
sympathetic activity Epidural- sympatholysis, less
arrhythmia
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NON SIGNIFICANT FACTORS
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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
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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
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DIGITALIS ? NO!
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AMIODARONE?
Acute pulmonary toxicity Causes: High FiO2, dose, COPD Post pneumonectomy?
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FLECAINIDE??
Contraindicated in: CAD Valvular HD Systolic dysfunction LVH
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JUSTIFICATION OF PROPHYLAXIS
Costs involved in hospital stay, treatment
Morbidity/ mortality Can justify using prophylaxis if adverse
effects minimal
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POSTOP AF?
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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
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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
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RHYTHM CONTROL
Beta blockers Diltiazem Amiodarone
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DURATION OF ANTI- ARRHYTHMICS?
Variable Minimum 1 week At least upto 6 weeks
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ANTICOAGULATION AFTER POST OP AF?? > 75 yr age Long standing hypertension LV dysfunction
Class II,
LOE A
Previous stroke/ TIA
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NEWER DRUGS??
Dronedarone Budiodarone Celivarone Vernakalant Adenosine A1 receptor antagonists
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IVABRADINE
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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
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CONT
Fluid/ analgesia for tachycardia Electrolyte optimization Rule out SIRS/ sepsis Ivabradine ‘ SOS ’ Amiodarone ( if not contraindicated ) in
AF Cardiology consult in unstable patients
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