Intra-Op arrhythmia

[dhb]

I'd like to know what kind of arrhythmia you guys have encountered? and how did you treat them? Do you try to convert to SR if the patient is hemodynamicaly stable?

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[TabesDorsalis]

I'd like to know what kind of arrhythmia you guys have encountered? and how did you treat them? Do you try to convert to SR if the patient is hemodynamicaly stable?

If otherwise stable, I would simply examine the pt, look at the perameters on my machine/ gas. If the arrhythmia is a few PVCs here and there with no ST changes, I won't do much except give a little mag, more Fentanyl, and increase the [O2]. I know you want to be agressive, but be cautious - it's easy to push IV meds, but not easy to take them back once they are pushed.

 

[Carm]

Was doing a pretty straight forward gyn case yesterday in an 83 yo female with some heart disease. Lost my P waves and heart rate went from 40's to 30's to 20's.

Dropped a TAP's probe in and paced her for about 10-15 minutes. Turned pacer off and she was back in sinus.

It's great being a CA-1 when almost every intervention is a new trick. First time to get to use TAP probe.

BTW - Post made it seem real off the cuff. However, I probably could have shared some of my heart rate with the patient.

 

[Carm]

It was about 20-30 minutes into the case. If my memory serves me correct, she only had 50mcg of Fentanyl right before induction. She was doing fine for a while. I can remember clearly her being in sinus rhythm early in the case. I was getting her tucked in and starting in on some paper work when I could hear the HR start to slow. Then alarms started to go off. Then my own heart started to go off.

I actually started to reach for a vial of atropine, but then took a second look at the EKG. I noticed that she dropped her P waves and was in a junctional rhythm. We have esophageal pacers (also have temp probes in them) in our carts. I had not used them before, but decided this might be the time.

Our more seasoned colleagues may shed more light on the subject. Atropine may have worked just fine, but she was experiencing a pretty significant drop in HR out of the blue. I have treated low 40's or high 30's with atropine in teh past, but this was moving into the low 30's upper 20's. I was afraid asystole was in short order.

I had to play some with the TAP box. The tricky part was getting the probe in the right position.

Trick worked on this day. After a short time pacing, she was back in NSR with a rate in high 50's.

More fun than I was looking for in my easy Gyn case day.

 

[2ndyear]

I had a junctional rhythm during a crani. Rate dropped pretty quickly to the 33-39 range. No p waves, but I didn't notice that at first. I had a triple lumen in and the CVP waveform on the screen. Instead of my nice a c v waves, I had one big old jump after the qrs on the EKG. Gave 0.2 of glyco, nothing, repeated it about 4 times, nothing. Atropine, up to 0.4 mg and still nothing. Ephedrine 20 mg, nothing. Called my attending. I sent out some stat labs and the Mag was low. Gave some mag, some calcium and the rhythm went back to sinus. Don't know if it was coincidental or not, but it didn't come back.

 

[Laryngospasm]

I had a junctional rhythm during a crani. Rate dropped pretty quickly to the 33-39 range. No p waves, but I didn't notice that at first. I had a triple lumen in and the CVP waveform on the screen. Instead of my nice a c v waves, I had one big old jump after the qrs on the EKG. Gave 0.2 of glyco, nothing, repeated it about 4 times, nothing. Atropine, up to 0.4 mg and still nothing. Ephedrine 20 mg, nothing. Called my attending. I sent out some stat labs and the Mag was low. Gave some mag, some calcium and the rhythm went back to sinus. Don't know if it was coincidental or not, but it didn't come back.

You were probably right on, electrolytes are a common cause of arrythmias.

 

[seattledoc]

I had over a screen-full of asystole in an 8 year old crani. The surgeon was washing out the debris from her cerebral ventricle at the end of the case and used very cold NS. I don't think this reflex has a name (does it?) but everybody in the room was speaking an octave higher for awhile
The rhythm improved to a sinus rhythm in the 20's, then some atropine improved it some more.

 

[TabesDorsalis]

I had over a screen-full of asystole in an 8 year old crani. The surgeon was washing out the debris from her cerebral ventricle at the end of the case and used very cold NS. I don't think this reflex has a name (does it?) but everybody in the room was speaking an octave higher for awhile
The rhythm improved to a sinus rhythm in the 20's, then some atropine improved it some more.

Yeah, I think its called an "open-crani diver's reflex"

 

[dhb]

All interesting post keep the cases coming

 

[Gern Blansten]

TAP probes are standard on our carts, but it seems not very many other places. I talk with people about it and get a lot of blank stares. They are very useful, but can be very frustrating when the probe is difficult to position or when the battery is not functioning even though the indicator says it is.

Has anyone had the joy of attending a code on someone with an ICD and getting zapped unexpectedly as the ICD fires? I hate when that happens.

 

[Carm]

TAP probes are standard on our carts, but it seems not very many other places. I talk with people about it and get a lot of blank stares. They are very useful, but can be very frustrating when the probe is difficult to position or when the battery is not functioning even though the indicator says it is.

Has anyone had the joy of attending a code on someone with an ICD and getting zapped unexpectedly as the ICD fires? I hate when that happens.

good point about the TAP and positioning. Since it was my first time using it I assumed that it was mainly that I was a dumb butt, but the hardest part was getting it in a position to 'capture'. After that it was just a matter of dialing in my rate.

 

[Anesthesia1979]

have had a few gyn surgery pts go jxn rhythm... first take a quick look to see what they're doing... belly insuflated? retraction on uterus? all things that can lead to jxn rhythm or heart block.. less pressure on the ole' uterus usually helps... deflating abdomen...

Haven't grabbed for atropine as much as glyco unless in peds cases... glyco usually does the trick...

Also it's amazing to see how quickly bigeminy, trigeminy, or frequent PVC's can resolve with a wiff of lidocaine

or how quickly peaked T's go down after 1/2 gram of ca2+

 

[VentdependenT]

A-fib during thoracic cases: Rate control (dilt fan, but you can give some esmolol first and see what she does), r/o MI as ischemia should be high on da list.

SVT: Adenosine/esmolol. Beware its not ventricular or youz could be in trouble with adenosine.

S-tach (150's-160's): Esmolol. Check for hypoxia/hypercarbia/light anes. Watch those ST seggies if they stay depressed after rate control you best be callen cards, given nitro, morphine, cranken o2.

You'll see plenty of PAC's (no sweat).

PVC's. Watch n' see if they are multiform vs uniform. Singlet, bigeminy, trigeminy (bad). Sometimes a blast o' lidocaine and/or mag will snuff them out. Depending on clinical situation and pt condition your workup/treatment may not end intraoperatively.

if its fast and your crappen yer pants there is always amiodarone. its on every friggen tachycardia algorithm. If its unstable, well its shocky time. Grab the pads and hold on to yer sphincter.

Brady: Glyco .2mg or Atropine 400mcg. Tell surgeon to stop pullen on whatever it is. If you go too low on your glyco or atropine you can get a PARADOXICAL bradycardia.

Thaz all the intraop stuff I've seen. Do yourself a favor and check some lytes if you get an arrythmia. ALways rule out hypercarbia and hypoxia (quick n' easy).

 

[dhb]

SVT: Adenosine/esmolol. Beware its not ventricular or youz could be in trouble with adenosine.

Or you can give flecainamide or propaferone which are good for both atrial and ventricular arhythmias

Brady: Glyco .2mg or Atropine 400mcg. Tell surgeon to stop pullen on whatever it is. If you go too low on your glyco or atropine you can get a PARADOXICAL bradycardia.

That's the central para-sympathic effect you can see when you're crapping yourself and barely pushing the atropine: you're giving 125mcg or less and then from 40/min your rhythm goes to 20

Great post Vent, thx

 

[ReefTiger]

Great thread! I'll add some stuff. First off, I don't know what a TAP is, what it looks like or how to use it. Could someone explain it?

I had a roller coaster last night myself. Firstly, I hadn't run a GA case in 6 weeks so I was itching to do a simple hand washout on an otherwise healthy 43 y/o male s/p trauma from changing a tire.

Pt in room, preoxy, aspiration meds and pt BP was 175/105 with pulse 80-90s.
Stated he hurt, titrate some fent. Surgeons don't need paralysis, so I thought from the look of the hand (open and a disaster) it may be a moderately stimulating washout so my plan was to run him as deep as blood pressure tolerated.

RSI, intubated with 170 propofol, 140 sux, 100 lido, 100mcg fent. (50 prior to induction, 50 at induction). Post tube pressure still 150's/100s. Titrate in another 50 fent and crank up sevo with n2o.

Get the patient to about 1.7 MAC and then junctional rhythm at 50-51 seen. OK, just lighten him up. First pressure I see is 65/35!! @##%%

10 of ephedrine crank back sevo, increase IVF (pt likely dry as hell as he is trauma pt). No change with ephed. Control BP measurement same.

At this point I kept having this thought repeating in the back of my mind from Jensen's Audio Blue- "Most CA-3 residents did not recognize that most cases of intraop MI are preceeded by bradycardia. Most chose to further delay diagnosis and temporize with atropine/glyco rather than aggressively treat with epinephrine".

BUT, I didn't freak and grab the epi, as everything else was OK. I did give glyco, and he converted and just ran fluids in. He did fine.

In the end my theory was that this was a dry patient who was sympathetically driven, I removed his sympathetic maintenance, and had him too deep. I felt like I unnecessarily caused my own problem, but was nevertheless proud of myself for systematically assessing and correctly fixing the problem after 6 weeks off!!

Any comments or other stories/cases?

 

[VentdependenT]

Great thread! I'll add some stuff. First off, I don't know what a TAP is, what it looks like or how to use it. Could someone explain it?

I had a roller coaster last night myself. Firstly, I hadn't run a GA case in 6 weeks so I was itching to do a simple hand washout on an otherwise healthy 43 y/o male s/p trauma from changing a tire.

Pt in room, preoxy, aspiration meds and pt BP was 175/105 with pulse 80-90s.
Stated he hurt, titrate some fent. Surgeons don't need paralysis, so I thought from the look of the hand (open and a disaster) it may be a moderately stimulating washout so my plan was to run him as deep as blood pressure tolerated.

RSI, intubated with 170 propofol, 140 sux, 100 lido, 100mcg fent. (50 prior to induction, 50 at induction). Post tube pressure still 150's/100s. Titrate in another 50 fent and crank up sevo with n2o.

Get the patient to about 1.7 MAC and then junctional rhythm at 50-51 seen. OK, just lighten him up. First pressure I see is 65/35!! @##%%

10 of ephedrine crank back sevo, increase IVF (pt likely dry as hell as he is trauma pt). No change with ephed. Control BP measurement same.

At this point I kept having this thought repeating in the back of my mind from Jensen's Audio Blue- "Most CA-3 residents did not recognize that most cases of intraop MI are preceeded by bradycardia. Most chose to further delay diagnosis and temporize with atropine/glyco rather than aggressively treat with epinephrine".

BUT, I didn't freak and grab the epi, as everything else was OK. I did give glyco, and he converted and just ran fluids in. He did fine.

In the end my theory was that this was a dry patient who was sympathetically driven, I removed his sympathetic maintenance, and had him too deep. I felt like I unnecessarily caused my own problem, but was nevertheless proud of myself for systematically assessing and correctly fixing the problem after 6 weeks off!!

Any comments or other stories/cases?

Sounds like the correction you made according to your eval of the situation was spot on. Junctionals are very common with general anesthesia. Don't worry about pushing the ephedrine. Its a relatively weak drug. You can slam in much more than 10mg to buy you some time until your agent comes down and your fluids go in. You can always throw in a colloid first if you think buster is really dry.

Same goes for neo. Even if you drop their rate to the 30's/40's with it from reflex brady it'll keep your MAP up to perfuse vital organs until things get sorted out. You can push 500mcg of that stuff easy, buy yourself some time, and not worry about catstrophic side effects UNLESS pt is in fulminant CHF. In this case ephedrine/DA/inotrope is the way to flow.


EPI is a DANGEROUS drug. Folks panic and push a full stick (1 mg) of that stuff and guess what? They cause an MI. Sure instances call for an EPI drip/full stick but hopefully the etiology is obvious: sick ass dude lost ton of blood, a rythmn combined with clinical condition which calls for it (bradycardia doesn't count man, atropine first), last ditch pressor.

Just to add in somethin bout pressors: Levo and Dopamine are first line pressors for septic shock and they work wonders. In addition looks like vasopressin is en vogue for vasodilatory shock as well. Not a bad drug to run on its own as well.

We mix up epi so that its 10mcg's per ml and give that mainly during liver, cardiac, and thoracic cases when need be. Its some powerful stuff, short acting (allows you to make interventions while it covers your butt), and gets the job done.

Apologies for the tangent.

 

[Anesthesia1979]

A few tid-bits.. Epi is a dangerous drug, but then again so are all the drugs we use (propofol, fentanyl, glyco, neo, etc)... they are less dangerous in the hands of those with experience... I could go off on a tangent about other specialties and how they think they should have equal access, but that would be for another thread...

I like to make epi drips at 8/ml; neo at 40 per ml if I am having a patient with an art line and terribly controlled HTN... makes the swings in BP more bearable and easier to manage...

Before turning to pressors though, remember to make sure the patient is adeqautely volume resucitated... amazing how much more I turn to pressors later in the day when the patient has been sitting with an IV attached to them for hours, but not getting their maintance fluids back...

Also one thing I've learned is to tx sx (low BP) but think about the underlying cause... one thing that some of my medicine friends may have a point in when saying that some of my colleagues are a bit lazy in saying low BP, low HR= ephedrine... low BP, high HR= phenylephrine... low HR= atropine, etc.

scary little case yesterday and wish I could show the rhytm strip that I somehow remembered to record... pt with h/o breast CA and partial mastectomy getting a breast reduction so the milk suppliers match... Maps around 60... sitting upright, leads placed posterior... about 3 hours into the case (teaching hospital)surgeons step back to access the equalness in size.. pt goes into "v tach".... I first ask what they're doing, they say nothing and look at the tele and they too go "oh poop"... I tell nurse get my attending in here now, but I realize I'm wearing his pager ( I had gotten back from break 2 mintues earlier)... so I say call overhead for help.... put her in t berg... back to sinus.... never dropped her pressures... when looking at the tele strip.... had a sharp point that looked like QRS that marched out... we thinks she had artifact but as to why???? maybe a loose lead. She did have some PVC's leading up to it and I was drawing up Lido when this happened... No change in EKG after case when compared to before case.

 

[Anesthesia1979]

Not to disagree with Vent too much, but while I agree that Levafed is the first that I turn to in septic shock, it isn't a written rule...

in fact with early goal directed therapy paper, you are allowed to use pressor of choice after volume, transfusion with goals of mixed venous SVO2>70, maps>60 or whatever... but then you are supposed to go to dobutamine...


That being said, I also really like vasopressin

I find it a bit strange that at the program I'm at, I've seen some say it's ok to run vasopressin at .20 while at another hospital in the same program it's almost impossible to run it any greater than .04... and Levafed maxes out at 20 or up to 30 depending on the hospital.... any thoughts about max doses, how they came up with those limits??

 

[medstudent99]

from my very limited experience as a prelim surgery intern pestering the anesthesia attending before the case started i noticed a rhythm with a few PAC's but wasn't sure why the patient was having them and the anesthesiologist didn't seem concerned.

 

[Idiopathic]

in fact with early goal directed therapy paper, you are allowed to use pressor of choice after volume, transfusion with goals of mixed venous SVO2>70, maps>60 or whatever... but then you are supposed to go to dobutamine...

Is this right or did you mean to say dopamine?

 

[Laurel123]

Is this right or did you mean to say dopamine?

No, in the paper about early goal directed therapy with shock, they the protocol recommends dobutamine.

 

[Idiopathic]

Okay, right. Now I remember that paper (just re-read it for clarification).