ARRHYTHMIAS AFTER THORACIC SURGERIES: REVIEW OF PROPHYLAXIS AND MANAGEMENT

Dr. Abhijit S. NairDr. G. Muthuswamy Consultant Anesthesiologist, Citizens Hospital, Serilingampally, Hyderabad, INDIA.

WHY IMPORTANT?

Increased LOS High cost of treatment Morbidity/ mortality Thrombo embolism Specific recommendations do not exist

PRESENTATION

Syncope Dizziness Hypotension Respiratory distress

INCIDENCE

3.8-37%: Non cardiac thoracic surgery 10.3-29.4%: Pneumonectomy

RISK FACTORS Male Elderly Magnitude of lung resection Duration CCF

RISK FACTORS CONT.

COPD Previous AF Pericardial & atrial dissection Bronchoscopy

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

MEDICAL CONDITIONS ASSOCIATED

Hyperthyroidism PE Pneumonia Pericarditis Dyslipidemia

POSSIBLE ETIOLOGIES BASELINE TACHYCARDIA! Hypoxia Hypovolemia Decreased vagal tone

ETIOLOGY CONT

Sepsis Electrolytes Increased afterload Handling Mediastinal dissection

PAIN RELIEF & ARRHYTHMIAS?

VAS > 6 Triggers tachycardia Pain: autonomic imbalance, increased

sympathetic activity Epidural- sympatholysis, less

arrhythmia

NON SIGNIFICANT FACTORS

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

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

DIGITALIS ? NO!

AMIODARONE?

Acute pulmonary toxicity Causes: High FiO2, dose, COPD Post pneumonectomy?

FLECAINIDE??

Contraindicated in: CAD Valvular HD Systolic dysfunction LVH

JUSTIFICATION OF PROPHYLAXIS

Costs involved in hospital stay, treatment

Morbidity/ mortality Can justify using prophylaxis if adverse

effects minimal

POSTOP AF?

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

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

RHYTHM CONTROL

Beta blockers Diltiazem Amiodarone

DURATION OF ANTI- ARRHYTHMICS?

Variable Minimum 1 week At least upto 6 weeks

ANTICOAGULATION AFTER POST OP AF?? > 75 yr age Long standing hypertension LV dysfunction

Class II,

LOE A

Previous stroke/ TIA

NEWER DRUGS??

Dronedarone Budiodarone Celivarone Vernakalant Adenosine A1 receptor antagonists

IVABRADINE

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

CONT

Fluid/ analgesia for tachycardia Electrolyte optimization Rule out SIRS/ sepsis Ivabradine ‘ SOS ’ Amiodarone ( if not contraindicated ) in

AF Cardiology consult in unstable patients