PERIOPERATIVE CARDIAC DYSRRHYTHMIAS

Agya Boakye Prempeh

FORMAT
INTRODUCTION

ANATOMY OF THE CARDIAC CONDUCTION SYSTEM

NORMAL CARDIAC ELECTROPHYSIOLOGY MECHANISM RISK FACTORS MANAGEMENT ANAESTHETIC CONSIDERATION CONCLUSION

INTRODUCTION
DEFINITION Abnormal cardiac rate or rhythm - Asymptomatic/Symptomatic/lethal

INCIDENCE Most frequent perioperative cardiovascular abnormality

- In a multicenter study with 17,201 patients 70.2% of cases had dysrrhythmias during cardiac or noncardiac surgery combined,1.6% were treated >90% of cases had dysrrhythmias during cardiac surgery alone

ANATOMY OF THE CARDIAC CONDUCTION SYSTEM

NORMAL CARDIAC ELECTROPHYSIOLOGY

SINOATRIAL NODE VENTRICULAR MUSCLE
1

MECHANISM OF CARDIAC DYSRRHYTHMIAS

There are two(2) broad groups:

A) Disorders of impulse initiation

B) Disorders of impulse conduction

DISORDERS OF IMPULSE INITIATION

This also grouped into two(2)

1) Alteration of Automaticity

2) Triggered Activity

ALTERATION OF AUTOMATICITY Defn: Alteration of spontaneous phase 4 depolarisation

Origin: SA node / Ectopic Focus(nonpacemaker attributes)

A Maximum diastolic potential (K+ conductance) - Ach eg. Vagal manuevres - Hypoxia/Hypokalaemia

B Slope of phase 4 (Na+ leak) - Catecholamines eg. pain - Ach C Threshold of Action Potential

TRIGGERED ACTIVITY Defn: Action Potential(AP) which initiates membrane potential oscillations(afterdepolarisation) during late phase 2 or Phase 3 or Phase 4. When the membrane potential oscillations reach threshold potential a new AP is formed. aetiology : intracellular calcium overload
( Digitalis toxicity, long QT syndrome)

DISORDERS OF IMPULSE CONDUCTION

This is grouped into two(2)

1) Conduction blocks along normal pathway

2) Abnormal pathway conduction

CONDUCTION BLOCKS ALONG NORMAL PATHWAY

Defn: There is failure of successful conduction of impulse along normal pathway. Aetiology : - Reduction in tissue excitability - Abnormalities of gap junctions btn cells

Site of Block : a) SA node

b) AV node

c) Intraventricular(BBB) doesnt slow heart

ABNORMAL PATHWAY CONDUCTION

Defn: Conduction of an impulse along an abnormal tract Tract maybe anatomical-(WPW) or functional-(SVTA)

3 Conditions to be satisfied

RISK FACTORS FOR DEVELOPING CARDIAC DYSRRHYTHMIAS

This can be grouped into three(3) - Patient related factors

- Anaesthesia related factors

- Surgery related factors

PATIENT RELATED FACTORS

1) CVS abnormality Preexisting cardiac disease eg. MI - Pulmonary/Coronary thrombosis 2) Respiratory abnormality : Tension pneumothorax

3) CNS abnormality : Intracranial diseases esp. SAH may show ECG abnormalities such as Q waves, ST segment changes, QT interval changes, U waves
4) Aging Degenerative changes in atrial anatomy

ANAESTHESIA RELATED FACTORS

Technique GA / CNAB Direct laryngoscopy and tracheal intubation - commonest cause Hypoxia/Hypercarbia/Acidosis Hypothermia/Hyperthermia Hypovolaemia Central venous cannulation Pressure from fingers can stimulate carotid
sinus reflexes during jugular venous cannul.

- Excessive insertion of catheter into right

atrium

SURGERY RELATED FACTORS 1) General surgery Traction on peritoneum (bradyarrhythmias)

2) Dental surgery Profound stimulation of both parasympathetic and sympathetic nervous systems 3) Cardiac surgery Retraction of beating heart - Taking sutures over the right atrium - Damage to conduction pathway by surgical incision - Immediate period following release of aortic cross clamp

MANAGEMENT OF CARDIAC DYSRRHYTHMIAS

Dependent on whether bradydysrrhythmia/tachydysrrhythmia

BRADYDYSRRHYTHMIAS Defn: Heart rate < 60bpm and inadequate for clinical condition Origin SA node (examples) / AV node(examples)

MANAGEMENT OF BRADYDYSRRHYTHMIAS

TACHYDYSRRHYTHMIAS Defn: Heart rate > 100 bpm Classification based on: 1. Appearance of QRS Complexes Narrow(<0.12sec) - Broad(>0.12 sec) 2. Rhythm Regular/ irregular

3. Origin SA node/ atria/ AV node/ Ventricle

MANAGEMENT OF TACHYDYSRRHYTHMIAS

ANAESTHETIC CONSIDERATION
ECG monitoring All patients - Lead 11 and V5 Routine measures intraop Airway patent eg. SAB - Breathing: Adequate ventilation and oxygenation - Cardiac history/pathology reevaluation - Depth of anaesthesia adequate - Electrolytes and ABGs optimum - Temperature Specific therapy depends on type of dysrrhythmia

CONCLUSION
Most perioperative dysrrhythmias are benign without significant haemodynamic consequences. However symptomatic patients whose dysrrhythmias can evolve to lifethreatening ones should be treated with anti-dysrrhythmic drugs or electrotherapy promptly. Finally, anti-dysrrhythmic drugs can also cause dysrrhythmias and often times the anaesthetist in an attempt to treat perioperative dysrrhythmias causes iatrogenesis and as such the knowledge of the physiology of cardiac rhythm, pathogenesis of dysrrhythmias, anaesthetic pharmacology and risk to benefit of anti-dysrrhythmic drugs are mandatory.

ACKNOWLEDGEMENT

Dr Baddoo Dr Djagbletey

THANK YOU