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Table 16.3 Common intraoperative dysrhythmias. Problem Differential diagnosis Remarks COMMON INTRAOPERATIVE PROBLEMS ● 255 Bradycardia b-blockers Probably the most common cause. Hypoxia Occurs with severe hypoxia. Myocardial infarction Likely if the right coronary artery and sinus node are involved in the infarction. Increased vagal tone Surgical stimulus on the gut, bladder, or other organs may increase vagal tone. Atropine and, later, deepening anesthesia may be indicated. May also be seen in athletes. 3rd degree heart block The ECG rhythm strip will provide the diagnosis. Calcium channel blockers Especially caused by diltiazem (used for this purpose in atrial fibrillation and flutter). Reversal of neuromuscular Co-administration of an anticholinergic medication blockade with (atropine or glycopyrrolate) is standard practice, so this cholinesterase inhibitors happens rarely. However, edrophonium may be used such as edrophonium or alone to try to convert SVT or a slow heart rate, during neostigmine testing for myasthenia gravis. Tachycardia Increased pain or surgical stimulus Premature ventricular contractions The most common cause at the start of the surgical procedure. May suggest insufficient anesthesia. Vasopressors or inotropes Ephedrine, epinephrine, norepinephrine, isoproterolol can all cause tachycardia Myocardial infarction The most common dysrhythmia associated with MI. Arrhythmias Atrial fibrillation, Ventricular Tachycardia. Malignant hyperthermia Tachycardia in MH follows an observed increased CO2 production and precedes hyperthermia. Atropine, scopolamine, These are commonly given as antisialogogues or glycopyrrolate (dry secretions), vagolytics (increase heart rate) or administration antiemetics (nausea control). b-adrenergic agonists Bronchodilators, tocolytics, and decongestant medications may cause tachycardia. Hypoxia Always consider hypoxia first. Myocardial ischemia Check a 12-lead when feasible. Metabolic acidosis/ Should always be high in the differential. Consider alkalosis checking a blood gas. Hypokalemia Patients on diuretic therapy, without potassium replacement, may have this. Patients on digoxin who are hypokalemic are at particular risk. Digoxin Commonly used for atrial dysrhythmia therapy. (continued)
256 ● ANESTHESIA STUDENT SURVIVAL GUIDE Table 16.3 (continued) Problem Differential diagnosis Ventricular tachycardia Premature atrial contractions Atrial Fibrillation/ Atrial Flutter Remarks Sympathomimetic drugs Ephedrine or pseudoephedrine (found in cold remedies). Hypomagnesemia Occurs in alcoholism or after prolonged use of diuretics like furosemide. Hypokalemia Especially pronounced with digoxin. Hypothermia Patients who are post cardiopulmonary bypass or post exposure injury may have this. Hypercarbia In postoperative patients with pre-existing PVCs, mild hypercarbia in the PACU may cause increases in rates of PVCs. Hypocarbia If severe enough to cause respiratory alkalosis, PVCs may occur. Myocarditis PVCs are common with viral myocarditis. Toxic overdose of drug Unlikely, but can occur from antidepressants. Same causes as PVCs Ventricular tachycardia may be thought of as three or more PVCs in a row. Hypoxia or ischemia Most likely acute causes in the OR. Hypovolemia Rapid diuresis and its effect on volume sensors in the atria may cause PACs and atrial fibrillation. Hypertension PACs commonly occur with concomitant hypertension. Previous thoracic surgery PACs occur in 25–30% of patients undergoing thoracic (lung, mediastinal, or esophageal) surgery. Mediastinal infection Consider anastomotic leak in recent esophagectomy. Same causes as PACs Approach includes: 1. Treat underlying causes 2. Control the heart rate by slowing the ventricular response 3. Convert back to sinus rhythm if possible Useful drugs include digoxin, diltiazem, metoprolol and amiodarone. Asystole Severe hypoxemia Treat underlying causes. Severe hypovolemia Severe electrolyte abnormality Myocardial infarction May require transcutaneous or transvenous pacing. Severe metabolic acidosis Treat underlying causes. Pneumothorax Pericardial tamponade (continued)
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Anesthesia Student Survival Guide
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Editors Jesse M. Ehrenfeld, MD, MPH
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Foreword As anesthesiologists and H
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Contents Case Studies xvii Section
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ContEntS ● xi 19 Physiology and A
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Contributors Basem Abdelmalak, MD S
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David C. Lai, MD Partner, Allenmore
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CASE STUDIES In order to focus your
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CASE StUDIES ● xix inhalation ane
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CASE StUDIES ● xxi around the job
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CASE StUDIES ● xxiii ● Although
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CASE StUDIES ● xxv ● You plan a
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CASE StUDIES ● xxvii ● What oth
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CASE StUDIES ● xxix Chapter 23 Ca
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CASE StUDIES ● xxxi of her left h
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CASE StUDIES ● xxxiii speechless.
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CASE StUDIES ● xxxv things go ver
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How to Be a “Star” Student, Car
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hOw tO Be A “stAr” student, CAr
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Pre-Op Holding Area Preoperative Ev
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History of Anesthesia and Introduct
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history of AnesthesiA And introduct
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Pharmacology Section II
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30 ● AnesthesiA student survivAl
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The Preoperative Patient Evaluation
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THe PreoPerATIve PATIenT evAluATIon
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Therapy-based indications radiation
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Table 8.5 Formulation an anesthetic
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Anesthesia Equipment and Monitors B
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AnesthesiA eQuiPment And mOnitOrs
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● ● ● AnesthesiA eQuiPment An
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Table 11.3 Data typically obtained
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Anesthetic Techniques: General, Sed
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Anesthetic techniques: GenerAl, sed
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Table 12.2 Stages of general anesth
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Table 12.6 (continued) Anesthetic t
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Anesthetic Techniques: Regional Ant
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Figure 13.2 Surface anatomy for neu
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Table 13.1 Risks of neuraxial anest
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Anesthetic techniques: reGionAl ●
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Chapter 20 Physiology and Anesthesi
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PhysioloGy And AnesthesiA for Gener
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Anesthesia for Urological Surgery P
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AnesthesiA for uroloGicAl surGery
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Physiology and Anesthesia for Pedia
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PhysioloGy And AnesthesiA for PediA
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Table 22.6 Common pediatric emergen
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Physiology and Anesthesia for Elder
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PhysioloGy And AnesthesiA for elder
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Chapter 24 Ambulatory Surgery and O
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AmbulAtOry Surgery ANd Out-Of-Or (O
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Perioperative Acute and Chronic Pai
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PerioPerAtive ACute And ChroniC PAi
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Chapter 27 Postoperative Anesthesia
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POstOPerAtive AnesthesiA CAre unit
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Introduction to Critical Care Bever
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introduction to criticAl cAre ● 4
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SVR = [(MAP - CVP)/CO] ´ 80 introd
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● ● ● ● ● introduction to
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Chapter 29 Professionalism, Safety,
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ProfessionAlism, sAfety, And teAmwo
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Chapter 30 Quality Assurance, Patie
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QuAlity AssurAnce, PAtient And Prov
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Chapter 32 Clinical Simulation in A
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Table 32.1 Matrix of categories of
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CliniCAl simulAtion in AnesthesiA e
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ASA Difficult Airway Algorithm Appe
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518 ● ANESTHESIA STUDENT SURVIVAL
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