POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE

PATIENT

Professor

Department of Anaesthesiology & Intensive Care

Adesh Institute of Medical Sciences and Research (AIMSR)

Bathinda, Punjab, India

Prof. Minnu M. Panditrao

PreviouslyConsultant

Department of Anesthesiology and Intensive CareRand Memorial Hospital

FreeportCommonwealth of Bahamas

Presented as a Faculty lecture on 29th December 2014:

Introduction

continuation of intraoperative

Process

new

occurrence in the postoperative period

Hemodynamic instability (HDI) in Postoperative Period

a very common

phenomenon !

Introduction

Care of patient with HDI in the early post-op. period

Shifting of patient from OR RR/ HDU/

ICU

Continuation of same level of (Intra-

operative) monitoring and

support

Accompany the patient during

shifting

Introduction

Hypertension Hypotension

Tachycardia Bradycardia

Cardiac Dysrhythmias

HDI in post-op. period can occur in the form of

Post-operative tachycardia and systemic hypertension are more predictive of adverse outcome than hypotension and bradycardia.

Hypertension

More common after G.A.

Occurs within 30 minutes, in up to 35% pts.

common causes are

• Preexisting essential hypertension

• Post-operative pain

• Emergence excitement

• Hypoventilation (Hypercarbia, Hypoxemia)

• Residual effect of sympathomimetic/anticholinergic drugs, ketamine etc.

• Rebound hypertension after withdrawal of hypotensive agents

• Distension of viscera esp. urinary bladder

Hypertension

Other likely causes are

• Hypervolemia

• Intracranial surgeries, raised ICP

• PONV, Shivering

• Elderly age, h/o cigarette smoking, renal disease etc.

• Substance withdrawal

• Hyperthyroidism, malignant hyperpyrexia etc.

Hypertension

Hypertension Management

• treat the cause

• adequate analgesia/sedation

• adequate ventilation/oxygenation

• Labetalol

• Esmolol, metoprolol

• Hydralazine

• Glyceryl trinitrite

• Nifedipine

Hypertension

Hypotension

Common occurrence after trauma/emergency surgeries in critically ill patients &neuraxial blocks

Incidence: post spinal in C.S.- 50-80%

Three types :

• Hypovolemic

• Cardiogenic

• Distributive

Hypotension Hypovolemic

• Inadequate intra op. fluid/blood replacement or ongoing losses

• Sympathetic blockade—residual effect of spinal/epidural, relative hypovolemia

• Management: treat the cause, head down position, oxygen supplementation, rapid boluses (250-500 mls.) of IV fluids (crystalloid/colloids), replace blood

• Vasopressors: Ephedrine, Phenylephrine, Mephentermine, Metaraminol

• Management of ongoing blood loss – surgical, clotting enhancing agents

Hypotension

• Myocardial ischemia, myocardial infarction, CHF

• Cardiomyopathies, valvular heart disease, pericardial disease

• Cardiac dysrhythmias

• Drug induced (β blockers, calcium channel blockers )

• Electrolyte disturbances, acidosis, sepsis

• Cardiac tamponade, pulmonary embolus, tension pneumothorax

Cardiogenic - decreased cardiac outputHypotension

Cardiogenic - Management

• CVP, Surface and Trans E.E., pulmonary artery catheter monitoring

• nitrates, opioids, β blockers and anticoagulants

• supportive treatment, optimizing the preload, diuretics, inotropic and vasodilator therapy

• Correction of electrolyte imbalance and acidosis, antiarrhythmics

• For cardiac tamponade and tension pneumothorax, appropriate surgical intervention

Hypotension

Distributive - decreased afterload

• Iatrogenic sympathectomy due to neuraxial blockade

• Allergic reactions: anaphylactic/anaphylactoid

• Sepsis

• Critically ill patients rely on exaggerated sympathetic tone to maintain systemic blood pressure and heart rate. In these patients even low doses of inhaled anesthetic agents/opioids/sedatives may decrease the sympathetic tone to produce marked hypotension.

Hypotension

Distributive - Management

• Vasopressors, atropine/glycopyrrolate, rapid IV fluids, supportive Tt.

• Epinephrine, Steroids and supportive treatment

• Fluid resuscitation, Nor-adrenaline, Phenylephrine, Vasopressin

Hypotension

Tachycardia

Pulse rate > 100 or an increase of > 20% of baseline P.R.

More common after G. A.

• Pain• Hypovolemia• Anemia

• Pyrexia

• Hypoxia/Hypercarbia

• Sympathomimetic drugs, ketamine

• Anticholinergic drugs

• Hypothermia/shivering

• Presence of endotracheal/other tubes/catheters

Tachycardia

• Cardiogenic/septic shock

• Pulmonary embolism

• Substance withdrawal

• Hyperthyroidism

• Malignant hyperpyrexia

Management:

• Treat the cause

• B blockers

Tachycardia

Bradycardia

Pulse rate < 60 BPM

More common after spinal up to 60%

• Often iatrogenic - β blockers, opioids, anticholinesterases, dexmedetomidine etc.

• Bowel distension, increased ICP/IOP

• High spinal/epidural block

• Cardiac origin

Management

• Moderate degree of bradycardia (PR of 45-50) may be allowed if the blood pressure is in the normal/high range

• Symptomatic bradycardia - anticholinergic agents

• Atropine IV 0.3mg boluses, Up to 3 mg

• Glycopyrrolate IV 0.1 -0.4 mg to get the desired effect

• Inotropes like dopamine/dobutamine

• Aminophylline IV may be given in refractory β blocked patients

• Pacing

• Supportive Tt.

Bradycardia

Cardiac dysrhythmias

May be atrial or ventricular

Hypoxemia/Hypercarbia hyperthermia

Pain/agitation myocardial ischemia/infarction

Hypovolemia/anemia electrolyte abnormalities/acidosis

Volume shifts/fluid overload hypertension

Endogenous/exogenous catecholamines digitalis intoxication

Anticholinesterases/anticholinergics substance withdrawal

Hypothermia pre-operative cardiac dysrhythmias

Atrial dysrhythmias

In up to 10% pts. after non-cardiac major surgeries, higher incidence after cardiac and thoracic surgeries

• Supraventricular tachycardia and Atrial fibrillation are common

Management: Treat the cause, Control of ventricular rate

• Prompt electrical cardioversion

• Adenosine 6 mg IV push, plus another 12 mg IV push if required

• Diltiazam 15-20 mg IV over 2 minutes followed by 5-15 mg/hour SVTs.

• For atrial fibrillation Esmolol (rapid onset and short duration)

• Amiodarone, if β- blockers are contraindicated

Cardiac dysrhythmias

Ventricular dysrhythmias

Pre-mature ventricular contractions (PVCS) and bigemini - commonTrue ventricular tachycardia may indicate cardiac pathology

Management: treat the cause• occasional PVCs without any fall in blood pressure - just observe• Significant numbers/runs of ectopics producing hypotension - IV Lidocaine 50-100

mg bolus, infusion 1-4 mg/minute • Amiodarone 150mg over 10minutes, 1mg/min for 6 hours, 0.5 mg/min for 18 hours• Ventricular tachycardia (rare), can progress to ventricular fibrillation, treat

immediately with IV Lidocaine (blood pressure stable) • If hypotension, DC cardioversion

Cardiac dysrhythmias

HDI

Tachycardia Bradycardia Dysrythmias

Hypotension Hypertension HypotensionHypertension

I/V fluid boluses

+ veResponse

- veResponse

Correct Blood/ fluid loss

CVP monitoring

Peripheral perfusion

CVP/PCWP monitoringTo rule out Cardiac pathology & specific treatment

Analgesia & sedation

Still hypertensive

β Blockersα adr. Agonists VasodilatorsCa++ channel blockersdiuretics

Monitor Urine output

Anti-cholinergics

IV Fluids

Vasoconstrictors

Inotropes

pacing

Sympathetic blockadeCardiac pathology

analgesia

sedation

Diuretics

Ventilation

Control of ICP

atrial Ventricular

SVT AFA fib. PVCs.

V tachV fib.

Cardioversion

Adenosine

Diltiazam

Beta blockers

Amiodarone

Digitalis

Observation

IV Lignocaine

Amiodarone

IV Lignocaine

CardioversionOxygenation/ventilation

CVP/IBP/ABG monitoringNormothermiaIntake/output/ electrolytes

Conclusion

Hemodynamic instability is one of the most frequently encountered complication in the early post-operative period

If diagnosed early and managed promptly and decisively, significant amount of morbidity and mortality can be prevented.

THANK YOU!!