ARITMIA

PERIOPERATIF

Peter Kabo
ARITMIA PERI-OPERATIF

 Aritmia peri-operatif adalah aritmia yang timbul

berrkaitan dengan suatu tindakan operasi
(44%).
 Pre-operative (21 hr)
 Intra-operative

 Post-operative (36 hr)

RISK FACTORS
 Age > 50 y.o.
 Unstable coronary syndrome
 Prior angina
 Recent-/post-MCI
 Heart failure (EF<35%)
 Previous arrhythmias
 Severe valvular disease
 Cerebrovascular disease
 Diabetes Mellitus
 Hypertension
 Smoker
 Chronic pulmonary disease
 Hematologic disorders:
 Anemia
 Polycythemia
 thrombocytopenia
PENYEBAB ARITMIA
 Stressors
 Reaksi thd anestetik

 Hipo-kalemia

 Hipoksemia

 Metabolic derangement

 Infeksi
Atrial level

RHYTHM ABNORMALITIES
ATRIAL FIBRILLATION / FLUTTER

• Valvular heart disease (+++ mitral valve)

• Manipulation of right atrium (canulation)
• Electrolyte disturbances
• Hypovolemia
• Hyperthyroidism http://www.emedu.org/
 Atrial fibrillation / Flutter

• Valvular heart disease (+++ mitral valve)

• Manipulation of right atrium (canulation)
• Electrolyte disturbances
• Hypovolemia
• Hyperthyroidism http://www.emedu.org/
 Atrial fibrillation / Flutter

• Valvular heart disease (+++ mitral valve)

• Manipulation of right atrium (canulation)
• Electrolyte disturbances
• Hypovolemia
• Hyperthyroidism http://www.emedu.org/
SINUS TACHYCARDIA

• Awake patient ( + Hypertension)

• Hypovolemia
• Hypoxia
• Hyperthyroidism
http://www.emedu.org/
SUPRAVENTRICULAR TACHYCARDIA

• Abnormal rhythm after weaning from CPB

• May be poorly tolerated
• Amiodarone

http://www.emedu.org/
SUPRAVENTRICULAR TACHYCARDIA

• Abnormal rhythm after weaning from CPB

• May be poorly tolerated
• Amiodarone

http://www.emedu.org/
 Supraventricular tachycardia

• Abnormal rhythm after weaning from CPB

• May be poorly tolerated
• Amiodarone, adenosine
http://www.emedu.org/
SUPRAVENTRICULAR TACHYCARDIA

http://www.emedu.org/
SUPRAVENTRICULAR TACHYCARDIA

http://www.emedu.org/
JUNCTIONAL TACHYCARDIA

• Valve surgery (+++)

http://www.emedu.org/
ECTOPIC ATRIAL TACHYCARDIA

• Valve surgery (+++)

http://www.emedu.org/
MULTIFOCAL ATRIAL TACHYCARDIA

• Valve surgery (+++): Mitral, tricuspid

• COPD and advanced Pulmonary hypertension
http://www.emedu.org/
http://www.emedu.org/
Ventricular level

RHYTHM ABNORMALITIES
VENTRICULAR FIBRILLATION

• Mechanical arrest
• Great O2 consumption +++
• Before CPB: critical ischemia (Left main, severe CAD)
• During CPB: poor myocardial protection
• On weaning from CPB: Reperfusion
• After CPB: Myocardial ischemia, electrolyte disturbances
PVC (ESV)

• Bigeminism
PVC (ESV)

• paired
PVC (ESV)

• Polymorphic
PVC (ESV)

• Triplet
PVC (ESV)

• Ischemic
• Ventricle irritation
http://www.emedu.org/
PVC (ESV)

http://www.emedu.org/
VENTRICULAR TACHYCARDIA
VENTRICULAR TACHYCARDIA

• Mechanical arrest or severe hypotension

• Great O2 consumption +++
• Before CPB: critical ischemia (Left main, severe CAD)
• After CPB: Myocardial ischemia, electrolyte disturbances
• electroshock

http://www.emedu.org/
CONDUCTION ABNORMALITIES
SINUS BRADYCARDIA

• Beta-blockers
• Calcium Channel blockers Katrina Kardos, MD
PGY-3
Albany Medical Center
LBBB

• Preoperative: HTA, LVH, CHF, Ischemia

• New LBBB
– MI
Risk of complete
– poor myocardial protection
heart bloc with
– incomplete revascularization
Swan Ganz KT
– Technical problem with graft (Kink, Twist)
– Air embolism
– Lesion to conduction tissues (AVR, MVR) http://www.emedu.org/
CONDUCTION SYSTEM

His Bundle

L Bundle

R Bundle

Katrina Kardos, MD
PGY-3
Albany Medical Center
RBBB

• Preoperative: Normal (10%), RVH

• New RBBB
– poor RV myocardial protection (imperfect retrograde cardioplegia)
– incomplete revascularization to RCA
– Technical problem with graft (Kink, Twist) to RCA
– Air embolism in the RCA ostium (+++ valve surgery)
– Lesion to conduction tissues (tricuspid)
http://www.emedu.org/
1ST DEGREE AV BLOCK

• Beta blockers
• Frequent in elderly
• AV node (valve surgery, MI) http://www.emedu.org/
1ST DEGREE AV BLOCK

• Beta blockers
• Frequent in elderly
• AV node (valve surgery, MI)
http://www.emedu.org/
2ND DEGREE AV BLOCK TYPE 1

– Lesion to conduction tissues (AVR, MVR, TVR)

2ND DEGREE AV BLOCK TYPE 2

– Lesion to conduction tissues (AVR, MVR, TVR)

http://www.emedu.org/
3RD DEGREE AV BLOCK

– Lesion to conduction tissues (AVR, MVR, TVR)

http://www.emedu.org/
JUNCTIONAL ESCAPE RHYTHM

http://www.emedu.org/
ANTI ARRHYTMIC DRUGS
MECHANISM OF ANTI ARRHYTHMIAS DRUG ACTION

Decreased phase 4 slope

• β blocker

Increased threshold
•Na+ channel blocker
•Ca++ channel blocker

Increased max – diastolic potential

•Adenosine
•Acetylcholine

Increased action potential duration

•K+ channel blocker

Ant arrhythmic drugs can cause arrhythmias

Some arrhythmias should not be treated
 CLASSIFICATION OF ANTI ARRHYTHMIA DRUGS

Sodium channel blocker

•Sodium channel (++)
•Diisopyramide, Quinidine, Procainamide
•Blocks K+ Efflux (+)
•Lidocaine, Mexiletine, Tocainide
•Sodium channel (+++)
•Flecainide, Encainide, Propafenone

Anti adrenergic
• β blocker

K+ channel Efflux blockers also Na+ blockers

•Amiodarone
•Sotalol
Ca++ channel blockers
•Verapamil & Diltiazem

Autonomic Effects
•Vagus stimulation
•Digoxin
•Adenosine receptor activation
•Adenosine
Farmakokinetik
O P Dosis Kadar Meta Eks Indikasi Efek samping
puncak b
KINIDIN + + 3 X 200 mg 60 – 90’ H G/H AF, SVT
PROKAINAMID + + 3X (250000 45 – 70’ H G VES, SVT Lupus like
– 500) mg syndrome,
leukopeni
DIISOPIRAMID + - 3X 100 mg 60 – 120’ H G VES, SVT Mulut kering,
konstipasi,
penglihatan kabur
LIDOKAIN - + 1 MG/ KG H VT (pasca hipotensi
bb =1mg/ miokard infark)
jam
PROPAFENON + + 3 x(150 - 60 – 180’ VES
300) mg
Kardiovaskular Hipotensi / Sinkop

•SA block
•QRS – Interval •AV block
•Long QT •Torsades de Poentes
• ↑ ventrikuler rate (efek
anti kolinergik)

Cinchonism

•Demam
•Tinitus
•Penglihatn kabur
•Diplopia
•Sakit kepala
•Delirium
•Prikosis
•Gangguan GIT
AMIODARON
Farmakokinetik indikasi Efek samping
O P T1/2 Dosis VT, AF Pro aritmik,
Hipotensi, gangguan fungsi: hati,
+ + 25 – 60 jam Loading 600 tiroid, paru & mata
s/d 800 mg/
hari
Maintenance
300mg/ hari

Sotalol
Farmakokinetik indikasi Efek samping
O P T1/2 Dosis SVT, VT Gagal jantung
+ - 11 jam 800 s/d 320
mg/hari
BRADICARDY

Sinus Bradicardy
1. Ephedrine
2. Aminophyline
3. Atropine (I.V.)

Heart Block
1. Atropine (I.V.)
2. Temporary Pacemaker
3. Permanent Pacemaker
PERMANENT PACEMAKER