post-operative management of hemodynamically unstable patient
TRANSCRIPT
![Page 1: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/1.jpg)
POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE
PATIENT
![Page 2: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/2.jpg)
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
![Page 3: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/3.jpg)
Presented as a Faculty lecture on 29th December 2014:
![Page 4: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/4.jpg)
Introduction
continuation of intraoperative
Process
new
occurrence in the postoperative period
Hemodynamic instability (HDI) in Postoperative Period
a very common
phenomenon !
![Page 5: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/5.jpg)
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
![Page 6: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/6.jpg)
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.
![Page 7: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/7.jpg)
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
![Page 8: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/8.jpg)
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
![Page 9: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/9.jpg)
Hypertension Management
• treat the cause
• adequate analgesia/sedation
• adequate ventilation/oxygenation
• Labetalol
• Esmolol, metoprolol
• Hydralazine
• Glyceryl trinitrite
• Nifedipine
Hypertension
![Page 10: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/10.jpg)
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
![Page 11: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/11.jpg)
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
![Page 12: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/12.jpg)
• 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
![Page 13: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/13.jpg)
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
![Page 14: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/14.jpg)
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
![Page 15: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/15.jpg)
Distributive - Management
• Vasopressors, atropine/glycopyrrolate, rapid IV fluids, supportive Tt.
• Epinephrine, Steroids and supportive treatment
• Fluid resuscitation, Nor-adrenaline, Phenylephrine, Vasopressin
Hypotension
![Page 16: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/16.jpg)
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
![Page 17: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/17.jpg)
Tachycardia
• Cardiogenic/septic shock
• Pulmonary embolism
• Substance withdrawal
• Hyperthyroidism
• Malignant hyperpyrexia
Management:
• Treat the cause
• B blockers
Tachycardia
![Page 18: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/18.jpg)
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
![Page 19: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/19.jpg)
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
![Page 20: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/20.jpg)
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
![Page 21: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/21.jpg)
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
![Page 22: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/22.jpg)
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
![Page 23: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/23.jpg)
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
![Page 24: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/24.jpg)
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.
![Page 25: POST-OPERATIVE MANAGEMENT OF HEMODYNAMICALLY UNSTABLE PATIENT](https://reader030.vdocuments.site/reader030/viewer/2022032421/55a72b001a28abf8208b459f/html5/thumbnails/25.jpg)
THANK YOU!!