What is the perioperative medication management of arrhythmia?

Updated: Jan 09, 2018
  • Author: Nafisa K Kuwajerwala, MD; Chief Editor: William A Schwer, MD  more...
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Treat life-threatening arrhythmia in the perioperative period.

Continue digoxin for control of atrial fibrillation and supraventricular tachycardia in the perioperative period. Bioavailabilities differ with oral and parenteral preparations; therefore, carefully administer appropriate dosages.

Because a risk of digitalis toxicity and perioperative arrhythmia exists, some clinicians prefer to withhold the medication 12 hours before surgery.

Patients on quinidine should receive their dose on the night before surgery. Intravenous lidocaine may be used for ventricular arrhythmia, and intravenous propranolol or verapamil can be used for supraventricular arrhythmias. Quinidine is restarted as soon as patient is on oral sips.

Patients on procainamide, similar to those on quinidine, should receive their dose on the night before surgery. To control arrhythmia in the intraoperative period, intravenous procainamide or lidocaine may be used. Poorly tolerated supraventricular arrhythmia may be treated with propranolol and verapamil.

Disopyramide has a negative inotropic effect with adverse anticholinergic effects of urinary retention and constipation; therefore, it is discontinued on the night prior to surgery and substituted with intravenous lidocaine in the perioperative period.

Tocainide is an oral agent similar to lidocaine and may be used for the treatment of ventricular arrhythmia. Administer the night before surgery, and use intravenous lidocaine until the patient resumes oral tocainide.

Discontinue amiodarone, used in life-threatening arrhythmia, on the night before surgery. It has a long half-life (30-60 d); therefore, it can be restarted safely after the patient is on oral feedings. If arrhythmia develops in the perioperative period, the intravenous preparation can be used in conjunction with conventional intravenous drugs (eg, procainamide, lidocaine).

A rare postoperative reaction in patients on amiodarone is acute respiratory distress syndrome, but the exact inciting anesthetic drug or intraoperative event is not understood.

Verapamil (for arrhythmia) is given with a sip of water on the morning of surgery, and an intravenous formulation can be used to cover the perioperative period.

To summarize, those patients on long-term therapy for supraventricular tachycardia should receive their usual medication in the perioperative period. Supplemental rate control can be achieved with calcium channel blockers, beta-blockers, or cautious use of digoxin. Treatment of sustained ventricular arrhythmia with oral medication should occur until the day of surgery, when substitution with intravenous procainamide or lidocaine is used.

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