Cardivascular in Pacu

Authors:David Broussard, MDKelly Ural, MDSection Editors:Natalie F Holt, MD, MPHJonathan B Mark, MDDeputy Editor:Nancy A Nussmeier, MD, FAHA Contributor Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Nov 2017. | This topic last updated: Nov 20, 2017. INTRODUCTION — Cardiovascular problems in the post-anesthesia care unit (PACU) include hemodynamic instability due to hypotension, hypertension, or arrhythmias, and complications such as myocardial ischemia or decompensated heart failure. Cardiovascular issues are the third most common problem requiring treatment in the immediate postoperative period, after nausea and vomiting or respiratory problems [1-3]. The likelihood of cardiovascular problems is related to: ● Severity of preexisting cardiovascular comorbidities (eg, coronary artery disease, chronic hypertension, congestive heart failure [CHF]) ● Invasiveness of the surgical procedure (eg, major vascular, thoracic, abdominal, spine surgery) ● Severity of perioperative stresses (eg, blood loss, fluid shifts, sepsis, pain, hypothermia) ● Effects of anesthetic agents and techniques In this topic, we review the rapid diagnosis and treatment of cardiovascular problems in the PACU after noncardiac surgery (eg, hypotension, hypertension, cardiac arrhythmias, myocardial ischemia, and decompensated heart failure). Postoperative complications after cardiac surgery are discussed separately. (See "Postoperative complications among patients undergoing cardiac surgery" and "Atrial fibrillation and flutter after cardiac surgery".) HYPOTENSION Initial assessment and treatment — Hypotension may be absolute (eg, systolic blood pressure [BP] <90 mmHg or mean BP <65 mmHg) or relative (eg, systolic BP decrease >20 percent of baseline). These values serve as a guide for treatment, although there is no widely accepted definition of perioperative hypotension [4]. Hypotension in the post- anesthesia care unit (PACU) is typically treated when the BP is reduced to these values described, or if there is evidence of hypoperfusion (eg, change in mental status or decreased urine output). Before treating hypotension, the accuracy of BP measurements should be assessed. Measurements using a noninvasive BP monitor may be inaccurate due to inappropriate cuff size, patient movement, or shivering. Measurements obtained from an intra-arterial catheter may be inaccurate due to technical reasons such as incorrect zeroing or leveling of the pressure transducer, or physiologic reasons such as peripheral arterial stenosis. Initial treatment includes intravenous (IV) isotonic crystalloid solution administered in 250- to 500-mL increments. If necessary, IV vasopressor/ inotropic agents (eg, phenylephrine 40- to 100-mcg increments or ephedrine 5- to 10-mg increments) are administered to increase BP. For severe or refractory hypotension, small bolus doses of diluted IV epinephrine 10 to 50 mcg, norepinephrine 4 to 16 mcg, or vasopressin 1 to 4 units may be administered, while a vasopressor/inotropic infusion is prepared (table 1). A quick assessment often points to an underlying etiology requiring specific treatment: ● Major surgical procedures pose a risk for hypovolemia due to large fluid shifts or significant bleeding. (See 'Hypovolemia' below.) ● Review of preoperative medications and anesthetic techniques and drugs may suggest that an antihypertensive drug, residual anesthetic, sympathectomy after neuraxial block, adrenal insufficiency, or an allergic drug reaction is causing hypotension. (See 'Drug effects' below and 'Sympathectomy due to neuraxial block' below and 'Drug allergy and anaphylaxis' below.) ● Myocardial dysfunction due to myocardial ischemia or decompensated heart failure (HF) is considered in patients at risk for these complications. (See 'Myocardial dysfunction' below and 'Myocardial ischemia' below and 'Decompensated heart failure' below.) ● Patients with profound hypotension or cardiovascular collapse may have a condition requiring urgent intervention (eg, anaphylaxis, septic shock, local anesthetic toxicity, tension pneumothorax, pulmonary embolus, pericardial tamponade, dynamic left ventricular outflow tract obstruction). (See 'Hypotensive emergencies' below.) Intraoperative administration of longer-acting IV agents (eg. section on 'Causes of intravascular volume derangements'. and may improve clinical outcomes (table 2). specific treatment is often necessary after initial assessment has determined the cause(s) of hypotension. fluid shifts). as well as adequacy of intraoperative fluid replacement. ongoing fluid or blood loss in the postoperative period).) Drug effects Antihypertensive agents — Effects of chronically or recently administered antihypertensive agents may cause hypotension. Inadequate fluid replacement — For patients who have had major surgery or are likely to be dehydrated. (See "Intraoperative fluid management".to 500-mL boluses and reassess volume status and BP after each bolus. Blood loss — For patients who had major surgery. intraoperative blood loss or fluid shifts. although it is poorly predictive of fluid responsiveness in many patients [5. urine output. It is also necessary to treat . serial measurements may be more useful than a single value. Use of this transfusion threshold is generally safe. section on 'Red blood cells'. central venous pressure (CVP) is measured to assess adequacy of intravascular volume. Also. preoperative fasting resulting in dehydration. For most patients. If available. or labetalol) may result in postoperative hypotension once painful surgical stimulation has ceased. metoprolol.Treatment of underlying causes — In addition to the initial treatment noted above. an individual Hgb value may not accurately reflect blood loss during or immediately after an acute bleeding episode. However. For these reasons. perioperative red blood cell (RBC) transfusions are administered only if Hgb is <7 to 8 g/dL.6]. we review estimated intraoperative blood loss versus replacement and measure hemoglobin (Hgb) level. Hypovolemia — A combination of factors may result in hypovolemia (eg. we administer IV isotonic crystalloid in 250. preoperative fluid deficit. diuresis. hydralazine. Treatment is administration of vasopressor/inotropic agents (see 'Initial assessment and treatment' above). reduces unnecessary transfusion.) If there is evidence of inadequate fluid replacement. (See "Intraoperative transfusion of blood products in adults". intraoperative blood loss is commonly underestimated [7] and may continue into the postoperative period due to circumstances that are case-specific (eg. we review the intraoperative records to assess blood loss and other fluid losses (eg. preexisting coagulation disorders). delayed blood loss after knee surgery with intraoperative use of a tourniquet) or patient-specific (eg. 5 to 1 mcg/kg/hour. It is also more likely in patients with preexisting hypertension [10]. (See "Acute opioid intoxication in adults". IV flumazenil may be administered in 0. (See 'Bradycardia' below. particularly in patients who have little pain after surgery. section on 'Management'. any ongoing neuraxial . and/or inhalational anesthetic agents are unlikely to cause postoperative hypotension because these agents are short-acting. section on 'Antidote (flumazenil)'. which may be shorter than the half-life of the opioid being reversed. repeat doses of naloxone may be administered. Intraoperative administration of propofol. Rarely. ● Benzodiazepines – If excessive benzodiazepine dosing is suspected. and myocardial ischemia (see 'Myocardial ischemia' below). IV naloxone 40 mcg may be administered every five minutes until the sedative and respiratory depressant effects are reversed. typically with resolution of hypotension.2-mg increments up to a maximum dose of 3 mg within any one hour. (See "Benzodiazepine poisoning and withdrawal".) Anesthetic agents — Residual effects of anesthetic agents or excessive opioid doses may result in hypotension. Such patients are typically somnolent or obtunded. or a continuous infusion may be started at 0. dexmedetomidine. as well as hypotensive. Flash pulmonary edema has also been reported after a large dose of naloxone [9].) ● Opioids – If excessive opioid dosing is suspected. with resolution of hypotension [8]. sudden reversal of analgesic effects causes extreme discomfort and a sympathetic surge resulting in hypertension. This is more likely when the sensory block is above the T6 level and when local anesthetics are infused through the epidural catheter. which typically hastens emergence from anesthesia. The half-life of naloxone is 1 to 1. Sympathectomy due to neuraxial block — Sympathectomy due to high neuraxial anesthetic block may result in hypotension. In these instances. If hypotension does not resolve after initial therapy with IV fluid boluses and vasopressor/inotropic agents (see above). tachycardia.5 hours.) Titration of such low doses of naloxone safely reverses opioid effects in most patients.bradycardia (due to the negative chronotropic effects of an antihypertensive drug) if this is contributing to hypotension. section on 'Adrenal crisis'. oral or facial edema.) Adrenal insufficiency — Acute adrenal insufficiency may occur in a patient who was receiving chronic glucocorticoid therapy but did not receive adequate perioperative replacement therapy. as appropriate (see 'Drug allergy and anaphylaxis' above).) Transfusion reaction — Typical signs and symptoms of acute transfusion reaction are fever. Also. particularly if hypotension is refractory to standard treatment with fluids and vasopressors. IV hydrocortisone 100 mg or dexamethasone 4 mg is administered. Standard treatment is initiated for a mild allergic reaction or for a more severe anaphylactic reaction. Allergic (hypersensitivity) reaction Drug allergy and anaphylaxis — Postoperative hypotension may occur due to exposure to latex or a medication administered during or after surgery. (See "Treatment of adrenal insufficiency in adults". The blood bank should be notified to determine the cause of the reaction. Perioperative medications commonly causing allergic reactions include antibiotics and protamine [11. and management". (See "Approach to the patient with a suspected acute transfusion reaction". bronchospasm.) Treatment for anaphylaxis is initiated immediately if the rash is accompanied by any evidence of hypotension. the transfusion is stopped and IV fluids and vasopressor/inotropic agents are administered. While uncommon. (See "Perioperative anaphylaxis: Clinical manifestations. and urticaria. or the infusion is changed to contain only an opiate.infusion of local anesthetic is decreased or temporarily discontinued. or inspiratory stridor. but these minor symptoms may not be noticed by a patient with residual postoperative sedation. etiology. section on 'Etiologies' and "Perioperative anaphylaxis: Clinical manifestations. (See "Anaphylaxis: Emergency treatment". Management of perioperative anaphylaxis is discussed in detail separately. it should be removed. section on 'Clinical manifestations and diagnosis'. etiology. If a hemolytic or anaphylactic transfusion reaction is suspected as the cause of hypotension during a transfusion. In such cases. and management". in addition to standard treatment with IV fluids and vasopressor/inotropic agents. If the epidural catheter is malpositioned.) Myocardial dysfunction — Acute myocardial ischemia or perioperative decompensation of preexisting HF may result in myocardial dysfunction . Allergic reactions typically present as itching and as a rash or hives. chills. the location of the epidural catheter is confirmed with aspiration to ensure that the tip has not migrated to enter a blood vessel or the intrathecal space. adrenal insufficiency is suspected in a patient on chronic therapy.12]. pruritus. ventricular arrhythmias). Central nervous system symptoms (eg. worsening oxygenation. ● Septic shock – Sepsis may be preexisting before surgery. seizures) commonly precede signs of cardiovascular toxicity. dyspnea. chest . IV fluids and vasopressor infusion(s) (eg. Support with vasopressor/inotropic agents is provided (table 1) while definitive treatment is underway (see 'Initial assessment and treatment' above). Sepsis should be suspected in susceptible patients with tachycardia and profound hypotension due to vasodilation (with high cardiac output if intravascular volume is adequate).) Hypotensive emergencies — Conditions that cause profound hypotension and/or hemodynamic collapse require immediate lifesaving interventions. section on 'Local anesthetic systemic toxicity'. The cardinal features of these conditions are summarized below to provide assistance in identifying a likely diagnosis. atrioventricular block. This may occur in the postoperative period due to intravascular location of a misplaced epidural or peripheral nerve catheter or. or may develop during or after surgery in patients with active infection. tingling of the lips.) ● Tension pneumothorax – Tension pneumothorax is suspected in patients with hypotension. norepinephrine.) ● Local anesthetic toxicity – Local anesthetic toxicity causes profound hypotension and arrhythmias (eg. Treatment is discussed separately. metallic taste. due to accidental IV administration of a local anesthetic infusion intended for epidural or perineural administration. Also. (See 'Myocardial ischemia' below and 'Decompensated heart failure' below. bradycardia. tachypnea. the surgeon and/or an infectious disease specialist are consulted to ensure that antibiotic coverage is appropriate and appropriate cultures are sent for testing. phenylephrine. rarely. and/or vasopressin (table 1)) are administered in the PACU to stabilize the patient. ringing in the ears. since early administration of antibiotics is critical for management of patients with severe sepsis and septic shock.severe enough to cause hypotension. agitation. Appropriate specialists are consulted to continue management and/or intensive care after the patient is stabilized and discharged from the PACU. (See "Evaluation and management of suspected sepsis and septic shock in adults". (See "Overview of peripheral nerve blocks". and known risk factors (eg. (See "Hypertrophic cardiomyopathy: Medical therapy".) HYPERTENSION Initial assessment and treatment — Hypertension occurring in the post- anesthesia care unit (PACU) is typically treated if systolic blood pressure (BP) is >180 mmHg or diastolic BP is >110 mmHg. trauma. recent thoracic or pericardial procedure. Urgent echocardiography is used to confirm the diagnosis and guide immediate treatment.) ● Pulmonary embolus – Pulmonary embolus (PE) is suspected in hypotensive patients with acute onset of shortness of breath. pain. particularly if hypertension is persistent after treatment of presumed etiologies. tachycardia. and follow-up of acute pulmonary embolism in adults". (See "Evaluation of and initial approach to the adult patient with undifferentiated hypotension and shock". prognosis. tachycardia. and/or a high catecholamine state in susceptible patients. hypotension. and hypoxia. Treatment of tension pneumothorax is emergent needle decompression. (See "Perioperative management of hypertension". pulsus paradoxus. tachycardia. Specific management of LVOT obstruction is described separately. section on 'Indications for and approach to therapy'. or chronic lung disease. section on 'Acute hemodynamic collapse in the setting of LVOT obstruction'. Specific details for management of patients with hemodynamically unstable PE are discussed elsewhere (algorithm 1). usually those with hypertrophic cardiomyopathy.) . distended neck veins. section on 'Tension pneumothorax'. (See "Treatment. section on 'Hemodynamically unstable'. prior pericardial effusion). surgery in the neck or thorax. tracheal deviation. elevated jugular venous pressure. (See "Cardiac tamponade". vasodilation. Rapid diagnosis is possible with echocardiography.) ● Dynamic left ventricular outflow tract obstruction – Dynamic left ventricular outflow tract (LVOT) obstruction associated with hypotension and mitral regurgitation can be precipitated by hypovolemia. or risk factors that include attempted or actual central line insertion.) ● Cardiac tamponade – Cardiac tamponade is suspected in patients with dyspnea. distant heart sounds. a cardiovascular emergency (eg. (See "Anesthesia for the adult with pheochromocytoma". seizures.) Treatment of underlying causes — In addition to the initial treatment noted above. hematuria. agitation. arrhythmias. stroke).Before treating hypertension. aortic dissection).16]. or renal injury (eg.) If patients are due for a dose of their usual antihypertensive medication(s). a pheochromocytoma may cause severe hypertension. or nicardipine 0. oral doses of those medications may be administered as initial treatment. section on . then small doses of rapid-acting intravenous (IV) antihypertensive agents are administered. labetalol 5 to 20 mg. acute decompensated heart failure [HF]. If response is inadequate or if oral administration of medications is not feasible. as well as the home medication list and timing of last doses of antihypertensive medications. Risks are particularly high when pheochromocytoma is previously undiagnosed. hydralazine 5 to 10 mg. Typically. specific treatment is often necessary after initial assessment has determined the cause(s) of hypertension. we review the patient's preoperative and baseline BP. Treatment thresholds for patients who had severe preoperative hypertension (ie. Additional treatment of hypertension depends upon the specific etiology. (See "Evaluation and treatment of hypertensive emergencies in adults". typically associated with tachycardia. metoprolol 1 to 5 mg. mortality in this setting approaches 80 percent [17]. and/or cardiovascular collapse [15. ≥180/≥120 mmHg) may vary. these agents are preferred if hypertension is associated with tachycardia [13. rising creatinine). withdrawal syndromes with rebound hypertension can occur with medications such as clonidine and beta blockers. acute coronary syndrome. particularly if the patient's chronically administered antihypertensive medications were not continued up until the time of surgery [18-22]. visual disturbances.14]. Since metoprolol and labetalol have beta-blocking properties.) Rarely. Preexisting hypertension — Undiagnosed or poorly controlled preexisting hypertension is the most common cause of perioperative hypertension.) The IV drugs used for emergency treatment of severe hypertension are discussed in detail elsewhere (table 3).2-mg increments are titrated to decrease systolic BP to a consistent value <160 mmHg. (See 'Treatment of underlying causes' below. In particular.) Hypertensive emergencies — Emergency treatment of severe hypertension is warranted if there is evidence of acute neurologic signs or symptoms (eg. stupor. delirium. (See "Perioperative management of hypertension". (See "Management of severe asymptomatic hypertension (hypertensive urgencies) in adults". (See "Drugs used for the treatment of hypertensive emergencies". and are discussed separately. 'Withdrawal syndromes' and "Perioperative management of hypertension". (See "Overview of post-anesthetic care for adult patients". (See "Delayed emergence and emergence delirium in adults".29].24].) ● Hypothermia with shivering – Hypothermia results in patient discomfort and sympathetic stimulation with hypertension and/or tachycardia.) Noxious stimuli ● Pain – Inadequately treated pain is a common cause of sympathetic stimulation resulting in hypertension and tachycardia in the PACU. In patients with ischemic heart disease. and the associated sympathetic stimulation may cause hypertension and/or tachycardia [1]. Treatment is discussed separately. section on 'Emergence delirium'.) ● Delirium and agitation – Emergence delirium with agitation. details are available elsewhere.) ● Hypoxia and/or hypercarbia – Respiratory problems causing hypoxia and/or hypercarbia are the second most common complication occurring in the PACU and may be accompanied by hypertension and/or tachycardia due to sympathetic stimulation [1]. (See "Management of acute perioperative pain". Details regarding causes and management of respiratory problems in this setting are available elsewhere. Therapy is directed at treating this primary problem. particularly after major invasive surgical procedures. or confusion occurs in up to 5 percent of adult patients after general anesthesia and may be accompanied by hypertension and/or tachycardia [23. section on 'Postoperative nausea and vomiting' and "Postoperative nausea and vomiting". section on 'Choice of drugs'. Details regarding management of acute postoperative pain are discussed separately. these may lead to myocardial ischemia and arrhythmias [28. Concurrent . as well as markedly increased myocardial O2 consumption due to shivering [25-27]. (See "Respiratory problems in the post-anesthesia care unit (PACU)".) ● Nausea and vomiting – Postoperative nausea and vomiting (PONV) is the most common complication occurring in the PACU. hyperexcitation. Management of alcohol withdrawal is discussed separately. Benzodiazepines (eg. section on 'Vasodilator therapy'. section on 'Inability to void'. ● Alcohol withdrawal – Symptoms of alcohol withdrawal (eg. IV lorazepam) are administered to treat withdrawal symptoms. Patients with >600 mL of urine noted on bladder ultrasound are treated with one-time catheterization. Vasodilator therapy (eg. (See 'Initial assessment and treatment' above. particularly in patients with recent anorectal surgery. section on 'Hypothermia or hyperthermia'). sweating.31]. priorities include treatment of hypothermia itself and treatment of shivering (see "Overview of post-anesthetic care for adult patients". opioids. excess intraoperative fluid administration. Initial therapy is administration of an IV diuretic. neuraxial block. tremulousness. Severe hypertension may develop in patients who have recently used any drug that causes a hyperadrenergic response (eg.) ● Bladder distention – A distended bladder is a common and often overlooked cause of sympathetic stimulation and hypertension in the PACU. or a monoamine oxidase inhibitor). anxiety) may manifest as early as 6 to 24 hours after the last drink and can progress to delirium tremens with worsening hypertension in 48 to 96 hours. section on 'Diuretics' and "Treatment of acute decompensated heart failure: Components of therapy". hypertension.) Use of alcohol. amphetamine. and other drugs — Patients chronically using alcohol or opioids may develop hypertension and/or tachycardia in the PACU due to sympathetic stimulation associated with withdrawal. IV nitroglycerin or nitroprusside infusions) (table 3) may be necessary to lower BP if hypervolemic hypertension is severe or associated with acute decompensated HF. (See "Overview of post-anesthetic care for adult patients". typically furosemide 20 to 40 mg.) Hypervolemia — Volume overload due to intraoperative fluid or blood administration may result in postoperative hypertension. cocaine. (See "Management of moderate and severe alcohol withdrawal syndromes". or a history of urinary retention [30. in addition to treatment of hypertension. nausea. (See "Treatment of acute decompensated heart failure: Components of therapy". Severe or persistent hypertension is addressed after initial treatment of hypothermia and shivering.) . phencyclidine. tachycardia. nausea. section on 'Treatment of complications'. or phencyclidine use – Recent use of drugs that produce a hyperadrenergic state (eg.) ● Recent cocaine. (See "Opioid withdrawal in the emergency setting" and "Management of acute perioperative pain". piloerection. However. hypertension.) • (See "Phencyclidine (PCP) intoxication in adults". anemia. hypoxemia. and cardiac arrhythmias.) Further details regarding management of cardiovascular complications of these drugs may be found elsewhere: • (See "Cocaine: Acute intoxication". hypokalemia should be identified and . amphetamine. (See 'Hypertensive emergencies' above. and a 12-lead ECG is obtained as soon as feasible in a patient with a new arrhythmia. amphetamine. administration of a sympathomimetic agent may precipitate severe hypertension or a cardiovascular or neurologic emergency requiring immediate treatment. mydriasis.) CARDIAC ARRHYTHMIAS — Most arrhythmias noted in the post- anesthesia care unit (PACU) are transient and clinically insignificant. tachycardia. section on 'Opioid-dependent patients'. section on 'Hypertension'. hypoventilation. dysphoria) typically begin 6 to 12 hours after the last opioid dose. or a monoamine oxidase inhibitor) can cause sympathetic overactivity and hypertension. section on 'Cardiovascular complications'. (See 'Myocardial ischemia' below.) Proper lead placement for the electrocardiogram (ECG) should be confirmed. acidemia. cocaine.) • (See "Acute amphetamine and synthetic cathinone ("bath salt") intoxication". In particular. tachycardia. phencyclidine.● Opioid withdrawal – Symptoms of opioid withdrawal (eg. Management of opioid withdrawal is discussed separately. In these patients. Contributing causes should be identified and treated (eg. electrolyte abnormalities). the appearance of a new arrhythmia may indicate myocardial ischemia in a patient with preexisting cardiovascular disease [21]. 2-mg increments up to 1 mg and/or ephedrine in 5 to 10 mg increments.) Severe bradycardia (HR <40 bpm) in a patient who is stable or has less severe symptoms may be initially treated with IV glycopyrrolate in 0. section on 'Management of specific arrhythmias'.corrected immediately. calcium channel blockers. (See "Clinical manifestations and treatment of hypokalemia in adults". section on 'Intravenous potassium repletion'.) Bradycardia Initial treatment — Severe bradycardia (heart rate [HR] <40 beats/minute [bpm]) in an unstable patient (eg. Further management of bradycardia is discussed separately. baseline (admission) HR is noted. HR 40 to 60 bpm) that remains stable in an asymptomatic patient does not require treatment. since atropine may cause undesirable tachycardia (eg. (See "Sinus bradycardia".5 mg.) A severe bradyarrhythmia or tachyarrhythmia may cause hemodynamic instability or cardiac arrest.) Assessment and treatment of underlying causes — For bradycardia occurring in the PACU. hypotension. In patients with ischemic heart disease. (See "Advanced cardiac life support (ACLS) in adults". (See "Anesthesia for noncardiac surgery in patients with ischemic heart disease". in elderly patients). Management of arrhythmias in unstable patients is summarized below and discussed in detail separately [32]. Mild sinus bradycardia (ie. in patients with ischemic heart disease) or altered mental status (eg.) • . For these patients. we review the following potential causes and institute appropriate specific therapy: ● Medications • Negative chronotropic agents – A beta blocker or other negative chronotropic agent (eg. section on 'Bradycardia'. digoxin. amiodarone) is the most common cause of postoperative bradycardia. altered mental status) is initially treated with intravenous (IV) atropine 0. these drugs are administered (chronically or recently) to maintain HR in the range of 50 to 80 bpm. section on 'Prevention of ischemia'. this dose is repeated every three to five minutes up to a total of 3 mg (algorithm 2). and bradycardia is treated only if it is severe (HR <40 bpm) or if symptoms develop. (See "Advanced cardiac life support (ACLS) in adults". ) • Bowel or bladder distention after abdominal surgery – Visceral distention of the bowel or bladder may initiate a vagal reflex. Also. bradycardia caused by blockade of the cardiac accelerator fibers responds best to beta-adrenergic agonists (eg. then followed by an epinephrine infusion if the bradycardia is persistent (table 1)).) • Neuraxial anesthesia – Neuraxial anesthesia with a T1 to T4 anesthetic level may cause bradycardia and hypotension [33-36]. neostigmine or edrophonium) used for reversal of nondepolarizing neuromuscular blocking agents (NMBAs) near the end of surgery.2 mg or atropine 0. (See "Respiratory problems in the post-anesthesia care unit (PACU)". Although atropine may be administered.) • Myocardial ischemia – Sinus bradycardia occurs in 15 to 25 percent of patients having an acute myocardial infarction. ephedrine 5 to 10 mg or. (See "Supraventricular arrhythmias after myocardial infarction". causing bradycardia. . epinephrine 10 to 20 mcg. particularly if ischemia involves the right coronary artery. if severe. the epidural infusion is reduced or temporarily discontinued. (See "Clinical use of neuromuscular blocking agents in anesthesia".4 mg is administered and may be repeated.Anticholinesterase agents – Bradycardia in the PACU may be caused by the muscarinic effects of an acetylcholinesterase inhibitor (eg. titrated to effect. If underdosing of the anticholinergic agent is suspected. glycopyrrolate or atropine). ● Adverse perioperative events • Hypoxia – Hypoxia inactivates pacemaker channels. The anesthesia record is reviewed to determine if the patient received an acetylcholinesterase inhibitor administered with an adequate dose of anticholinergic agent (eg. section on 'Sinus bradycardia' and 'Myocardial ischemia' below. leading to a reduction in the pacemaker rate of the sinoatrial node and consequent bradycardia. an additional dose of IV glycopyrrolate 0. For stable patients with regular. ● Atrial fibrillation – Atrial fibrillation (AF) is a narrow complex irregular arrhythmia (waveform 1 and waveform 2).) ● Regular supraventricular tachycardia – Treatment of regular supraventricular tachycardia (SVT) with either narrow (<120 milliseconds) or wide (≥120 milliseconds) QRS complex depends on hemodynamic stability (algorithm 3). sinus tachycardia is treated with an IV beta blocker (eg. • Anemia – hypotension typically also present (see 'Blood loss' above). section on 'Tachycardia'. pulmonary edema). acute anemia. HR 100 to 120 bpm). ● Sinus tachycardia – Sinus tachycardia with HR >100 bpm is common in the PACU due to: • Pain – hypertension typically also present (see 'Noxious stimuli' above). Treatment of AF depends upon hemodynamic stability (algorithm 3). (See "Advanced cardiac life support (ACLS) in adults". myocardial ischemia. treatment of the underlying causes is adequate. .38]. For most patients with mild sinus tachycardia (ie. Risk factors include preexisting AF or ischemic heart disease. hypotension.Atrial tachyarrhythmias — For atrial tachyarrhythmias causing hemodynamic instability (eg. while specific factors in the PACU include increased sympathetic activity due to operative stress. unless it is certain that the rhythm is sinus tachycardia (algorithm 3). or myocardial irritability caused by procedures performed near the heart (eg. urgent cardioversion is recommended. pulmonary or esophageal surgery) [37. hypoxia. provided that blood pressure (BP) is adequate and there are no contraindications. pain. For patients with known or possible ischemic heart disease or those with HR >120 bpm. • Hypovolemia – hypotension typically also present (see 'Hypovolemia' above). bolus doses of esmolol 10 to 25 mg or metoprolol 1 to 5 mg) to decrease HR to ≤80 bpm. or monomorphic ventricular tachycardia – Ventricular fibrillation.) ● (See "Approach to the management of wide QRS complex tachycardias".39]. they typically resolve without treatment. flutter. adenosine 12 mg rapid IV push is administered.) ● (See "Reentry and the development of cardiac arrhythmias".) ● Polymorphic ventricular tachycardia (torsades de pointes) – Torsades de pointes is an irregular polymorphic ventricular tachycardia associated with a prolonged QT interval (waveform 6).) ● (See "Overview of the acute management of tachyarrhythmias". or monomorphic ventricular tachycardia (waveform 3 and waveform 4 and waveform 5) requires initiation of cardiopulmonary resuscitation (CPR) and immediate defibrillation as the first steps in the advanced cardiac life support (ACLS) guidelines (algorithm 4). vagal maneuvers are attempted. If the patient loses consciousness or the rhythm degenerates into ventricular . section on 'Ventricular fibrillation and pulseless ventricular tachycardia'. section on 'Tachycardia'. section on 'Regular wide complex'. (See "Advanced cardiac life support (ACLS) in adults". (See "Advanced cardiac life support (ACLS) in adults". followed by administration of adenosine 6 mg rapid IV push. ● Ventricular fibrillation. flutter.) Further details regarding management of atrial tachyarrhythmias can be found elsewhere: ● (See "Advanced cardiac life support (ACLS) in adults". section on 'Regular narrow complex' and "Advanced cardiac life support (ACLS) in adults". If cardioversion does not occur. and this 12 mg dose may be repeated once. narrow complex SVT.) Ventricular tachyarrhythmias ● Premature ventricular contractions – Premature ventricular contractions (PVCs) are relatively common in the PACU due to increased sympathetic stimulation. Expert consultation is recommended for all patients with wide complex tachycardia as soon as possible [32. particularly if dual antiplatelet therapy was prematurely discontinued for surgery. Myocardial ischemia — Patients at high risk for perioperative myocardial ischemia or infarction include those having in-hospital surgery with one or more additional risk factors in the revised cardiac risk score (table 4). we recommend obtaining a 12-lead ECG and troponin measurements.) In patients with symptoms or signs suggestive of myocardial ischemia. as well as avoiding hypothermia and fluid overload (table 5). section on 'Irregular wide complex'. (See "Anesthesia for noncardiac surgery in patients with ischemic heart disease".) Optimal myocardial oxygen (O2) supply and minimal O2 demand are achieved by maintaining a low to normal heart rate. (See "Overview of the acute management of tachyarrhythmias". normal to high blood pressure (BP). (See "Advanced cardiac life support (ACLS) in adults". ACLS with CPR is initiated and immediate defibrillation is performed. section on 'Screening'. section on 'Polymorphic ventricular tachycardia'. hypertension.) CARDIOVASCULAR COMPLICATIONS — Myocardial ischemia or decompensated heart failure (HF) may occur in the post-anesthesia care unit (PACU) with or without associated hemodynamic instability (eg. and adequate arterial oxygen content. If . (See "Noncardiac surgery after percutaneous coronary intervention".) The highest-risk patients are those having urgent or emergent surgery with: ● Recent myocardial infarction or unstable angina [22]. II and V5) and computerized ST-segment analysis.) ● Recent percutaneous coronary intervention (PCI). hypotension. Other recommendations for screening for myocardial ischemia in high-risk patients are discussed separately.) The management of the stable conscious patient having recurrent episodes of torsades de pointes is discussed separately. fibrillation.) In high-risk patients. continuous electrocardiography (ECG) monitoring for myocardial ischemia includes multiple leads (eg. section on 'Very high-risk patients'. arrhythmias). (See "Perioperative myocardial infarction after noncardiac surgery". (See "Evaluation of cardiac risk prior to noncardiac surgery". section on 'Prevention of ischemia'. (See "Perioperative myocardial infarction after noncardiac surgery". if available in the PACU. ) ● Administration of intravenous (IV) diuretics to relieve pulmonary congestion or fluid overload [40]. This is due to intraoperative factors such as fluid overload resulting from fluid shifts during major surgery. severe hypertension. (See "Perioperative myocardial infarction after noncardiac surgery" and "Role of echocardiography in acute myocardial infarction". respiratory acidosis. supine positioning of a patient who cannot tolerate this position while awake). a cardiologist is consulted since urgent subspecialist interventions will be necessary if an acute coronary syndrome is developing (table 6). and/or hypoxia despite oxygen therapy. ● Initiation of vasodilator therapy in the following settings: early IV nitroglycerin as a component of therapy in patients with refractory HF (eg.available. ● For persistent respiratory distress. as well as those with diastolic HF (also called HF with preserved ejection fraction).) Treatment for acute decompensated HF incudes (table 7): ● Administration of supplemental O2.) Decompensated heart failure — Patients at increased risk for development of acute HF in the immediate postoperative period include those with a history of chronic left or right HF. anemia. initiation of noninvasive ventilation (NIV) or endotracheal intubation and mechanical ventilation. inadequate response to diuretics and/or low cardiac output). The diagnosis and management of perioperative myocardial infarction are discussed separately. section on 'Postoperative management'. (See "Perioperative management of heart failure in patients undergoing noncardiac surgery". Also. myocardial ischemia. stress-induced (Takotsubo) cardiomyopathy. bedside transthoracic echocardiography can be used to quickly detect regional wall motion abnormalities. or prolonged unfavorable surgical positioning (eg. or IV .) Acute HF typically manifests as respiratory distress with or without overt pulmonary edema. Respiratory distress may be accompanied by hypertension due to hypervolemia or hypotension due to cardiogenic shock or excess vasodilator use. (See "Noninvasive ventilation in acute respiratory failure in adults". section on 'Cardiogenic pulmonary edema'. (See "Approach to acute decompensated heart failure in adults". as indicated. in combination with a vasopressor (eg. norepinephrine 4 to 16 mcg. Details regarding management of acute decompensated HF are available elsewhere. (See "Treatment of acute decompensated heart failure: Components of therapy".to 500-mL increments and. ● Initiation of an inotropic infusion (eg. if necessary. Severe or refractory hypotension is treated with IV bolus doses of epinephrine 10 to 50 mcg. a cardiologist or other specialist (eg. adrenal insufficiency.) • Additional treatment of hypotension depends upon the specific etiology (eg.) SUMMARY AND RECOMMENDATIONS ● Hypotension in the post-anesthesia care unit (PACU) is treated when systolic blood pressure (BP) is <90 mmHg or has decreased >20 percent of baseline. . an intensivist) is consulted to arrange further management and transfer to an intensive care unit (ICU). IV vasopressor/inotropic agents (eg. (See 'Initial assessment and treatment' above. (See 'Treatment of underlying causes' above. myocardial dysfunction). drug effects due to antihypertensive or anesthetic agents. or if the patient develops symptoms or other evidence of hypoperfusion (eg. norepinephrine) if necessary to maintain systemic BP. allergic reaction. while a vasopressor/inotropic infusion is prepared (table 1). septic shock. If symptoms do not rapidly resolve in the PACU.) • Severe hypotension or hemodynamic collapse requiring immediate lifesaving intervention may occur due to anaphylactic shock. hypovolemia due to inadequate fluid replacement or blood loss. change in mental status or decreased urine output). (See 'Initial assessment and treatment' above. milrinone or dobutamine) in patients with known systolic HF and signs of cardiogenic shock. phenylephrine 40 to 100 mcg or ephedrine 5 to 10 mg increments).) • Initial treatment includes intravenous (IV) isotonic crystalloid solution administered in 250.nitroprusside as arterial vasodilator therapy to reduce afterload in patients with severe hypertension (table 3). or vasopressin 1 to 4 units. aortic dissection) (table 3). particularly if it persists after treatment of presumed etiologies.) • Additional treatment of hypertension depends upon the specific etiology (eg. (See "Drugs used for the treatment of hypertensive emergencies".) ● Hypertension is typically treated when systolic BP is >180 mmHg or diastolic BP is >110 mmHg. acute decompensated heart failure [HF]. amphetamine. alcohol or opioid withdrawal. stroke) or a cardiovascular emergency (eg. stupor. sympathetic stimulation due to pain or other noxious stimuli. (See 'Hypotensive emergencies' above.) • Initial treatment is with small bolus doses of rapid-acting antihypertensive agents such as labetalol 5 to 20 mg. tension pneumothorax. or phencyclidine).local anesthetic toxicity. recent use of cocaine. titrated to decrease systolic BP to a stable value <160 mmHg. (See 'Initial assessment and treatment' above. cardiac tamponade. seizures. or dynamic left ventricular outflow tract obstruction.) • Underlying causes should be identified and treated.) ● Severe bradycardia or tachyarrhythmias causing hemodynamic instability require emergency treatment. (See 'Treatment of underlying causes' above.) • Emergency treatment of severe hypertension is warranted if there is evidence of acute neurologic signs or symptoms (eg. visual disturbances. For severe or refractory hypertension. delirium.) . hypervolemia. (See 'Cardiac arrhythmias' above and 'Assessment and treatment of underlying causes' above. agitation. poorly controlled preexisting hypertension. a vasodilator infusion is prepared (table 3). acute coronary syndrome. pulmonary embolus. (See 'Initial assessment and treatment' above. (See "Advanced cardiac life support (ACLS) in adults". Metoprolol or labetalol are preferred for treating hypertension associated with tachycardia due to their beta-blocking properties. section on 'Management of specific arrhythmias'. Support with vasopressor/inotropic agents is necessary while definitive treatment is underway (table 1). Anesth Analg 2011. Hartmann B. Complications occurring in the postanesthesia care unit: a survey. prospective. 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