From the Guidelines
When investigating post-cesarean delivery tachycardia, a systematic approach is crucial to identify the underlying cause, and the most recent guidelines from the Enhanced Recovery After Surgery (ERAS) Society recommendations should be followed. The approach should include ruling out hemorrhage through careful assessment of vital signs, uterine tone, and vaginal bleeding, as well as checking complete blood count, coagulation studies, and considering bedside ultrasound to evaluate for intra-abdominal bleeding 1. Some key points to consider in the assessment and management of post-cesarean delivery tachycardia include:
- Assessing for infection by monitoring temperature, examining the surgical site, and ordering blood cultures, complete blood count with differential, and urinalysis if indicated
- Evaluating for pulmonary embolism with D-dimer testing and considering CT pulmonary angiography if suspicion is high
- Ruling out cardiac causes with ECG and cardiac enzymes
- Ensuring adequate analgesia with scheduled acetaminophen and ibuprofen, supplemented with opioids if needed, as pain and anxiety can cause tachycardia
- Checking for medication side effects, particularly from beta-agonists like terbutaline or ephedrine
- Assessing fluid status and considering a bolus of 500-1000mL crystalloid if hypovolemia is suspected, while being mindful of the risks of perioperative fluid overload 1
- Documenting the patient's baseline heart rate for comparison, as some patients normally have higher resting heart rates This systematic approach, guided by the most recent and highest quality evidence, helps identify the underlying cause of post-cesarean tachycardia, allowing for appropriate targeted treatment and prioritizing morbidity, mortality, and quality of life as outcomes.
From the Research
Research Tips for Post-Caesarean Tachycardia
- Monitor patients closely for signs of tachycardia during and after cesarean section, as seen in a case where ventricular tachycardia appeared 16 minutes after uterotonics were applied 2
- Consider the potential for autonomic nervous imbalance induced by combined spinal and epidural anesthesia, ephedrine, and oxytocin, as well as ergometrine, which may cause intraoperative tachycardia in patients without structural cardiac disease 2
- Be aware that supraventricular tachycardia is a common arrhythmia during pregnancy, and Wolff-Parkinson-White syndrome accounts for the majority of cases in this population 3
- Epidural anesthesia may be preferred in patients with Wolff-Parkinson-White syndrome undergoing emergency cesarean section, as it provides hemodynamic stability and post-operative analgesia 3
- Total intravenous anesthesia with propofol and remifentanil may be a suitable option for patients with complex cardiac conditions, such as Ebstein's anomaly, undergoing cesarean section 4
- Spinal anesthesia may be used for emergency cesarean delivery in patients with intractable paroxysmal supraventricular tachycardia, and the tachycardia may spontaneously convert to normal sinus rhythm after delivery 5
- Intravenous verapamil may be effective in converting supraventricular tachycardia to sinus rhythm during spinal anesthesia for cesarean section, and further investigations may be necessary to confirm underlying conditions such as Wolff-Parkinson-White syndrome 6