How to manage tachycardia in a preoperative orthopedic (ortho) patient?

Management of Tachycardia in Preoperative Orthopedic Patients

Initial Assessment and Management

Beta-blockers are the first-line treatment for managing tachycardia in preoperative orthopedic patients, with metoprolol being the preferred agent due to its cardioselectivity and established safety profile. 1, 2

When encountering tachycardia in a preoperative orthopedic patient, follow this approach:

1. Identify the type of tachycardia:

   • Sinus tachycardia (most common)
   • Atrial fibrillation/flutter
   • Supraventricular tachycardia
   • Ventricular tachycardia

2. Investigate underlying causes:

   • Pain
   • Anxiety
   • Hypovolemia
   • Hypoxemia
   • Electrolyte abnormalities
   • Medication effects
   • Ongoing myocardial ischemia
   • Pulmonary embolism 3

Pharmacological Management

For Sinus Tachycardia:

• First-line: Beta-blockers

  • Metoprolol 2.5-5 mg IV bolus (can be repeated to total of 15 mg) 2, 4
  • Esmolol 500 mcg/kg IV over 1 minute, followed by 60-200 mcg/kg/min infusion (for short-acting control) 2

• Alternative: Non-dihydropyridine calcium channel blockers

  • Diltiazem 0.25 mg/kg IV (if beta-blockers contraindicated) 2
  • Verapamil 0.075-0.15 mg/kg IV 2

For Atrial Fibrillation/Flutter:

• Beta-blockers are most effective for controlling ventricular response 1
• For patients with pre-existing atrial fibrillation, continue current rate control medications 1
• Consider anticoagulation management if patient is on chronic therapy 1

For Supraventricular Tachycardia:

• Vagal maneuvers first
• Adenosine 6 mg rapid IV push, followed by 12 mg if needed 2
• Beta-blockers or calcium channel blockers for ongoing management 1

For Ventricular Tachycardia:

• Urgent cardiology consultation
• Lidocaine, procainamide, or amiodarone for sustained ventricular tachycardia 1
• Electrical cardioversion for hemodynamic instability 1

Special Considerations

Patients with Cardiac Implantable Electronic Devices (CIEDs):

• Identify if patient has a pacemaker or ICD before surgery 1
• Determine if patient is pacemaker-dependent 1
• For pacemaker-dependent patients:
  • Reprogram to asynchronous mode (VOO or DOO) during surgery 1
  • Or place magnet over device during surgery 1
• For ICD patients:
  • Deactivate tachyarrhythmia treatment algorithms before surgery 1
  • Continuous monitoring required when device therapy is inactivated 1

Contraindications and Cautions:

• Heart failure: Use beta-blockers with caution; may precipitate heart failure 4
• Bronchospastic disease: Consider selective beta-1 blockers at lowest effective dose 4
• Diabetes: Be aware that beta-blockers may mask tachycardia from hypoglycemia 4
• Pheochromocytoma: Beta-blockers should only be used after alpha blockade 4

Perioperative Management

1. Continue monitoring throughout perioperative period:

   • Continuous ECG monitoring
   • Peripheral pulse monitoring (manual palpation, pulse oximeter, arterial line) 1

2. For persistent tachycardia despite medical therapy:

   • Consider delaying elective surgery
   • Cardiology consultation for further evaluation
   • Assess for structural heart disease or CAD 1

3. For emergency surgery with uncontrolled tachycardia:

   • Optimize medical therapy
   • Consider invasive hemodynamic monitoring 1
   • Have temporary pacing and defibrillation equipment immediately available 1

Pitfalls to Avoid

• Do not abruptly discontinue beta-blockers in patients with coronary artery disease; can cause severe exacerbation of angina, MI, and ventricular arrhythmias 4

• Do not use non-dihydropyridine calcium channel blockers in patients with decompensated heart failure 2

• Do not overlook pulmonary embolism as a cause of acute tachycardia, especially in orthopedic patients 3

• Do not use digoxin or calcium channel blockers in pre-excited atrial fibrillation 1

• Do not ignore ventricular arrhythmias that cause hemodynamic compromise or are associated with structural heart disease 1

By following this algorithm, you can effectively manage tachycardia in preoperative orthopedic patients while minimizing perioperative cardiovascular complications.