How to manage tachycardia in a 65-year-old female with hypertension, left ventricular hypertrophy (LVH), and atrial flutter undergoing ERCP (Endoscopic Retrograde Cholangiopancreatography) under total intravenous anesthesia (TIVA)?

Management of Tachycardia in Atrial Flutter During ERCP Under TIVA

Your anesthetic management was reasonable given the circumstances, though adding esmolol or another beta-blocker would have been optimal for this high-risk patient with hypertension, LVH, and atrial flutter presenting with HR 130-140s. 1

Immediate Intraoperative Considerations

Current Situation Assessment

• Your TIVA regimen (midazolam 2mg, ketamine 25mg, propofol 25mg, remifentanil 1.0-1.2 mcg/kg/min) is appropriate for procedural sedation during ERCP 1
• The HR of 130-140s in atrial flutter represents inadequate rate control in a patient with significant cardiac risk factors (hypertension, LVH) 1
• Patients with LVH are particularly vulnerable to tachycardia-induced ischemia and hemodynamic compromise due to impaired diastolic filling and increased myocardial oxygen demand 1

Why Esmolol Would Have Been Ideal

Intravenous esmolol is specifically recommended for short-term control of supraventricular tachycardia and hypertension in the perioperative setting 1. Key advantages include:

• Ultra-short half-life (9 minutes) allowing rapid titration and quick offset if complications arise 1
• Effective rate control in atrial flutter by slowing AV nodal conduction 1
• Particularly useful in hemodynamically stable patients during procedures 1
• Safer than non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in patients with potential LV dysfunction 1

What You Can Do Now (Case Already Done)

If Procedure Completed Successfully

• Monitor closely in recovery for any signs of hemodynamic instability, chest pain, or worsening tachycardia 1
• Obtain post-procedure ECG and troponin if patient had any concerning symptoms, though universal troponin testing is not required in stable patients with recurrent paroxysmal arrhythmias 2
• Ensure adequate rate control is established before discharge with oral medications 1

Post-Procedure Management Priorities

Rate control should initially aim for HR <110 bpm, with stricter control if symptomatic or if LV function deteriorates 1. For this patient:

• Beta-blockers are preferred given hypertension and LVH 1
• Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) are alternatives if beta-blockers contraindicated, though use cautiously if any concern for reduced LV systolic function 1
• Avoid diltiazem/verapamil in patients with heart failure with reduced ejection fraction 1

Critical Learning Points for Future Cases

Pre-Procedure Assessment

Patients with atrial flutter, hypertension, and LVH require aggressive rate control strategy before elective procedures 1. Specifically:

• Target HR <110 bpm minimum, ideally <100 bpm in patients with LVH 1
• Consider delaying elective procedures if rate poorly controlled 1
• Have esmolol immediately available for intraoperative rate control 1

Intraoperative Rate Control Algorithm

For hemodynamically stable patients with atrial flutter and tachycardia during procedures:

1. First-line: IV esmolol - bolus 500 mcg/kg over 1 minute, then infusion 50-200 mcg/kg/min titrated to effect 1
2. Alternative: IV diltiazem - 0.25 mg/kg (typically 15-20mg) over 2 minutes, may repeat 0.35 mg/kg after 15 minutes if needed, then infusion 5-15 mg/hr 1, 3
3. Alternative: IV metoprolol - 2.5-5mg boluses every 5 minutes up to 15mg total 1

For hemodynamically unstable patients: synchronized cardioversion is indicated 1

Special Considerations in This Patient Population

Patients with LVH depend heavily on atrial contribution to ventricular filling (atrial kick), making them particularly symptomatic with loss of AV synchrony and tachycardia 1. Additionally:

• LVH increases risk of sudden cardiac death, particularly with uncontrolled tachycardia 1, 4
• Regression of LVH with optimal BP control reduces arrhythmia risk 4
• Avoid medications that prolong QT interval in patients with LVH due to increased proarrhythmic potential 1

Anticoagulation Consideration

This patient has CHA2DS2-VASc score ≥2 (age 65=1, female=1, hypertension=1), indicating need for oral anticoagulation for stroke prevention 1. Ensure this is addressed in post-procedure follow-up.

Common Pitfalls to Avoid

• Do not assume tachycardia will resolve with deeper anesthesia alone - atrial flutter requires specific rate control 1
• Do not use calcium channel blockers or beta-blockers if pre-excitation suspected (though not applicable here) 1
• Do not use flecainide or propafenone for rate control without AV nodal blocking agents - risk of 1:1 AV conduction and paradoxical acceleration 1
• Do not overlook the increased cardiovascular risk that persistent tachycardia poses in patients with LVH 1, 4

For future similar cases: have esmolol drawn up and ready, with a clear plan for rate control targets before induction 1.