What is the cause of tachycardia in a post-laparoscopic appendectomy (lap appy) patient with anxiety, who denies chest pain?

From the Guidelines

The patient's tachycardia (heart rate in the 130s) following a laparoscopic appendectomy should be addressed by first ruling out other causes of tachycardia such as pain, hypovolemia, or infection with appropriate vital sign monitoring and physical examination. To address this situation, consider administering a short-acting benzodiazepine such as lorazepam 0.5-1mg orally or IV for immediate anxiety relief, as the patient's anxiety is likely contributing to the tachycardia 1. For ongoing management, propranolol 10-20mg orally every 6 hours as needed can help control both the physical symptoms of anxiety and the tachycardia, as recommended for postoperative tachycardia management 1. Ensure adequate pain control with scheduled acetaminophen and as-needed opioids, as pain can exacerbate both anxiety and tachycardia, and consider the use of validated pain scales to guide treatment planning and adjustment 1. Nonpharmacological interventions should include reassurance, calm environment, deep breathing exercises, and early ambulation as tolerated. The tachycardia is likely multifactorial, stemming from surgical stress, pain, and anxiety, with the sympathetic nervous system activation causing the elevated heart rate. Close monitoring of vital signs and response to interventions is essential to ensure the patient's condition improves appropriately during post-operative recovery. It is also important to note that postoperative pain management is crucial in preventing complications such as respiratory infectious complications, and that a sudden increase in pain, especially associated with the appearance of tachycardia, hypotension, or hyperthermia, requires an urgent comprehensive assessment of the patient's condition 1. In terms of specific arrhythmia management, the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery recommends that sustained, regular, narrow-complex tachycardia can be terminated with vagal maneuvers or with intravenous medications such as adenosine or verapamil 1. However, in this case, the patient's tachycardia is likely related to anxiety and pain, and therefore, addressing these underlying issues is the priority.

From the Research

Patient Presentation

• The patient is experiencing a heart rate of 130 beats per minute, which is considered tachycardic.
• The patient denies any chest pain, but endorses anxiety.
• The patient does not normally take any medication for anxiety.

Possible Causes

• Supraventricular tachycardia (SVT) is a possible cause of the patient's symptoms, as it can present with palpitations, anxiety, and dyspnea 2, 3.
• SVT is a common admission diagnosis in the emergency department and requires immediate attention 4.

Treatment Options

• Vagal maneuvers, such as the modified Valsalva maneuver, can be effective in terminating SVT 3.
• Adenosine is a commonly used medication for treating SVT, and high-dose adenosine may be effective in cases where standard dosing regimens fail 4.
• Calcium channel blockers, beta blockers, and antiarrhythmic agents may be used as management options for SVT 2, 3.
• Catheter ablation is a highly effective treatment option for preventing recurrence of SVT, with success rates of 94.3% to 98.5% 3.

Anxiety Management

• Beta blockers, such as propranolol, have been used to treat anxiety disorders, but there is limited evidence to support their effectiveness 5.
• The use of beta blockers for anxiety disorders is increasing, but there is a need for further research to determine their safety and efficacy 5.