From the Guidelines
Bradycardia after anterior cervical discectomy and fusion (ACDF) surgery should be managed with close monitoring and intervention if symptomatic, prioritizing patient morbidity, mortality, and quality of life. According to the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay 1, the management of bradycardia after cardiac surgery is primarily based on historical surgical practice, but these principles can be applied to other types of surgery, such as ACDF.
Key Considerations
- For asymptomatic bradycardia (heart rate 40-60 bpm), observation is usually sufficient as this can be a normal postoperative finding due to vagal stimulation during neck surgery.
- For symptomatic bradycardia (heart rate <40 bpm with hypotension or altered mental status), treatment with atropine 0.5-1 mg IV is recommended, which can be repeated every 3-5 minutes up to a maximum of 3 mg.
- If bradycardia persists, consider dopamine infusion (2-10 mcg/kg/min) or epinephrine infusion (2-10 mcg/min).
- Temporary pacing may be necessary in severe cases.
Pathophysiology and Risk Factors
- The bradycardia following ACDF often results from surgical manipulation near the carotid sinus and vagus nerve, causing increased parasympathetic tone.
- This is usually transient, resolving within 24-48 hours postoperatively.
- Patients with pre-existing cardiac conditions or those taking beta-blockers or calcium channel blockers may be at higher risk.
Additional Measures
- Ensure adequate oxygenation and correct any electrolyte abnormalities, particularly potassium and magnesium, which can exacerbate bradycardia.
- The need for temporary pacing after surgery is highly variable and primarily depends on the type of surgery, as well as a number of risk factors such as older age, AF, prior surgery, preoperative renal failure, and active endocarditis 1.
From the Research
Postoperative Bradycardia from ACDF
- Postoperative bradycardia is a potential complication that can occur after various surgical procedures, including anterior cervical discectomy and fusion (ACDF) 2.
- The exact cause of postoperative bradycardia from ACDF is not explicitly stated in the provided studies, but it can be related to the use of certain medications, such as beta-blockers, calcium channel blockers, and digoxin, which can contribute to the development of symptomatic bradycardia 3.
- Glycopyrrolate has been shown to be effective in preventing bradycardia induced by neostigmine injection after general anesthesia surgery, and it may be a suitable alternative to atropine in preventing postoperative bradycardia 4, 5.
- The treatment of postoperative bradycardia may involve the use of medications such as atropine, glycopyrrolate, or glucagon, depending on the underlying cause and severity of the condition 4, 3, 5.
- It is essential to monitor patients closely after surgery and to be aware of the potential risks and complications associated with postoperative bradycardia, including cardiac arrhythmias, ischemic stroke, and myocardial infarction 2, 6.
Prevention and Treatment
- Glycopyrrolate may be a more effective option than atropine in preventing postoperative bradycardia, as it has been shown to reduce hemodynamic instability during carotid angioplasty and stenting 5.
- The use of prophylactic medications, such as beta-blockers, amiodarone, and sotalol, may help reduce the risk of postoperative atrial fibrillation, which can contribute to the development of bradycardia 6.
- In patients undergoing cardiac surgery, the continuation of pre-existing beta-blocker therapy may help reduce the risk of postoperative bradycardia, unless contraindications develop 6.
Complications and Risks
- Postoperative bradycardia can lead to various complications, including cardiac arrhythmias, ischemic stroke, and myocardial infarction 2, 6.
- The development of postoperative atrial fibrillation can increase the risk of morbidity and mortality, as well as prolong hospitalization and increase hospital costs 6.