Intraoperative arrhythmias - NYSORA

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Intraoperative arrhythmias

Learning objectives

  • Define and classify arrhythmias
  • Describe the patient, anesthetic, and surgical risk factors for developing intraoperative arrhythmias 
  • Management of intraoperative arrhythmias 

Definition and mechanisms 

  • Arrhythmias are accelerated, slowed, or irregular heartbeats caused by abnormalities in the electrical impulses of the myocardium
  • 60% of patients may experience perioperative arrhythmias 
  • The majority are benign, but rhythm disturbance can be associated with potentially serious adverse outcomes


Bradyarrhythmia (HR <60 bpm)

  • Sinus arrhythmia: Sinus bradycardia
  • Conduction defects
    • AV blocks
      • First-degree AV block
      • Second-degree AV block
      • Third-degree AV block
    • Intraventricular blocks
      • Right bundle branch block
      • Left bundle branch block
    • Fascicular block
      • Left anterior hemiblock
      • Right anterior hemiblock
    • Bifascicular block
    • Trifascicular block

Tachyarrhythmia (HR >100 bpm)

  • Sinus arrhythmia: Sinus tachycardia
  • Supraventricular arrhythmias
  • Ventricular arrhythmias
    • Premature ventricular contractions
    • Ventricular tachycardia
    • Ventricular fibrillation
    • Torsade de pointes


Risk factors

Patient factors

Anesthetic factors

Surgical factors

  • Catecholamines
    • Endogenous (from any surgical stimulus)
    • Exogenous (topical or infiltrated epinephrine)
  • Autonomic stimulation
    • Peritoneal and visceral traction
    • Peritoneal insufflation
    • Trigeminovagal reflexes (oculocardiac reflex)
    • Laryngoscopy, bronchoscopy, esophagoscopy
    • Carotid artery and thyroid surgery
  • Direct stimulation of the heart during cardiac or thoracic surgery
  • Embolism
  • Other
    • Aortic cross-clamping
    • Limb reperfusion
    • Glycine intoxication

Treatment goals

  • Prevent thromboembolism formation
  • Control heart rate
  • Correct the condition causing the arrhythmia
  • Reduce other risk factors for heart disease and stroke


  • More than one factor is likely to contribute to the development of an intraoperative arrhythmia 
    • Identify the rhythm
    • Evaluate its significance (in the context of)
      • Coexisting medical problems and their treatment
      • Surgical condition
      • Operative procedure
      • Anesthetic drugs and technique
      • Hemodynamic effect of the arrhythmia and the risk of progression to a more serious arrhythmia
    • Identify and correct any precipitating factors 
  • Take an ABC approach
  • Treat the whole patient, not just the ECG 

intraoperative arrhythmias, tachyarrhythmias, bradyarrhythmias, ventricular tachycardia, amiodarone, polymorphic ventricular tachycardia, supraventricular tachycardia, atrial fibrilation, atrial flutter, atropine, glycopyrrolate, adenosine


intraoperative arrhythmias, bradycardia, tachycardia, hemodynamic unstable, CPR, defibrillation, cardioversion, narrow QRS, wide QRS, regular, irregular, pacing, atropine, beta-agonist, beta-blockers, calcium antagonist, amiodarone, adenosine, procainamide, sotalol


  • Keep surgical manipulations that can precipitate arrhythmias to a minimum
  • An adequate depth of anesthesia may prevent or control intraoperative arrhythmias
  • Prevent hypoxia, hypotension, hypovolemia, and hypothermia during surgery

Suggested reading

  • Noor ZM. Md. Life-Threatening Cardiac Arrhythmias during Anesthesia and Surgery. Cardiac Arrhythmias – Translational Approach from Pathophysiology to Advanced Care. 2021. doi: 10.5772/intechopen.101371.
  • Pollard BJ, Kitchen G. Handbook of Clinical Anaesthesia. 4th ed. Taylor & Francis group; 2018. Chapter 30 Management problems, Shelton C.

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