P015: HEMODYNAMIC INSTABILITY FROM INDUCTION OF ANESTHESIA WITH ATRIAL FIBRILLATION AND SEPSIS
Taimoor A Khan, MD1; Salar Khan, CAA2; Cameron Howard, MD2; 1Memorial Healthcare System; 2Envision Physician Services
Key Words: sepsis, atrial fibrillation, cardioversion, hemodynamics
Introduction: Synchronized electrical cardioversion is employed to rescue hemodynamically unstable supraventricular tachycardias by delivering electrical current meant to depolarize an aberrant re-entrant circuit. This case report details the utilization of synchronized cardioversion immediately after induction of anesthesia in a septic patient with known atrial fibrillation with rapid ventricular rhythm (RVR.)
Case: The patient is a 63-year-old male with a past medical history of hypertension, atrial fibrillation with RVR, CVA with residual left sided weakness, severe peripheral vascular disease, and coronary artery disease treated with a bypass graft surgery one year prior. He was seen in the ER for weakness, met diagnostic criteria for sepsis, and was scheduled for incision and drainage of a perineal abscess. After standard preoperative evaluation revealing hemodynamic stability and modest rate control with a ventricular rate of 100 bpm and systolic BP in the 170s, a radial arterial line was placed and the patient was brought to the operating room.
Upon induction of anesthesia with a 1:1 combination of etomidate and propofol, the patient demonstrated profound hypotension and an increase in the ventricular response rate to 160. ACLS was initiated with chest compressions, endotracheal intubation, and call for crash cart and additional personnel.
Circulatory support with epinephrine and chest compressions continued for approximately 2 minutes until placement of conduction pads. Subsequent delivery of a 100J synchronized shock restored a regular sinus rhythm at a rate of 80 bpm, which achieved hemodynamic stability even upon discontinuation of pressors. A decision was made to proceed with surgery given the need for source control of the sepsis, and the patient was safely extubated at the end of the case. After 24 hours of observation in the ICU, the patient was downgraded to the floor and continued to show clinical improvement until discharge.
Discussion: The immediate and catastrophic hemodynamic instability which occurred on induction of anesthesia in this case was multifactorial, likely from sepsis-related decreases in SVR in the setting of baseline atrial fibrillation [2.] Emergent cardioversion in the operating room is rare, but having experienced personnel and specific on-site training in use of the devices can be of immense benefit as in this case. The use of invasive blood pressure monitoring was also essential despite the anticipated ease and swiftness of the planned operation, given the patient’s risk factors.
Notes on Informed Consent: This case report was documented after a discussion at length with the patient and healthcare surrogate, who fully understood the course of events and unique circumstances documented herein. All questions were answered and consented to the anonymized use of their clinical course and medical history for the purposes of this report.