Management of arrhythmias in the perioperative setting

Advancing arrhythmia education through the CDIO approach: a new paradigm in nursing student training

BACKGROUND

The accurate diagnosis and effective management of arrhythmias are crucial, with nurses playing a key role in the early detection and treatment, significantly impacting patient outcomes. Improving education on arrhythmias among nurses, especially in critical care and perioperative settings, can enhance patient safety and the quality of care.

METHODS

A total of 116 trainee nurses were randomly divided into two groups: one utilizing the conceive-design-implement-operate (CDIO) model and the other employing a traditional lecture-based learning (LBL) method, to undergo arrhythmia training. The studyassessed the effects of the two teaching methods and investigated the students' attitudes toward these educational practices, with all participants completing pre- and post-course tests.

RESULTS

The CDIO model significantly enhances nursing students' arrhythmia proficiency, yielding higher test scores and sustained improvement after 24-week compared to the traditional LBL method, alongside markedly better self-learning enthusiasm, understanding, satisfaction with the teaching approach and effectiveness, and interest in learning arrhythmia. The CDIO model in nursing arrhythmia courses boosts theoretical knowledge and application, showing potential in clinical skill enhancement.

CONCLUSIONS

Our study introduces the CDIO model in nursing arrhythmia courses, with improvement in knowledge and skills, and promise for broader application.

Differences in Outcomes After Anesthesia-Related Adverse Events in Older and Younger Patients

Because more older adults undergo surgical procedures, it is incumbent on us to learn how to provide them with the safest possible perioperative care. We conducted a retrospective cohort study at a large tertiary care center to determine whether outcomes after anesthesia-related adverse events differed between patients aged 65 years and older versus patients under age 65. One thousand four hundred twenty-four cases were referred to the Performance Improvement committee of the Department of Anesthesiology from the years 2007-2015. After exclusions of cases that were not anesthesia-related, could not be identified, or were duplicates, 747 cases with anesthesia-related adverse events were included in the study. Two hundred eighty-six were aged 65 years and older and 461 were under age 65. Anesthesia-related adverse events occurred more commonly in the postoperative period in older patients relative to younger patients (37.7% vs. 21.9%, p = .001), and older patients had a greater incidence of mortality compared with a propensity-matched group of younger patients (adjusted odds ratio 1.87 [1.14-3.12], p < .05). We concluded that older patients have a greater likelihood of mortality as a result of suffering an anesthesia-related adverse event and may benefit from increased vigilance in the postoperative period.

Use of Emergency Manuals to Treat Intraoperative Supraventricular Tachycardia and Hypotension During Exploratory Laparotomy

Although intraoperative tachyarrhythmias are relatively common, their appropriate management is pertinent to reducing morbidity and mortality. In certain clinical scenarios, the initial steps of managing intraoperative tachyarrhythmias may be ambiguous. Emergency manuals (EMs) are cognitive aids that improve the outcome of critical events by providing current, medically established guidelines on management. The case of a patient with an intraoperative supraventricular tachycardia with narrow, irregular QRS complexes and refractory hypotension is described here. Relevant sections of Stanford Anesthesia Emergency Manual were activated immediately and guided the anesthesiologists in treating the patient’s arrhythmia. The utilization of an EM allowed rapid selection of a pharmacologic agent that achieved hemodynamic stability. EMs allow healthcare providers to respond more appropriately and efficiently during critical events and thus directly improve patient care.

Postoperative atrial fibrillation after cesarean delivery

Background and Aims

Atrial fibrillation (AF) is the most common arrhythmia seen clinically. Due to the lack of literature and guidelines on maternal AF as a postoperative complication following cesarean delivery (CD), we undertook a study to characterize parturients who developed AF following CD and to evaluate arrhythmia management and outcomes in this patient population.

Methods

After receiving ethics committee approval, a retrospective chart review was performed to determine the incidence, possible risk factors, treatment, and outcome of women who developed AF following CD performed between 2003 and 2012 at New York Methodist Hospital in Brooklyn, New York.

Results

A total of 17,039 CDs were performed at New York Methodist Hospital from 2003 to 2012. Of these, seven parturients developed AF after CD. The incidence of AF following CD in this patient population was 1:2,434 (0.04%). The age range was 26-41 years, with a median of 33 years. All 7 parturients were at term or postterm. Two deliveries were elective and five were emergent. Two of the seven parturients had prior history of paroxysmal AF. One patient was identified as having mitral regurgitation. All seven had low levels of serum magnesium postoperatively. Out of the seven, two parturients had spontaneous conversion to normal sinus rhythm, one required electrical cardioversion and four required pharmacologic cardioversion.

Conclusions

Postoperative AF (POAF) exists as a rare complication in women who undergo CD with an incidence of 0.04% in our patient population. All parturients in our study were noted to have hypomagnesemia in the postoperative period. Occurrence of AF increased length of hospital stay and utilization of hospital resources.

Intraoperative cardiac emergencies

Intraoperative cardiac emergencies require prompt recognition and management in order to optimize patient safety and recovery. This article addresses the perioperative management of hypertension, myocardial infarction, arrhythmias, autonomic dysreflexia, tamponade, and tension pneumothorax. These complications can occur in patients with underlying coexisting disease, but can also occur in surgical patients regardless of the underlying disorder.

Landiolol: a review of its use in intraoperative and postoperative tachyarrhythmias

Landiolol (Onoact(®)) is an intravenously administered, ultra short-acting β1-blocker with an elimination half-life of 3-4 min and ≈8-fold greater cardioselectivity than esmolol in vitro. It is approved in Japan for the treatment of intraoperative and postoperative tachyarrhythmias, but in clinical practice is also used to prevent postoperative tachyarrhythmias, such as atrial fibrillation after coronary artery bypass grafting. Randomized controlled trials in patients undergoing open-heart surgery demonstrated that various dosages of landiolol (0.0005-0.04 mg/kg/min) [0.5-40 μg/kg/min] were more effective than diltiazem in converting postoperative atrial fibrillation to normal sinus rhythm during the first 8 h after surgery, and were more effective than placebo (or no landiolol) in preventing the development of atrial fibrillation during the first week after surgery (primary efficacy endpoints). In patients undergoing surgical procedures, landiolol 0.125 mg/kg/min for 1 min followed by 0.04 mg/kg/min for 10 min was superior to placebo in improving intraoperative tachycardia in randomized double-blind trials. The beneficial effects of landiolol in attenuating adverse haemodynamic or other changes that can occur during surgery or invasive procedures (e.g. percutaneous coronary intervention) have been demonstrated in a large number of randomized controlled trials. For example, several studies showed that landiolol attenuated the increase in heart rate associated with tracheal intubation, without adversely affecting blood pressure or other haemodynamic parameters. Landiolol was generally well tolerated in clinical trials, with a relatively low risk of hypotension and bradycardia, although routine monitoring of cardiac function during landiolol administration is important. In general, adverse events such as reduced blood pressure resolve quickly after discontinuation of landiolol. Thus, as an ultra short-acting β1-blocker with a rapid onset of action and readily titratable and rapidly reversible effects, landiolol represents an important agent for the management of intraoperative and postoperative tachyarrhythmias.