| Intraoperative bradycardia with HR <60 bpm or rapidly decreasing HR with hemodynamic instability (ie, causing hypotension or poor perfusion)¶ |
| Identify and treat potential causes of bradycardia |
- Vagal reflexes
- Initial treatment: cease surgical or interventional stimulus (eg, oculocardiac reflex during ophthalmic surgery, peritoneal stretching during laparoscopic surgery)
- Persistent bradycardia: atropine 0.5 mg (may repeat up to a total of 3 mg) in a hemodynamically unstable patient; or glycopyrrolate 0.2 mg (may repeat up to a total of 1 mg) in a hemodynamically stable patient
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- Neuraxial anesthesia with a high (ie, T1 to T4) anesthetic level
- Initial treatment: ephedrine 5 to 10 mg or epinephrine 10 to 20 mcg
- Persistent or severe bradycardia: larger doses of epinephrine (ie, 100 mcg) and/or continuous epinephrine infusion, as well as atropine 0.5 mg (may repeat up to a total of 3 mg)
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- Medications that increase risk for sinus bradycardia (chronically or acutely administered)
- Negative chronotropic agents (eg, beta blockers, calcium channel blockers)
- Initial treatment: ephedrine 5 to 10 mg
- Persistent or severe bradycardia: epinephrine 10 to 20 mg and/or continuous epinephrine infusion, as well as atropine 0.5 mg (may repeat up to a total of 3 mg)
- Anticholinesterase agents, opioids, vasoconstrictors
- Initial treatment: glycopyrrolate 0.2 mg (may repeat up to a total of 1 mg)
- Persistent or severe bradycardia: atropine 0.5 mg (may repeat up to a total of 3 mg)
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- Auto-PEEP or high peak inspiratory pressures
- Initial treatment: hand ventilation with attention to airway pressures
- Persistent or severe bradycardia: atropine 0.5 mg (may repeat up to a total of 3 mg)
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- Less common causes of bradycardia: identify and treat as needed:
- "H's": hydrogen ion (ie, acidemia), hypoglycemia, hypokalemia, hyperkalemia, hypermagnesemia, hypothermia, hyperthermia (ie, malignant hyperthermia)
- "T's": tamponade, tension pneumothorax
- Myocardial ischemia
- Local anesthetic systemic toxicity (LAST)
- Exacerbation of pulmonary hypertension
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| Persistent bradycardia that does not respond to pharmacologic treatment |
- Temporary pacing
- Initial treatment: transcutaneous pacing
- Persistent bradycardia: prepare for transvenous pacing (ie, insertion of a pacing lead or pacing PA catheter) via central venous access
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- Expert cardiology consultation
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- Transfer to intensive care unit for postoperative management
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| Severe or persistent bradycardia progressing to asystole, pulseless electrical activity (PEA) |
- Begin CPR and ACLS and call for help (in addition to treatments listed above)Δ
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- Consider other therapies◊
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