Skip to content

Arrhythmias

SHARE VIA:

Share on facebook
Share on twitter
Share on linkedin
Share on whatsapp
  • Prevalence of postoperative arrhythmia: 15-48%
  • At risk: young age, low body weight, long CPB time, complex surgery, presence of residual defects
  • Prevalence of postoperative arrhythmia is up to 50%
  • Haemodynamic impairment in >50%
  • Aggressive treatment in >50% required
  • Most common is sinus bradycardia with/without junctional escape; then premature complexes; then supraventricular tachycardia; then AV block; then JET
  • Mechanisms: re-entry: on/off, inducible, overdriveable, cardiovertable; automatic/ectopic: warm up, not inducible, not overdriveable, not cardiovertable

Prevention and unspecific treatment:

Strict maintenance of normothermia, avoid triggering drugs, avoid volume overload, avoid acidosis, Mg++ >1.0, Ca++ >1.0, K+ 4.5-5 mmol/L


Bradyarrhythmia

Sinus bradycardia causes: increased vagal tone, elevated ICP, drugs (digoxin, β-blocker, amiodarone, dexmedetomidine), respiratory (hypoxia), metabolic (hypoglycaemia, hyper/hypocalcaemia, hypomagnesiaemia), post-surgical (Fontan circulation, Mustard/Senning)

Sinus bradycardia treatment: correction of underlying cause, atropine 0.02 mg/kg, isoprenaline 0.1-2 mcg/kg/min infusion, pacing (AAI, DDD, DDI)

AV block causes: congenital, increased vagal tone, drugs, respiratory, metabolic, post-surgical (VSD, AVSD, ccTGA, TGA, Fontan circulation)

AV block treatment: correction of underlying cause, pacing (VVI, DDD, DDI)


Tachyarrhythmia

Sinus tachycardia causes: central (pain, awake, fever, seizure), cardiovascular (hypovolaemia, LCOS, pulmonary hypertension), respiratory (hypoxia, hypercarbia), heart failure

Sinus tachycardia treatment: correction of underlying cause, sedation, fluid bolus, general prevention and treatment

Intraatrial reentry tachycardia (IART ≈ atypical atrial flutter) causes: post-surgical (Fontan circulation, Mustard/Senning, ccTGA, TOF, Ebstein's anomaly, VSD, ASD, TGA)

Intraatrial reentry tachycardia treatment: adenosine (100 mcg/kg IV, increasing up to 300 mcg/kg); overdrive pacing if rate low enough; cardioversion (1 J/kg); amiodarone (loading 25 mcg/kg/hr for 4 hours followed by 5-15 mcg/kg/min infusion for rate control or digoxin (20 mcg/kg IV in infants, 30-40 mcg/kg in children). Titrate for effect. AV reciprocating tachycardia (WPW if preexcitation on baseline ECG).

Atrial ectopic tachycardia (AET ≈ chaotic atrial tachycardia): difficult to control pharmacologically –

  • β -blocker: esmolol (bolus up to 500 mcg/kg IV followed by 100-1000 mcg/kg/min infusion) or propranolol (bolus 10-100 mcg/kg slowly IV)
  • Digoxin, procainamide, flecainide (3-6 mg/kg/day), sotalol (2-6 mg/kd/day), amiodarone
  • Overdrive-pacing if rate low enough
  • Catheter ablation
  • Consider sedation if compromised cardiac output

Atrial fibrillation causes: preexcitation syndromes, post-surgical (ASD, Fontan circulation, AS)

Atrial fibrillation treatment: amiodarone, overdrive pacing, cardioversion (1 J/kg). Consider anticoagulation if persistent >48 hrs

Junctional ectopic tachycardia (JET) (180-250 bpm) causes: congenital, post-surgical (ASD, VSD, AVSD, TOF, Fontan circulation)

Junctional ectopic tachycardia (JET)  treatment: decrease adrenergic drugs if feasible, electrolyte correction (Mg++and K+), sedation and paralysis, overdrive pacing, amiodarone, surface cooling to 35°C to slow heart rate (and allow AV sequential pacing)

Premature ventricular contraction (PVC): < 1/min acceptable, otherwise – treatment of underlying cause. Beta-blocker if clinically indicated.

Ventricular tachycardia causes: respiratory, metabolic (inborn errors of metabolism), drugs (Class I, Class III, digitalis toxicity), anatomical (myocarditis), post-surgical, idiopathic.

Ventricular tachycardia treatment: in anunstable patient – immediate cardioversion (1-4 J/kg) and CPR; correction of underlying cause; amiodarone (loading over 20 mins at 5 mg/kg IV) or procainamide (loading over 30 mins: 10 mg/kg IV), catheter ablation, ICD .

Torsade de pointes (polymorph VT) causes: TCA intoxication, long QT Syndrome, dyselectrolytaemia, see also VT

Torsade de pointes treatment: MgSO4 (0.2 mmol/kg), consider beta-blocker or pacing if recurrent.

Ventricular fibrillation: immediate DC and CPR – resuscitation.


References:

[1] Critical Heart Disease in Infants and Children; 2nd ed, Nichols et al: Arrhythmia

[2] Am J Emerg Med. 2008 Mar;26(3):348-58: O'Connor et al: The pediatric electrocardiogram part II: Dysrhythmias

[3] Anaesth Intensive Care. 2009 Sep;37(5):705-19: Skippen et al: Diagnosis of postoperative arrhythmias following paediatric cardiac surgery

[4] Nat Clin Pract Cardiovasc Med. 2008 Aug;5(8):469-76. Snyder: Postoperative ventricular tachycardia in patients with congenital heart disease: diagnosis and management

[5] Pacing Clin Electrophysiol. 2008 Feb;31 Suppl 1:S2-6: Roos-Hesselink et al: Significance of postoperative arrhythmias in congenital heart disease

[6] Circulation. 2007 Jun 26;115(25):3224-34: Walsh: Interventional electrophysiology in patients with congenital heart disease

[7] Circulation. 2007 Jan 30;115(4):534-45: Walsh et al: Arrhythmias in adult patients with congenital heart disease

[8] Z Kardiol. 2004 May;93(5):371-80: Haas et al: Postoperative junctional ectopic tachycardia (JET)

[9] Circ Arrhythm Electrophysiol. 2010 Apr 1;3(2):134-40: Chang et al: Amiodarone versus procainamide for the acute treatment of recurrent supraventricular tachycardia in pediatric patients

[10] Pediatr Emerg Care. 2007 Mar;23(3):176-85; Manole MD: Emergency department management of the pediatric patient with supraventricular tachycardia


All Marc's PICU cardiology FOAM can be found on PICU Doctor and can be downloaded as a handy app for free on iPhone or AndroidA list of contributors can be seen here.

About the authors

KEEP READING

High flow therapy – when and how?

Chest compressions in traumatic cardiac arrest

Searching for sepsis

The missing link? Children and transmission of SARS-CoV-2

Don’t Forget the Brain Busters – Round 2

An evidence summary of Paediatric COVID-19 literature

Urticaria

The fidget spinner craze – the good, the bad and the ugly

Parenteral Nutrition

DFTB WORLD

EXPLORE BY TOPIC

We use cookies to give you the best online experience and enable us to deliver the DFTB content you want to see. For more information, read our full privacy policy here.
[cmplz-manage-consent]