Objectives

Bradycardia in theatre should not be treated as an isolated variable: remember to tailor treatment to the patient and the situation.

Follow the full steps to exclude a serious underlying problem.

START

❶ Immediate action: Stop any stimulus, check pulse, rhythm and blood pressure:

  • If no pulse OR not sinus bradycardia OR severe hypotension: use Box A.
  • If pulse present AND sinus bradycardia: use Box B.

❷ Adequate oxygen delivery

  • Check fresh gas flow for circuit in use AND check measured FiO2.
  • Visual inspection of entire breathing system including valves and connections.
  • Rapidly confirm reservoir bag moving OR ventilator bellows moving.

❸ Airway

  • Check position of airway device and listen for noise (including larynx and stomach).
  • Check capnogram shape compatible with patent airway.
  • Confirm airway device is patent (consider passing suction catheter).

❹ Breathing

  • Check chest symmetry, rate, breath sounds, SpO2, measured VTexp, ETCO2.
  • Feel the airway pressure using reservoir bag and APL valve <3 breaths.

❺ Circulation

  • Check rate, rhythm, perfusion, recheck blood pressure.

❻ Depth

  • Consider current depth of anaesthesia AND adequacy of analgesia.

❼ Consider underlying problem (Box C).

❽ Call for help if problem not resolving quickly.

❾ Consider transcutaneous pacing (Box D).

 

 

Box A: CRITICAL BRADYCARDIA

Give atropine 20 µg.kg-1 (adult 0.5-1 mg) with fluid flush.

If no pulse: (or heart rate <60 bpm infant or neonate):

  • Delegate (minimum) 1 person to chest compressions
  • → 2-1 Cardiac arrest

Box B: DRUGS FOR BRADYCARDIA

  • Glycopyrrolate 5 µg.kg-1 (adult 200-400 µg)
  • Ephedrine 100 µg.kg-1 (adult 3-12 mg)
  • Atropine 10 µg.kg-1 (adult 300-600 µg)
  • Isoprenaline 0.5 µg.kg.min-1 (adult 5 µg.min-1)
  • Adrenaline 1 µg.kg-1 (adult 10-100 µg) in emergency only

Box C: POTENTIAL UNDERLYING PROBLEMS

  • Consider whether you could have made a drug error.
  • Consider known drug causes (eg. remifentanil, digoxin etc).
  • Surgical stimulation with inadequate depth.
  • Also consider: high intrathoracic pressure; pneumoperitoneum; local anaesthetic toxicity (→ 3-10);  beta-blocker; digoxin; calcium channel blocker; myocardial infarction, hyperkalaemia, hypothermia, raised intra-cranial pressure.

Box D: TRANSCUTANEOUS PACING

  • Attach pads and ECG leads from pacing defibrillator.
  • Set to PACING MODE.
  • Set PACER RATE.
  • Increase PACER OUTPUT from 60 mA until capture (spikes align QRS).
  • Confirm capture: electrical AND mechanical (femoral pulse).
  • Set PACER OUTPUT 10 mA above capture.

 

Editorial Information

Author(s): The Association of Anaesthetists of Great Britain & Ireland 2018. www.aagbi.org/qrh Subject to Creative Commons license CC BY-NC-SA 4.0. You may distribute original version or adapt for yourself and distribute with acknowledgement of source. You may not use for commercial purposes. Visit website for details. The guidelines in this handbook are not intended to be standards of medical care. The ultimate judgement with regard to a particular clinical procedure or treatment plan must be made by the clinician in the light of the clinical data presented and the diagnostic and treatment options.

Version: 1