Perioperative arrhythmias are among the most frequently encountered cardiac events during anesthesia and surgery, with an incidence ranging from 40% to 70% depending on the patient population and surgical complexity.
These rhythm disturbances range from transient, clinically silent episodes to sustained, life-threatening ventricular arrhythmias.
From an anesthesiologist’s perspective, arrhythmias are not merely electrical disorders but manifestations of physiologic imbalance—hypoxia, ischemia, autonomic swings, or anesthetic depth variations.
The intraoperative heart rhythm is a real-time biomarker of systemic stress.
At the end of this chapter, the reader should be able to:
Understand the molecular basis of perioperative arrhythmias.
Recognize ECG patterns and differentiate arrhythmia types.
Implement guideline-based pharmacologic and electrical interventions.
Integrate preventive strategies into perioperative anesthesia plans.
Appreciate emerging technologies in arrhythmia prediction and management.
“Every intraoperative arrhythmia tells a story—whether of hypoxia, electrolyte shift, anesthetic imbalance, or myocardial strain. The anesthesiologist’s art is to interpret that story before it becomes a crisis.”
References
London MJ, Hollenberg M, Wong MG, et al. Anesthesiology. 1988;69(2):232–41.
Aranki SF, Shaw DP, Adams DH, et al. Circulation. 1996;94(3):390–7.
Electrocardiographic studies show transient rhythm abnormalities in up to 70% of patients under general anesthesia, though only 10–15% are clinically significant. The incidence peaks in cardiac, thoracic, and neurosurgical procedures.
Patient-related:
Coronary artery disease
Heart failure (EF <40%)
Valvular disease (esp. mitral stenosis → AF)
Electrolyte and metabolic imbalances
Prior arrhythmias
Procedure-related:
Thoracic and upper abdominal surgeries
Laparoscopic CO₂ insufflation
Head and neck dissection
Autonomic-rich areas (ocular, carotid, mediastinum)
Anesthetic-related:
Volatile anesthetics prolong QT (sevoflurane, desflurane)
Opioids and dexmedetomidine → bradyarrhythmias
Ketamine → sympathetic surge → tachycardia
Succinylcholine → potassium efflux and asystole in susceptible patients
AF increases postoperative stroke risk 2–3×.
Sustained VT/VF carries 30–50% perioperative mortality if untreated.
Bradyarrhythmias may lead to hypotension and hypoperfusion.
References
Priori SG, Blomström-Lundqvist C, et al. Eur Heart J. 2015;36(41):2793–867.
Cardiac depolarization and repolarization are governed by finely balanced ionic fluxes:
Phase 0: Rapid Na⁺ influx (INa)
Phase 1: Transient K⁺ efflux (Ito)
Phase 2: Plateau via Ca²⁺
