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Canadian Journal of Anesthesia, Vol 28, 6-16, Copyright © 1981 by Canadian Anesthesiologists' Society

Anaesthetic Problems Associated with the Treatment of Cardiovascular Disease: I. Digitalis Toxicity

D. C. CHUNG 1

1 Department of Anaesthesia, University of Western Ontario, University Hospital, London, Ontario, Canada

Digitalis intoxication is still a common clinical problem affecting a fifth to a quarter of all digitalized patients. In the surgical patients there are many factors-including fluid, electrolyte and acid-base disturbances, hypoxaemia, abnormal renal function and drug interactions - that can enhance the sensitivity of the heart to digitalis. Unfortunately, the cardiac as well as other systemic signs of digitalis toxicity are non-specific and the difference between therapeutic and toxic serum concentrations is ill-defined. Clinical acumen together with a knowledge of the preparation being used, its pharmacokinetics, factors that can enhance the sensitivity of the heart, and the serum concentration is still necessary in the diagnosis of toxicity.

Whether to proceed with anaesthesia and operation in the toxic patient depends on the urgency of surgery. Elective surgery should be postponed until toxicity subsides. In an emergency, the urgency of the operation precludes any delay, and cardio-toxicity should be treated aggressively before, during and after operation.

Treatment of digitalis toxicity should include the withdrawal of the cardiac glycoside and the elimination of all factors enhancing the toxic effects of digitalis. When the arrhythmia is causing haemodynamic instability or when there is ventricular irritability, treatment with anti-arrhythmic agents is indicated. Potassium chloride, lidocaine and diphenylhydantoin are the drugs of choice in the treatment of tachyarrhythmias and ventricular premature beats. Atropine can be used to counteract the vagal effect of digitalis in bradycardia and heart block. If atropine is ineffective, the placement of a temporary artificial pacemaker may be necessary. When congestive heart failure is a complication, the use of a vasodilator to decrease ventricular preload and afterload will improve the mechanical efficiency of the heart, increase cardiac output and relieve pulmonary congestion.

Key Words: ANAESTHESIA, cardiovascular disease • HEART, digitalis toxicity • TOXICITY, digitalis






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Copyright © 1981 by the Canadian Anesthesiologists' Society.