Bradicardia Management in Surgical Procedures under Anesthesia

Medications for Bradicardia

The American Heart Association recommends atropine as the first-line treatment for bradicardia during surgical procedures under anesthesia, with a dose of 0.5-1 mg IV, which can be repeated every 3-5 minutes until a maximum total dose of 3 mg is reached 1
The American Academy of Pediatrics recommends atropine for pediatric patients with a dose of 0.02 mg/kg IV/IO, with a minimum dose of 0.1 mg and a maximum dose of 0.5 mg for children and 1.0 mg for adolescents 2, 3
Atropine can be repeated every 5 minutes until a maximum total dose of 1 mg in children and 2 mg in adolescents is reached 2, 3
The onset of action after IV administration of atropine is within 3 minutes 4

The American Heart Association recommends epinefrina as a second-line treatment for bradicardia, with a dose of 2-10 mcg/min IV or 0.1-0.5 mcg/kg/min IV, titrated to the desired effect 1, 5
The American Academy of Pediatrics recommends epinefrina for pediatric patients who do not respond to atropina, with a dose of 0.1-0.5 mcg/kg/min IV, titrated to the desired effect 2, 3
Isoproterenol can be used as an alternative to epinefrina, with a dose of 20-60 mcg IV in bolus, followed by 10-20 mcg, or infusion of 1-20 mcg/min, according to the response of the heart rate 1, 6

The American College of Cardiology recommends that patients with advanced age (>60-65 years), comorbidities (ASA class III or IV), baseline low heart rate (<60 bpm), or concomitant use of beta-blockers are at higher risk for intraoperative bradycardia 7
The American Heart Association recommends that atropine be administered prophylactically to prevent bradycardia associated with rapid sequence induction, with a dose of 0.01-0.02 mg/kg IV (minimum dose: 0.1 mg; maximum dose: 1 mg) before the administration of sedatives/anesthetics and paralyzing agents 2, 3

The American Heart Association recommends identifying bradycardia (heart rate <60 bpm) and evaluating hemodynamic stability as the first step in treatment 1
Ensuring adequate oxygenation and ventilation is the first measure to be taken 2, 3
If the patient is hemodynamically unstable (hypotension, altered mental status), atropine 0.5-1 mg IV (adults) should be administered, and the patient should be reevaluated after 3-5 minutes 1
If bradycardia persists, atropine can be repeated until a maximum total dose of 3 mg is reached 1
If there is no response to atropine, epinefrina or dopamina infusion should be initiated, and isoproterenol can be considered if there is no suspicion of coronary ischemia 1, 6