Anesthesia Management for Patients with Postural Orthostatic Tachycardia Syndrome (POTS)

Preoperative Optimization

The American College of Cardiology recommends salt and fluid loading in the days leading up to surgery for patients with POTS to ensure adequate preoperative hydration 1, 2

The American College of Cardiology strongly prefers regional anesthesia (neuraxial or peripheral nerve blocks) over general anesthesia when surgically appropriate for patients with POTS, as it minimizes sympathetic disruption 3, 4
The American College of Cardiology recommends avoiding volatile agents over total intravenous anesthesia for cardiac protection in noncardiac surgery for patients with POTS, as there is no evidence favoring their use 3

The American College of Cardiology recommends implementing continuous arterial pressure monitoring or plethysmography for all but the most minor procedures in patients with POTS 3, 4

The American Society of Anesthesiologists recommends extubating patients with POTS fully awake in a semi-upright or lateral position 5, 6
The American Society of Anesthesiologists recommends avoiding the supine position during emergence and recovery, as it exacerbates orthostatic symptoms 5, 7

The American Society of Anesthesiologists recommends prioritizing regional analgesia techniques and multimodal non-opioid analgesia over systemic opioids for patients with POTS 5, 6
The American Society of Anesthesiologists recommends excluding opioids from the epidural infusion when possible to reduce adverse effects in patients with POTS 6

The American Society of Anesthesiologists recommends continuing cardiac monitoring in the immediate postoperative period with continuous pulse oximetry for patients with POTS 5
The American College of Cardiology recommends modifying early mobilization protocols used in enhanced recovery pathways, as upright exercise can worsen orthostatic intolerance and cause postexertional malaise in patients with POTS 2
The American College of Cardiology recommends using recumbent or semi-recumbent activities initially when mobilization begins for patients with POTS 2