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Cardiovascular problems in the post-anesthesia care unit (PACU)

David Broussard, MD
Kelly Ural, MD
Section Editors
Natalie F Holt, MD, MPH
Jonathan B Mark, MD
Deputy Editor
Nancy A Nussmeier, MD, FAHA


Cardiovascular problems in the post-anesthesia care unit (PACU) include hemodynamic instability due to hypotension, hypertension, or arrhythmias, and complications such as myocardial ischemia or decompensated heart failure. Cardiovascular issues are the third most common problem requiring treatment in the immediate postoperative period, after nausea and vomiting or respiratory problems [1-3].

The likelihood of cardiovascular problems is related to:

Severity of preexisting cardiovascular comorbidities (eg, coronary artery disease, chronic hypertension, congestive heart failure [CHF])

Invasiveness of the surgical procedure (eg, major vascular, thoracic, abdominal, spine surgery)

Severity of perioperative stresses (eg, blood loss, fluid shifts, sepsis, pain, hypothermia)

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Literature review current through: Nov 2017. | This topic last updated: Nov 20, 2017.
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  1. Hines R, Barash PG, Watrous G, O'Connor T. Complications occurring in the postanesthesia care unit: a survey. Anesth Analg 1992; 74:503.
  2. Rose DK, Cohen MM, DeBoer DP. Cardiovascular events in the postanesthesia care unit: contribution of risk factors. Anesthesiology 1996; 84:772.
  3. Kluger MT, Bullock MF. Recovery room incidents: a review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS). Anaesthesia 2002; 57:1060.
  4. Bijker JB, van Klei WA, Kappen TH, et al. Incidence of intraoperative hypotension as a function of the chosen definition: literature definitions applied to a retrospective cohort using automated data collection. Anesthesiology 2007; 107:213.
  5. Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 2008; 134:172.
  6. Mark JB. Central venous pressure monitoring: clinical insights beyond the numbers. J Cardiothorac Vasc Anesth 1991; 5:163.
  7. Solon JG, Egan C, McNamara DA. Safe surgery: how accurate are we at predicting intra-operative blood loss? J Eval Clin Pract 2013; 19:100.
  8. Romazicon [package insert]. Basel, Switzerland: Roche Pharmaceuticals; 1994
  9. Taff RH. Pulmonary edema following naloxone administration in a patient without heart disease. Anesthesiology 1983; 59:576.
  10. Klasen J, Junger A, Hartmann B, et al. Differing incidences of relevant hypotension with combined spinal-epidural anesthesia and spinal anesthesia. Anesth Analg 2003; 96:1491.
  11. Berroa F, Lafuente A, Javaloyes G, et al. The incidence of perioperative hypersensitivity reactions: a single-center, prospective, cohort study. Anesth Analg 2015; 121:117.
  12. Gurrieri C, Weingarten TN, Martin DP, et al. Allergic reactions during anesthesia at a large United States referral center. Anesth Analg 2011; 113:1202.
  13. Lonjaret L, Lairez O, Minville V, Geeraerts T. Optimal perioperative management of arterial blood pressure. Integr Blood Press Control 2014; 7:49.
  14. Aronson S, Varon J. Hemodynamic control and clinical outcomes in the perioperative setting. J Cardiothorac Vasc Anesth 2011; 25:509.
  15. Myklejord DJ. Undiagnosed pheochromocytoma: the anesthesiologist nightmare. Clin Med Res 2004; 2:59.
  16. Sheinberg R, Gao WD, Wand G, et al. Case 1--2012. A perfect storm: fatality resulting from metoclopramide unmasking a pheochromocytoma and its management. J Cardiothorac Vasc Anesth 2012; 26:161.
  17. O'Riordan JA. Pheochromocytomas and anesthesia. Int Anesthesiol Clin 1997; 35:99.
  18. Gal TJ, Cooperman LH. Hypertension in the immediate postoperative period. Br J Anaesth 1975; 47:70.
  19. Colson P, Saussine M, Séguin JR, et al. Hemodynamic effects of anesthesia in patients chronically treated with angiotensin-converting enzyme inhibitors. Anesth Analg 1992; 74:805.
  20. Coriat P, Richer C, Douraki T, et al. Influence of chronic angiotensin-converting enzyme inhibition on anesthetic induction. Anesthesiology 1994; 81:299.
  21. Ghadimi K, Thompson A. Update on perioperative care of the cardiac patient for noncardiac surgery. Curr Opin Anaesthesiol 2015; 28:342.
  22. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2215.
  23. Radtke FM, Franck M, Hagemann L, et al. Risk factors for inadequate emergence after anesthesia: emergence delirium and hypoactive emergence. Minerva Anestesiol 2010; 76:394.
  24. Bitsch M, Foss N, Kristensen B, Kehlet H. Pathogenesis of and management strategies for postoperative delirium after hip fracture: a review. Acta Orthop Scand 2004; 75:378.
  25. Frank SM, Fleisher LA, Olson KF, et al. Multivariate determinants of early postoperative oxygen consumption in elderly patients. Effects of shivering, body temperature, and gender. Anesthesiology 1995; 83:241.
  26. Sun KO. Severe postoperative shivering and hypoglycaemia. Anaesth Intensive Care 1993; 21:873.
  27. De Witte J, Sessler DI. Perioperative shivering: physiology and pharmacology. Anesthesiology 2002; 96:467.
  28. Frank SM, Fleisher LA, Breslow MJ, et al. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial. JAMA 1997; 277:1127.
  29. Lenhardt R, Marker E, Goll V, et al. Mild intraoperative hypothermia prolongs postanesthetic recovery. Anesthesiology 1997; 87:1318.
  30. Baldini G, Bagry H, Aprikian A, Carli F. Postoperative urinary retention: anesthetic and perioperative considerations. Anesthesiology 2009; 110:1139.
  31. Dal Mago AJ, Helayel PE, Bianchini E, et al. Prevalence and predictive factors of urinary retention assessed by ultrasound in the immediate post-anesthetic period. Rev Bras Anestesiol 2010; 60:383.
  32. Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S444.
  33. Gratadour P, Viale JP, Parlow J, et al. Sympathovagal effects of spinal anesthesia assessed by the spontaneous cardiac baroreflex. Anesthesiology 1997; 87:1359.
  34. Lesser JB, Sanborn KV, Valskys R, Kuroda M. Severe bradycardia during spinal and epidural anesthesia recorded by an anesthesia information management system. Anesthesiology 2003; 99:859.
  35. Caplan RA, Ward RJ, Posner K, Cheney FW. Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors. Anesthesiology 1988; 68:5.
  36. Keats AS. Anesthesia mortality--a new mechanism. Anesthesiology 1988; 68:2.
  37. Bhave PD, Goldman LE, Vittinghoff E, et al. Incidence, predictors, and outcomes associated with postoperative atrial fibrillation after major noncardiac surgery. Am Heart J 2012; 164:918.
  38. Danelich IM, Lose JM, Wright SS, et al. Practical management of postoperative atrial fibrillation after noncardiac surgery. J Am Coll Surg 2014; 219:831.
  39. Link MS, Atkins DL, Passman RS, et al. Part 6: electrical therapies: automated external defibrillators, defibrillation, cardioversion, and pacing: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S706.
  40. WRITING COMMITTEE MEMBERS, Yancy CW, Jessup M, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013; 128:e240.