Outpatient surgery + Paroxysmal Afib

[Planktonmd]

This is not an unusual zebra just a simple private practice situation:
70 Y/O patient undergoing mastoidectomy under GA.
Case started by partner, I come on call and take over, I stop by the room to check on things and I see irregularly irregular rhythm on the monitor at 140-150, BP = 95/50, The CRNA says that the patient has been having multiple episodes of AFIB since the beginning of the case (3 hours ago) but the ENT and my partner did not think much of it and she was giving Esmolol here and there.
I go through the chart, The PMH is significant for HTN, DM, Obesity, CAD with a remote history of MI (10 years ago) but recent stress echo (7 days ago) is negative and EF= 55%.
No mention of AFIB and preop EKG is NSR.
Electrolytes are normal.
There is minimal blood loss.
SPO2 is 100 %.
Good urine output.
I tell the CRNA to start a Phenylephrine drip and once the pressure is a little better to give some Metoprolol.
These two interventions improved the situation and we were able to finish the surgery with less frequent episodes of AFIB.
Patient goes to recovery.
She continues to have episodes of AFIB every 5-10 minutes and each one lasts 1-2 minutes.
The initial plan was for her to go home and the ENT guy does not understand why he should change this plan, his logic is:
She had a negative stress test, she probably has this arrhythmia all the time she can see her cardiologist as an out patient
What would you say to him?
What is the plan of action?

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[apma77]

call her cardiologist and possibly admit her to the hospital until you hear from cardiologist if the surgery center is closing down for the night.
i wouldnt let this patient go home without consulting the cardiologist

 

[zippy2u]

Ya want this lady seen today. Best case scenario gets played like this: call her PP and tell him the spiel, hopefully he'll tell ya what ya want to hear which is: send her over to my office now and I'll evaluate and make recs and handle it from here. If he tells ya he'll see her in a couple of days, blow him off and tell her designated driver to take her now over to the emergency room for evaluation. What ya don't really need is the full blown ambulance ride over to the ER and all the hysteria associated with that. Dude, you're off the hook if she's seen THE SAME DAY by her PP, cardiologist or ER doc. Regards, ----Zippy

 

[dhb]

What would you say to him?
What is the plan of action?

1- tell him his grandma was alive until the day she died
2- ecg, enzymes if negative rate control and start lovenox 8h post surgery i would keep her cause you're going to be dealing with post-op pain + risk of bleeding and arrythmia in a CAD patient, not the best of combos in my book.

 

[zippy2u]

DHB, the pt is at an ASC, where ya goin' to keep her-- in the linen closet? Dude, she needs the RIDE! One last thing, contrary to popular belief with various media outlets, America does not need another phuckin' HERO--- do not ride with the pt in the ambulance if that is your only option or ride to the PP office/ER with the designated driver-- stay at the ASC! Regards, ----Zip

 

[deleted9493]

Given the patient's medical history and age, I can understand how the ENT guy might slip into thinking that "she probably has this arrhythmia all the time."

A-fib since the beginning of the case? I'd express my concern that the intubation/induction was more than her diseased heart could bear. I'd have an EKG, enzymes, chest x-ray and a call to the hospital of choice for a fine night of telemetry and a cardiologist's appraisal.

Granted, much could change based on further inquiry/examination postoperatively but given only what is listed here, it's what I would do.

 

[IceDoc]

I'm really not all that concerned about ischemia, as Afib is rarely caused by ischemia alone. However, when in AFib, her ventricular rate is unacceptably high. And paroxysmal Afib has much more propensity for stroke than other types. Therefore, she gets telemetry, rate controlled, and possibly anticoagulated (depending on risk yada yada etc...). In the meantime, some intern or hospitalist can work up all the usual causes of Afib.

To sum up: I would be concerned that as a post op overnight, she would develop this AFib RVR and not return to a regular sinus rate.

The normal stress test is irrelevant. It's only a predictor; it tells you nothing about what the patient has NOW. And finally, a persistent fast rate could cause ischemia even with a normal stress test.

 

[militarymd]

If the patient is stable in the PACU, my cardiologists tend to have them go home and followup as an outpatient....like any other patient incidentally found to have a rhythm other than sinus and who is other wise stable.

 

[toughlife]

This is not an unusual zebra just a simple private practice situation:
70 Y/O patient undergoing mastoidectomy under GA.
Case started by partner, I come on call and take over, I stop by the room to check on things and I see irregularly irregular rhythm on the monitor at 140-150, BP = 95/50, The CRNA says that the patient has been having multiple episodes of AFIB since the beginning of the case (3 hours ago) but the ENT and my partner did not think much of it and she was giving Esmolol here and there.
I go through the chart, The PMH is significant for HTN, DM, Obesity, CAD with a remote history of MI (10 years ago) but recent stress echo (7 days ago) is negative and EF= 55%.
No mention of AFIB and preop EKG is NSR.
Electrolytes are normal.
There is minimal blood loss.
SPO2 is 100 %.
Good urine output.
I tell the CRNA to start a Phenylephrine drip and once the pressure is a little better to give some Metoprolol.
These two interventions improved the situation and we were able to finish the surgery with less frequent episodes of AFIB.
Patient goes to recovery.
She continues to have episodes of AFIB every 5-10 minutes and each one lasts 1-2 minutes.
The initial plan was for her to go home and the ENT guy does not understand why he should change this plan, his logic is:
She had a negative stress test, she probably has this arrhythmia all the time she can see her cardiologist as an out patient
What would you say to him?
What is the plan of action?

Depends, if you are at an ASC then I agree with sending her to an outside ER for management or to her cardiologist.

If you can, get a cards consult and let them take over. If you are one who will continue to care for her post-op then I would start her on a cardiazem gtt or bolus her with amio and start an amio gtt and see if she responds. You can always cardiovert her if you know for a fact she has been on it less than 48hrs and you are sure she does not have a thrombus sitting in her ticker. All of the above is provided she is unstable.

 

[Planktonmd]

So we are at the ASC and the patient is in the PACU, it's 03:30 PM and I have no OR's running anymore.
The patient is stable, sys BP > 100, No distress.
Continues to have frequent episodes of AFIB at 140 -150 even after 10 mg Lopressor.
I give her 5 mg Verapamil and this slows the ventricular rate to around 110 during the episodes alternating with SR at 70 BPM.
The ENT guy wants her discharged home, He has been in this town for 25 years and knows everyone including the CEO, he is definitely more politically connected than I am.
What would you do?

 

[zippy2u]

If you were slick, get your 12 lead ECG when she was runnin' 140-150s and look closely for any minute ischemic changes even if old, the ENT dude's eyes will glaze over. Muscle em up by pointing out these ischemic changes and tellin' him your "medication gimmick" with verapamil was just a temporizing therapeutic modality that will wear off in a couple o' hours. Bang him into reality with buzz words like STEMI and NSTEMI and MACE. Push comes to shove, the anes. doc is typically the medical director of the ASC and that position trumps any surgeon, even the politically connected one of 25 years. Ya gotta find yourself some muscle, dog and use it. Regards, ----Zippy

 

[LongSnow]

This will happen - do it like in House of God - Buff and Turf.

Get a real good strip of the arrythmia. It is fun to have the nurses paste it to the bottom of your note - perhaps this is useful to the consultee.

My favortite buffing agent is Breviblock, Lopressor, then CARDIZEM. Diltiazem seems to always work when beta's fail.

MY favortire turfee - Cardiology, followed by Emergency.


Tell the ENT - "New Onset Afib". end of discussion.


Regards to all,

Long Snow

 

[dfk]

drop the amiodarone, send her to f/u....

 

[Noyac]

My favortite buffing agent is Breviblock, Lopressor, then CARDIZEM. Diltiazem seems to always work when beta's fail

You ever seen the profound bradycardia when mixing the beta blockers and diltiazem?

I usually skip the lopressor and go straight to dilt. if the esmolol doesn't do the trick.

 

[Noyac]

If the patient is stable in the PACU, my cardiologists tend to have them go home and followup as an outpatient....like any other patient incidentally found to have a rhythm other than sinus and who is other wise stable.

Not mine.

140-150 bpm usually gets their attention even if it is intermittent and they want to see them.

If they don't then I would send her to the ER and tell the ER doc to call the cardiologist. They won't give me a hard time about seeing someone I feel needs to be seen again.

 

[Noyac]

BTW, esmolol sucks in this situation.

 

[dhb]

DHB, the pt is at an ASC, where ya goin' to keep her-- in the linen closet? Dude, she needs the RIDE! One last thing, contrary to popular belief with various media outlets, America does not need another phuckin' HERO--- do not ride with the pt in the ambulance if that is your only option or ride to the PP office/ER with the designated driver-- stay at the ASC! Regards, ----Zip

didn't know the ASC wasn't connected to a hospital (not very frequent were i live) by keeping i meant f/u in some form... so i agree give her the RIDE

 

[LongSnow]

Not seen so much profound bradycardia as I have hypotension - will sometimes have to set up some neo. I agree with you that skipping the lopressor is probobly the way to go; if esmolol doesn't work then lopressor really shouln't work either.

On a side note, I will usually check BP manually, since the NIMP cuff might give inaccurate readings with A-fib. The NIMP is usually right, or at least close enough, though.

 

[militarymd]

BTW, esmolol sucks in this situation.

This is why I don't like esmolol.

It is just not as good as metoprolol for the equivalent amount of rate control.

ie...esmolol will cause more hypotension than metorpolol when given at doses to slow the heart rate to equivalent rates.


I can't remember the last time I used a calcium channel blocker.

 

[toughlife]

So we are at the ASC and the patient is in the PACU, it's 03:30 PM and I have no OR's running anymore.
The patient is stable, sys BP > 100, No distress.
Continues to have frequent episodes of AFIB at 140 -150 even after 10 mg Lopressor.
I give her 5 mg Verapamil and this slows the ventricular rate to around 110 during the episodes alternating with SR at 70 BPM.
The ENT guy wants her discharged home, He has been in this town for 25 years and knows everyone including the CEO, he is definitely more politically connected than I am.
What would you do?

the ENT guy can then write in the chart that he personally discharged the patient against the anesthesiologist's recommendation of further medical workup and management of a new onset arrythmia.

 

[toughlife]

drop the amiodarone, send her to f/u....

Was she on amio?

Why would you drop it?

 

[toughlife]

You ever seen the profound bradycardia when mixing the beta blockers and diltiazem?

I usually skip the lopressor and go straight to dilt. if the esmolol doesn't do the trick.

I have. I usually try lopressor and then go straight for either amio or cardizem. Seen both used with good results.

 

[Planktonmd]

Was she on amio?

Why would you drop it?

Yes, I am not sure what that means either.

 

[Planktonmd]

If you were slick, get your 12 lead ECG when she was runnin' 140-150s and look closely for any minute ischemic changes even if old, the ENT dude's eyes will glaze over. Muscle em up by pointing out these ischemic changes and tellin' him your "medication gimmick" with verapamil was just a temporizing therapeutic modality that will wear off in a couple o' hours. Bang him into reality with buzz words like STEMI and NSTEMI and MACE. Push comes to shove, the anes. doc is typically the medical director of the ASC and that position trumps any surgeon, even the politically connected one of 25 years. Ya gotta find yourself some muscle, dog and use it. Regards, ----Zippy

I think we have all done what Zippy describes at some point of doing this business: Use the available data in your favor and count on the others lack of knowledge to get your point across with minimal conflict.

 

[toughlife]

I think we have all done what Zippy describes at some point of doing this business: Use the available data in your favor and count on the others lack of knowledge to get your point across with minimal conflict.

This is the reason why you need a physician anesthesiologist in charge. Medical issues will arise that are beyond the scope of practice and knowledge of a CRNA and they are not medically trained to argue about medical issues with the surgeon and advocate for the patient. Issues like this are best dealt with at an attending-to-attending level.

 

[dfk]

Was she on amio?

Why would you drop it?

for rhythm control.

it's funny you question the use here, then in your following post,
you use it.

and your blanket statement re: beyond scope and knowledge of CRNAs is a little far fetched that all stool-sitting robots think/know the same.

 

[Planktonmd]

for rhythm control.

it's funny you question the use here, then in your following post,
you use it.

and your blanket statement re: beyond scope and knowledge of CRNAs is a little far fetched that all stool-sitting robots think/know the same.

I am not sure I understand how you want to start a patient who might be discharged home on Amiodarone.
Have you ever seen a patient leave the ASC with a new prescription of Amiodarone?

 

[Planktonmd]

You ever seen the profound bradycardia when mixing the beta blockers and diltiazem?

I usually skip the lopressor and go straight to dilt. if the esmolol doesn't do the trick.

The problem with Diltiazem is that you need to start an infusion while Verapamil can be given as intermittent bolus which is convenient when you don't want to make things too complicated.

 

[Noyac]

The problem with Diltiazem is that you need to start an infusion while Verapamil can be given as intermittent bolus which is convenient when you don't want to make things too complicated.

Very true.

And this is usually what I do.

 

[Planktonmd]

Here is how the story ended:
I insisted that we can't let her go home with a new onset paroxysmal A fib without some CYA plan and told the ENT that if she strokes it would be seen as his fault as well as mine if we did not do something about it, I tried to remain objective and polite.
I called the cardiologist on call and he happened to be at the hospital nearby rounding so he agreed to stop by and take a look.
This cardiologist is aggressive and comes from a military background so he actually wrote a note stating that it's OK to discharge her home and that he will see her in the morning at his office.
He also gave her a prescription of Atenolol.
I don't necessarily agree with his management but I felt that I did my part and there was nothing more I could do.
I posted this case as an example of the daily situations that you have to deal with where you need to try to do the right thing but at the same time avoid rocking the boat too much.

 

[toughlife]

for rhythm control.

it's funny you question the use here, then in your following post,
you use it.

and your blanket statement re: beyond scope and knowledge of CRNAs is a little far fetched that all stool-sitting robots think/know the same.

PLease re-read your post. You make no sense.

This is a medical issue that is NOT to be managed by a nurse. Do you agree?

 

[dfk]

PLease re-read your post. You make no sense.

This is a medical issue that is NOT be managed by a nurse. Do you agree?

i don't disagree

 

[urge]

This cardiologist is aggressive and comes from a military background...

WTF is that supposed to mean? Do they know more medicine than the rest of us, or do they whack their pts without fearing lawsuits since they work for the government? I'm leaning towards the latter.

 

[Planktonmd]

WTF is that supposed to mean? Do they know more medicine than the rest of us, or do they whack their pts without fearing lawsuits since they work for the government? I'm leaning towards the latter.

I think they are used to think less about the legal consequences of their actions since they don't get sued as much.

 

[militarymd]

I think they are used to think less about the legal consequences of their actions since they don't get sued as much.

why don't you do a little research about military medical liability...it's on the internet

 

[Planktonmd]

why don't you do a little research about military medical liability...it's on the internet

Or maybe you could educate us and correct any misunderstanding.

 

[militarymd]

Or maybe you could educate us and correct any misunderstanding.

The only people who cannot bring suit are the folks who are Active Duty. Once you retire, you can sue...dependents can and do sue.

I've been sued a couple of times while AD.

The only thing that AD physicians have in their favor is that they won't lose their personal assets in the suit...the reason for that is because AD physicians have essentially no assets....not like the PP folks.

The government will pay the settlement if there is one, but the provider's name will go into the national practitioner database just like everyone else's....and when you get out of the military, it follows you around just like anyone else.

 

[Planktonmd]

The only people who cannot bring suit are the folks who are Active Duty. Once you retire, you can sue...dependents can and do sue.

I've been sued a couple of times while AD.

The only thing that AD physicians have in their favor is that they won't lose their personal assets in the suit...the reason for that is because AD physicians have essentially no assets....not like the PP folks.

The government will pay the settlement if there is one, but the provider's name will go into the national practitioner database just like everyone else's....and when you get out of the military, it follows you around just like anyone else.

Thank you for the info.
I thought that it was difficult for an active duty soldier to actually decide to sue a physician who is a higher ranking officer unless there is real negligence.

 

[Planktonmd]

Thank you for the info.
I thought that it was difficult for an active duty soldier to actually decide to sue a physician who is a higher ranking officer unless there is real negligence.

Actually that's what you said.
So they can sue after they get discharged?

 

[radslooking]

Here is how the story ended:
I insisted that we can't let her go home with a new onset paroxysmal A fib without some CYA plan and told the ENT that if she strokes it would be seen as his fault as well as mine if we did not do something about it, I tried to remain objective and polite.
I called the cardiologist on call and he happened to be at the hospital nearby rounding so he agreed to stop by and take a look.
This cardiologist is aggressive and comes from a military background so he actually wrote a note stating that it's OK to discharge her home and that he will see her in the morning at his office.
He also gave her a prescription of Atenolol.
I don't necessarily agree with his management but I felt that I did my part and there was nothing more I could do.
I posted this case as an example of the daily situations that you have to deal with where you need to try to do the right thing but at the same time avoid rocking the boat too much.

I'm not exactly sure what you mean re: if she "strokes out". She doesn't need urgent anticoagulation. She can start anticoagulation (if deemed necessary) within the next week. New onset afib isn't more risky for strokes than other types of afib, to my knowledge. If you want to have her seen to work up ischemia as a cause of her afib, or if you feel her rate will be so high as to cause problems, then you can send her to ER or whatever. But the reason I don't think should be "stroke out". my two cents.

 

[Planktonmd]

I'm not exactly sure what you mean re: if she "strokes out". She doesn't need urgent anticoagulation. She can start anticoagulation (if deemed necessary) within the next week. New onset afib isn't more risky for strokes than other types of afib, to my knowledge. If you want to have her seen to work up ischemia as a cause of her afib, or if you feel her rate will be so high as to cause problems, then you can send her to ER or whatever. But the reason I don't think should be "stroke out". my two cents.

You don't think a new onset paroxysmal Afib is an immanent risk for thrombus formation and stroke?
I am not saying you need to anti-coagulate her right now (she just had surgery remember) but if you treat her properly maybe you can put her back in sinus rhythm and not even need anticoagulation.
This is not a patient who went into afib post op and staid there, she was going in and out of AFIB every few minutes.

 

[militarymd]

Actually that's what you said.
So they can sue after they get discharged?

yes

 

[militarymd]

You don't think a new onset paroxysmal Afib is an immanent risk for thrombus formation and stroke?
I am not saying you need to anti-coagulate her right now (she just had surgery remember) but if you treat her properly maybe you can put her back in sinus rhythm and not even need anticoagulation.
This is not a patient who went into afib post op and staid there, she was going in and out of AFIB every few minutes.

A fib is the most common periop arythmia.....see it ALL the time in the unit...and depend on what type of surgery...you can COUNT on it happening.

Anticoagulation...don't even bother thinking about it until after 48 hours.


Like I said, my Cards guy would have done what this guy did.

 

[Planktonmd]

I think a new onset paroxysmal afib with rapid ventricular response post op deserves an admission to the hospital and an early attempt to restore sinus rhythm chemically or electrically.

 

[radslooking]

I think a new onset paroxysmal afib with rapid ventricular response post op deserves an admission to the hospital and an early attempt to restore sinus rhythm chemically or electrically.

i dont disagree with the rvr...but one thing to consider is if you restore sinus without determining if they have a clot (or have been anticoagulated for a period of weeks), their risk of throwing a clot is higher. if you're sure she just went into the bad rhythm, and want to try to get her back to the correct rhythm, then yes, I think that's reasonable.

 

[Planktonmd]

if you restore sinus without determining if they have a clot

She is doing that on her own every few minutes (going from AFIB to SR).
But anyway this whole management debate was not the point of the thread.

 

[cfdavid]

You ever seen the profound bradycardia when mixing the beta blockers and diltiazem?

I usually skip the lopressor and go straight to dilt. if the esmolol doesn't do the trick.

I recently had a case where lopressor dropped the guys BP too much and really didn't touch the rate (only up to 130's).

I put the guy on a cardizem drip (he had h/o paroxysmal Afib) which DID help but only brough the rate down to the 110's, which I accepted until morning. I DID consult cardiology after I added Digoxin with little improvement. Cards saw dude in the a.m., but I wasn't going to wake a cards dude up for that (others may disagree). (I was post-call, so not sure what cards did but may check in today on that patient to see. If so, i'll feedback here).

****My question is, have any of you guys had success with ADDING Digoxin to either a BB or Diltiazem?? I recently saw a presentation by an EP dude saying it was an effective cocktail to control rate. But, he didn't give a dose of Digoxin.

However, when I added the Digoxin, honestly, I didn't have a good reference for dosing, so I went all conservative with 300mcg x 1 only (way below the traditional loading dose). The cardizem, or lopressor gtt's could be titrated, where it seems most useful to have a "go to" Digoxin dose handy for such cases.

Thanks in advance for any input.

cf

 

[cfdavid]

Very true.

And this is usually what I do.

Do you think a bolus of verapamil is more effective than a bolus of say lopressor 5mg IV??

 

[Planktonmd]

Do you think a bolus of verapamil is more effective than a bolus of say lopressor 5mg IV??

Absolutely.
But if you are going to use Verapamil it is better to give small increments and wait (2.5mg every time).
Verapamil can cause profound bradycardia and AV blockade.

As for Digoxin, we used to use it all the time in the past and I think there is no harm of giving a small dose in addition to your usual medications but I would not do a loading dose if I am combining it with a calcium blocker or a beta blocker.
And make sure they don't have WPW before you start playing with Digoxin and Verapamil

 

[cfdavid]

Absolutely.
But if you are going to use Verapamil it is better to give small increments and wait (2.5mg every time).
Verapamil can cause profound bradycardia and AV blockade.

As for Digoxin, we used to use it all the time in the past and I think there is no harm of giving a small dose in addition to your usual medications but I would not do a loading dose if I am combining it with a calcium blocker or a beta blocker.
And make sure they don't have WPW before you start playing with Digoxin and Verapamil

Good advice. Thanks.

cf