Post cross clamp off V fib

[urge]

How do you manage it?

1 let the surgeon defibrillate as many times as needed, no drugs at all.
2 defibrillate 4 or 5 times, then add a drug
3 prophylactic drug before clamp is off
4 if you are giving a drug, which drug? Amio, lido, magnesium, epi, esmolol, other?

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[WholeLottaGame7]

How do you manage it?

1 let the surgeon defibrillate as many times as needed, no drugs at all.
2 defibrillate 4 or 5 times, then add a drug
3 prophylactic drug before clamp is off
4 if you are giving a drug, which drug? Amio, lido, magnesium, epi, esmolol, other?

Defibrillate 2 or 3 times, lido and mag, defibrillate a couple more times. If VT or some other rhythm, maybe amio. Have never seen VF refractory to all of that.

 

[thinkorswim]

I usually start with lidocaine and let the surgeon defibrillate once or twice. If that doesn't work, then amiodarone with additional defibrillations.

 

[sethco]

Mag before clamp comes off depending on cardioplegia solution. If VFib/Tach still occurs, Lidocaine as surgeon reaches for paddles. If refractory to >2 shocks, Amiodarone bolus followed by infusion. Also make sure no air pockets in LV or pulmonary veins, no electrolyte abnormalities and pt is sufficiently rewarmed (I.e. Differential Diagnosis, etc)

 

[urge]

Seems like people pull the trigger on drugs pretty quickly. I usually let them defibrillate a bunch of times before using any antiarhythmic.

 

[sevoflurane]

Our plegia solution has mag in it. If we have significant arrhytmias prebypass our perfusionist usually gives 100mg of lido b/4 coming off.
Defibrillate several times b4 amio as it can and does drop the pressure if given too fast while attempting to seperate from CPB.

 

[WholeLottaGame7]

Our plegia solution has mag in it. If we have significant arrhytmias prebypass our perfusionist usually gives 100mg of lido b/4 coming off.
Defibrillate several times b4 amio as it can and does drop the pressure if given too fast while attempting to seperate from CPB.

Yeah we use the Del Nido stuff, also, but I still wonder what the actual mag level is. Like is it normal, or better but still low? Don't think I've ever sent a mag right after cross-clamp comes off but I'm kind of curious.

 

[sevoflurane]

Yeah we use the Del Nido stuff, also, but I still wonder what the actual mag level is. Like is it normal, or better but still low? Don't think I've ever sent a mag right after cross-clamp comes off but I'm kind of curious.

I never check mag levels intra-op. There is however a large body of evidence that suggests that POAF is reduced with magnesium administration perioperatively.
As per the AATS, it is a class IIb indication for prevention of POAF. Hypomagnasemia seems to be a common electrolyte abnormality in cardiac and spine cases.
But you know me... I love mag.

From the AATS:

-See top of page e166 and the table on e167-

http://aats.org/multimedia/files/Guidelines/AFIB-guidelines.pdf

 

[KungPOWChicken]

We run a magnesium infusion at 1gm/hr throughout the case. Lidocaine for refractory v.fib.

 

[urge]

We run a magnesium infusion at 1gm/hr throughout the case. Lidocaine for refractory v.fib.

We would have magnesium toxicity on every case if we did that. Our surgeons are too slow.

 

[Libertas]

OB runs it at 2gm / hour after a 4gm bolus no? If they trust OB with it how dangerous could it be?

 

[KungPOWChicken]

We would have magnesium toxicity on every case if we did that. Our surgeons are too slow.

Ordered as a 6gm bag so max of 6gm to clarify

 

[drmwvr]

Pretty high threshold for amiodarone. Once organized rhythm is restored, mag/lido is plenty especially with AVR's. But that's with less than 1 hr pump times.