A Fib with abberancy - what would you do?

[GasAllDay]

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Hello all, I'm a long-time lurker/admirer, and an M4 applying into anesthesiology. When I was on the cardiology consult team, we got called about the patient below. The case was cancelled right after we were called; but that decision did not appear to be straightforward to me, based on my reading. I would truly appreciate your thoughts; thank you very much in advance for your responses!

Patient is a 72 yo male with hx of ALS, HTN well controlled, stroke 9 years ago, has an implanted pacemaker (unsure why but it was placed sometime after the stroke) that showed A Fib for the past 5 months when it was interrogated. He was started on metoprolol at that time for rate control. Normal echo with EF 50% a month ago. He was asymptomatic when I saw him. Electrolytes were within normal limits. Hgb fine.

He was supposed to go to the OR for elective PEG tube placement; the plan was to do MAC. He was admitted from preop clinic 3 days earlier because HR in 140s, still in A Fib. On the day of surgery, unsustained VTach was called on the tele. However, EKG showed A Fib with abberancy, HR 130s (at least, the cards fellow and I thought so). By the time we got the page and saw the EKG, the anesthesiologist had already cancelled the case. The cardiology fellow told me he would have recommended proceeding with the case and using rate control agents intraop for goal HR <110.

My questions are:
1) Would you proceed with the case? How does the aberrant conduction factor into your decision?
2) What would you use intraop for rate control? Esmolol? IV metoprolol?
3) Would you cancel the case? What's your reason - to rule out ischemia?

 

[nimbus]

ALS patients are extraordinarily fragile. They have zero pulmonary reserve and if they can't eat, they cannot clear their airway either. They do not do well with anesthesia or sedation. The patient and the family need to know that there is a high risk of anesthetic complication for this case and that the complication can precipitate death.

In most other situations, I would proceed after rate control using whatever. IV dilt would be my choice.

In this situation, the cardiology fellow has tunnel vision and only sees the recent "normal" echo and is probably not looking at the whole patient. The patient is more than a heart. It was probably a good cancellation by the anesthesiologist. You need all your ducks lined up before embarking on an anesthetic with these patients.

 

[somedumbDO]

Hello all, I'm a long-time lurker/admirer, and an M4 applying into anesthesiology. When I was on the cardiology consult team, we got called about the patient below. The case was cancelled right after we were called; but that decision did not appear to be straightforward to me, based on my reading. I would truly appreciate your thoughts; thank you very much in advance for your responses!

Patient is a 72 yo male with hx of ALS, HTN well controlled, stroke 9 years ago, has an implanted pacemaker (unsure why but it was placed sometime after the stroke) that showed A Fib for the past 5 months when it was interrogated. He was started on metoprolol at that time for rate control. Normal echo with EF 50% a month ago. He was asymptomatic when I saw him. Electrolytes were within normal limits. Hgb fine.

He was supposed to go to the OR for elective PEG tube placement; the plan was to do MAC. He was admitted from preop clinic 3 days earlier because HR in 140s, still in A Fib. On the day of surgery, unsustained VTach was called on the tele. However, EKG showed A Fib with abberancy, HR 130s (at least, the cards fellow and I thought so). By the time we got the page and saw the EKG, the anesthesiologist had already cancelled the case. The cardiology fellow told me he would have recommended proceeding with the case and using rate control agents intraop for goal HR <110.

My questions are:
1) Would you proceed with the case? How does the aberrant conduction factor into your decision?
2) What would you use intraop for rate control? Esmolol? IV metoprolol?
3) Would you cancel the case? What's your reason - to rule out ischemia?

Look at all the studies slogoff did in 90's hr > 106 dramatic incr in periop cardiac events. After hr control bring to OR

 

[urge]

He was supposed to go to the OR for elective PEG tube placement; the plan was to do MAC.

There. What's not straight forward about that decision making?

The real question is why a service, that is doing a poor job at controlling rapid a fib, pushing for a totally elective case?

Put a dobhoff, do a better job at controlling a fib, and call me when you are ready.

 

[urge]

Hello all, I'm a long-time lurker/admirer, and an M4 applying into anesthesiology. When I was on the cardiology consult team, we got called about the patient below. The case was cancelled right after we were called; but that decision did not appear to be straightforward to me, based on my reading. I would truly appreciate your thoughts; thank you very much in advance for your responses!

Patient is a 72 yo male with hx of ALS, HTN well controlled, stroke 9 years ago, has an implanted pacemaker (unsure why but it was placed sometime after the stroke) that showed A Fib for the past 5 months when it was interrogated. He was started on metoprolol at that time for rate control. Normal echo with EF 50% a month ago. He was asymptomatic when I saw him. Electrolytes were within normal limits. Hgb fine.

He was supposed to go to the OR for elective PEG tube placement; the plan was to do MAC. He was admitted from preop clinic 3 days earlier because HR in 140s, still in A Fib. On the day of surgery, unsustained VTach was called on the tele. However, EKG showed A Fib with abberancy, HR 130s (at least, the cards fellow and I thought so). By the time we got the page and saw the EKG, the anesthesiologist had already cancelled the case. The cardiology fellow told me he would have recommended proceeding with the case and using rate control agents intraop for goal HR <110.

My questions are:
1) Would you proceed with the case? How does the aberrant conduction factor into your decision?
2) What would you use intraop for rate control? Esmolol? IV metoprolol?
3) Would you cancel the case? What's your reason - to rule out ischemia?

You understand that the patient got admitted to treat his afib with RVR before the procedure, right? However under your care you send the patient to have the procedure still with afib and RVR and now with new onset wide complexes which your "experienced" fellow is calling aberrant conduction.

The guy has been 3 days in the hospital for a fib treatment... and now is even worse than he started.

And your big recommendation after wasting the poor guys time is to give some metoprolol? WTF have been doing for your patient?

This is a travesty.

 

[Colba55o]

Your cardiology fellow (and you for that matter) should get familiar with the ACC/AHA guidelines for non cardiac surgery

circ.ahajournals.org/content/116/17/1971.full.pdf

Based on the algorithm this is NOT an emergent surgery. The patient does have an active cardiac condition which must be evaluated and treated. It doesnt sound like it was treated effectively, so why should the anesthesiologist be responsible for treating it intraoperatively?

PEG tube insertion under MAC sounds like a benign case, but what happens with the surgical intern perfs the stomach thru and thru and the patient winds up with free air in the abdomen? Take this patient with poorly controlled A-fib with aberrancy for an ex-lap? May as well call the funeral home on the way to the OR

 

[urge]

Based on the algorithm this is NOT an emergent surgery. The patient does have an active cardiac condition which must be evaluated and treated. It doesnt sound like it was treated effectively, so why should the anesthesiologist be responsible for treating it intraoperatively?

They haven't controlled the rate it in 3 days despite being admitted just for that, but suddenly it is my responsibility to control it at the last minute?

Unbelievable.

 

[pgg]

Cut the OP some slack, he's a student here asking why his fellow did what he did and why the anesthesiologist did what he did. 🙂

 

[urge]

Do you want me to cut him another week to treat a fib with RVR? They should get consent from the patient, the surgeon, and the anesthesiologist then, if they plan to waste everybody's time.

 

[caligas]

Cut the OP some slack, he's a student asking why his fellow did what he did and why the anesthesiologist did what he did. 🙂

Seriously. A med student posts an interesting case and asks for input and we attack! dont let 'em get you down, OP.

 

[PonyUp]

Do you want me to cut him another week to treat a fib with RVR? They should get consent from the patient, the surgeon, and the anesthesiologist then, if they plan to waste everybody's time.

I don't know any medical students that "treat" anything. Do you? So why is it his problem?

OP - thank you for posting this case.

 

[pgg]

Do you want me to cut him another week to treat a fib with RVR? They should get consent from the patient, the surgeon, and the anesthesiologist then, if they plan to waste everybody's time.

I don't disagree that the patient ought to have been managed differently by cardiology, but that's on the fellow and cardiology attending (if the attending was even involved). You can't blame a week (or was it 3 days?) of suboptimal management on the rotating med student, and to his credit, the med student IS doing his job ... researching, studying, and learning about the issue.

When a cardiologist "clears" a patient for spinal anesthesia I don't blame the med student rotating with him.

 

[urge]

When I say you, or your, I mean the cardiology service not the student per se. We all know this is above his pay grade.

 

[Planktonmd]

The anesthesiologist did not think it's worth taking a risk for a purely elective procedure... nothing wrong with that!
The patient had a history of Afib but the widened QRS that the OP calls abbarent conduction is new...
So we are facing a new onset of widened QRS that some cardiology fellow wants to call "abbarent conduction" to avoid any further workup.
Could that be some electrolyte abnormality in this guy who is obviously having trouble swallowing because of his neurological disease?
Hyperkalemia? Hypocalcemia? Hypomagnesimeia....
Not everything the cardiology fellow says is always the absolute truth!

 

[norwood]

Hello all, I'm a long-time lurker/admirer, and an M4 applying into anesthesiology. When I was on the cardiology consult team, we got called about the patient below. The case was cancelled right after we were called; but that decision did not appear to be straightforward to me, based on my reading. I would truly appreciate your thoughts; thank you very much in advance for your responses!

Patient is a 72 yo male with hx of ALS, HTN well controlled, stroke 9 years ago, has an implanted pacemaker (unsure why but it was placed sometime after the stroke) that showed A Fib for the past 5 months when it was interrogated. He was started on metoprolol at that time for rate control. Normal echo with EF 50% a month ago. He was asymptomatic when I saw him. Electrolytes were within normal limits. Hgb fine.

He was supposed to go to the OR for elective PEG tube placement; the plan was to do MAC. He was admitted from preop clinic 3 days earlier because HR in 140s, still in A Fib. On the day of surgery, unsustained VTach was called on the tele. However, EKG showed A Fib with abberancy, HR 130s (at least, the cards fellow and I thought so). By the time we got the page and saw the EKG, the anesthesiologist had already cancelled the case. The cardiology fellow told me he would have recommended proceeding with the case and using rate control agents intraop for goal HR <110.

My questions are:
1) Would you proceed with the case? How does the aberrant conduction factor into your decision?
2) What would you use intraop for rate control? Esmolol? IV metoprolol?
3) Would you cancel the case? What's your reason - to rule out ischemia?

To go back to the original question:

1. No way. AF with a pulse of 130 will get an elective case cancelled - clearly the AF isn't under control.
2. If this were something emergent instead of a PEG tube, and I therefore had to go to OR with him, probably Cardizem.
3. Yep. Reason is that his AF is not rate controlled, therefore pt is not optimized. He'll never be low risk, but he doesn't have to be quite as high risk as he currently is.

As nimbus mentioned, this is also the kind of case where anesthesia, surgery, pt, and family all need to have a hard talk about the risks, benefits, and goals of care.

 

[GasAllDay]

OP here, thank you all for your replies; I truly do appreciate it! And thank you to those who defended me. I don't take it personally because I try to remain aware of the limits of my knowledge, and actively explore those. I am here to learn, even/especially from situations that are very straightforward to you all. And I thought it would be a great exercise instead of agonizing over the match.

A different team was managing the patient, we just got called on what was seen on tele. By the time we were informed about this patient, all the above events had already happened (up to the case getting cancelled), and this conversation was just between me and the fellow. And simply me trying to learn from this case; I was not trying to take sides.

Thank you, planktonmd, for mentioning electrolytes - a few things I did consider were: electrolyte abnormalities (especially for an ALS patient at risk for malnutrition), anemia, hypoxia, and structural heart disease (if known). As I mentioned above, electrolytes were within normal limits: Na 138, K 4.2, Mg 2.1, Calcium was low but ionized Ca was normal, albumin 2.5 or in that neighborhood. Hgb 8.4; he had normal work of breathing, comfortable on room air. He had no valvular disease. EF 50% on TTE, nothing really stood out from what I remember (maybe grade 1 diastolic dysfunction). No signs of infarct/ischemia on 12-lead EKG.

Is there anything else you would have considered?

 

[GasAllDay]

To go back to the original question:

1. No way. AF with a pulse of 130 will get an elective case cancelled - clearly the AF isn't under control.
2. If this were something emergent instead of a PEG tube, and I therefore had to go to OR with him, probably Cardizem.
3. Yep. Reason is that his AF is not rate controlled, therefore pt is not optimized. He'll never be low risk, but he doesn't have to be quite as high risk as he currently is.

As nimbus mentioned, this is also the kind of case where anesthesia, surgery, pt, and family all need to have a hard talk about the risks, benefits, and goals of care.

Thank you for your response.
Yes, nimbus and norwood are absolutely right about his goals of care here. Unfortunately, that's all another story. It had been discussed with him and his family before.
This patient has been through so much, and has a lot of family support. When I was asking him about his expectations and goals of care, there seemed to be a disparity between what he seemed to want and what his family wanted. Of course, ultimately, it is his decision. But from our conversation it sounded like they were at different stages of grief; his family members were a bit angry and had persuaded him to remain full code.

 

[urge]

Thank you, planktonmd, for mentioning electrolytes - a few things I did consider were: electrolyte abnormalities (especially for an ALS patient at risk for malnutrition), anemia, hypoxia, and structural heart disease (if known). As I mentioned above, electrolytes were within normal limits: Na 138, K 4.2, Mg 2.1, Calcium was low but ionized Ca was normal, albumin 2.5 or in that neighborhood. Hgb 8.4; he had normal work of breathing, comfortable on room air. He had no valvular disease. EF 50% on TTE, nothing really stood out from what I remember (maybe grade 1 diastolic dysfunction). No signs of infarct/ischemia on 12-lead EKG.

Is there anything else you would have considered?

Considered regarding what?

I don't understand what you are trying to figure out by the above.

What is your question?
1 Is it why is he in afib? - Who knows! If you figure that one out you might get the Nobel prize, not that it means much since Obama has one.
2 Is it why is he in RVR? - Who knows!
3 Is it why is he having new wide complexes? - Who knows!
4 Is it why cardiology is failing to treat this patient? - Who knows!
5 Is it why did it get cancelled? We already told you that one.

What do any of your "considerations" have to do with the case?

 

[urge]

I don't understand what you are trying to figure out by the above.

What is your question?
1 Is it why is he in afib? If you figure that one out you might get the Nobel prize, not that it means much since Obama has one.
2 Is it why is he in RVR?
3 Is it why is he having new wide complexes?
4 Is it why cardiology is failing to treat this patient?
5 Is it why did it get cancelled? We already told you that one.

What do any of your "considerations" have to do with the case?

What I consider relevant is the attending cardiologist's impression of the wide complexes and whether it was treated or not. Not your random differential list that can be applied to any patient under any situation.

 

[urge]

..............

 

[nimbus]

Been a few days. Any followup? Was he ever rate controlled?

 

[Bostonredsox]

Maybe I'm missing something here but why is his guy going to the or for a peg placement? And why is anesthesia involved? At my shop these pts go to endo, get a pulse ox, etco2 monitor and tele monitor on them, 2 of versed 50 of fentanyl and a peg put in and here back in there room on the floor in 30 minutes. It falls under moderate sedation which many non anesthesia providers perform on their own. If propofol is involved gas attending/CRNA is involved. Otherwise not.

Aside from that, agree that any fib pt whose rate is still above 100 isn't ideally controlled and there regimen needs to be adjusted, provided there is nothing else wrong (lytes, volume status, etc)

 

[Bostonredsox]

Duplicate

 

[Jay K]

OP, thanks for asking your question here.

Excellent responses.

Quality educational thread.

 

[GasAllDay]

Thank you, everyone, for your responses. I really appreciate it.

So the patient's HR was better controlled, and he ended up going to the OR for his PEG tube. His code status ended up getting changed a few days before discharge.

Maybe I'm missing something here but why is his guy going to the or for a peg placement? And why is anesthesia involved? At my shop these pts go to endo, get a pulse ox, etco2 monitor and tele monitor on them, 2 of versed 50 of fentanyl and a peg put in and here back in there room on the floor in 30 minutes. It falls under moderate sedation which many non anesthesia providers perform on their own. If propofol is involved gas attending/CRNA is involved. Otherwise not.

Aside from that, agree that any fib pt whose rate is still above 100 isn't ideally controlled and there regimen needs to be adjusted, provided there is nothing else wrong (lytes, volume status, etc)

The purpose of the PEG tube was to maintain nutrition while he can still eat. Although, from speaking with him, eating was becoming an arduous task. For ALS patients with bulbar symptoms, those who received enteral nutrition via a PEG tube were observed to have lower mortality (effect seen after 6 months) when compared to matched ALS patients who refused a PEG tube. Also better nutritional status, improved BMI, and better of quality of life.

Citation for one article I found: Mazzini, L. et al. "Percutaneous Endoscopic Gastrostomy and Enteral Nutrition in Amyotrophic Lateral Sclerosis." J Neurol. 1995 Oct;242(10):695-8.

I don't know why his was not done under moderate sedation. I speculate that it may have been due to his limited pulmonary reserve, possibly being unable to protect his airway, or risk of aspiration, given his current symptoms.

 

[Bostonredsox]

Thank you, everyone, for your responses. I really appreciate it.

So the patient's HR was better controlled, and he ended up going to the OR for his PEG tube. His code status ended up getting changed a few days before discharge.



The purpose of the PEG tube was to maintain nutrition while he can still eat. Although, from speaking with him, eating was becoming an arduous task. For ALS patients with bulbar symptoms, those who received enteral nutrition via a PEG tube were observed to have lower mortality (effect seen after 6 months) when compared to matched ALS patients who refused a PEG tube. Also better nutritional status, improved BMI, and better of quality of life.

Citation for one article I found: Mazzini, L. et al. "Percutaneous Endoscopic Gastrostomy and Enteral Nutrition in Amyotrophic Lateral Sclerosis." J Neurol. 1995 Oct;242(10):695-8.

I don't know why his was not done under moderate sedation. I speculate that it may have been due to his limited pulmonary reserve, possibly being unable to protect his airway, or risk of aspiration, given his current symptoms.

Im not sure why you posted the lit on peg tubes in als....we all know why he got the peg tube. he is most definitely a peg candidate. my question was why he needed to go to the or for it and why he needed general anesthesia. this would be a versed/fentanyl or mac case with propofol in the endo suite at my shop.

 

[GasAllDay]

Im not sure why you posted the lit on peg tubes in als....we all know why he got the peg tube. he is most definitely a peg candidate. my question was why he needed to go to the or for it and why he needed general anesthesia. this would be a versed/fentanyl or mac case with propofol in the endo suite at my shop.

Can't answer that for you. At our institution it's typically MAC, at least the PEG tube cases I've seen.

 

[fakin' the funk]

The purpose of the PEG tube was to maintain nutrition while he can still eat. Although, from speaking with him, eating was becoming an arduous task. For ALS patients with bulbar symptoms, those who received enteral nutrition via a PEG tube were observed to have lower mortality (effect seen after 6 months) when compared to matched ALS patients who refused a PEG tube. Also better nutritional status, improved BMI, and better of quality of life.

And decreased dignity. Maybe the patients who refused PEG did so for a damn good, personal reason. The intervention this study looks at isn't the PEG per se but the patient's choice to have the PEG. That's different.

Not to mention, this study is from 1995, long enough ago for practices re: sacral decub prophylaxis, DVT prophylaxis, and prolonged vent/trach care were probably vastly inferior to now.