Anxiety and A. fib w/ RVR

[DrOwnage]

Recently overnight in the ICU, 70 y/o s/p LUL lobectomy for adenocarcinoma, a fib, HTN, HLD. Came out of surgery in a fib with RVR 2 days prior in the 140s, w/ steady pressures. Hard to rate control, but manageable the past 2 days. At 3AM get a call, hes a. fib in the 160-170s pressure 120/60, received 1 x metop push during the day, 25 mg atenolol BID that day. At bedside patient is extremely anxious, excessively worried about his heart rate, however not fidgety or agitated. Adminstered 1 x 5mg metop does not budge. Patient unable to be consoled verbally, states hes having a panic attack.

Weighing options (haldol, ativan, precedex), I went with low dose ativan x 1 in the setting of his very fast heart rate (higher than age predicted) and didn't want to give haldol or QTc prolonging medications. I did this knowing full well the stigma against benzos (however, dose dependent) in the ICU setting and having read the literature. 5 minutes afterwards, patient calmed down, heart rate at 115, gave another IV metop 5mg, which brought his HR down to 100.

Next morning post call got reemed with a text from the CT fellow saying how could you use lorazepam!?! Looking back on it I probably should have used low dose precedex to calm him down, but I didn't think what I did was necessarily that bad and in this setting was effective. Thoughts?

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[engineeredout]

Sounds like a pile of Monday morning quarterbacking by a surgeon (go figure).

I don't think anyone can argue that there is never a place for Benzos. The problem with Benzos in the ICU comes about from two places: someone is on a continuous infusion of essentially whiskey and everyone wonders why they won't wake up appropriately, or people are trying to treat delirium with a class of drugs that causes more delirium, causing them to get more benzos, causing more delirium, more benzos, and the cycle continues.

Based on what you're saying, it doesn't sound like you were treating delirium. If I was someone without medical knowledge laying in the ICU post-major procedure with a continuously alarming monitor saying my HR was 150s, I'd probably be anxious too. He is going to release all his endogenous catacholamines, which are only going to exacerbate his underlying AF. You essentially proved this by giving him an av nodal blocker which didn't do anything. All you need is to give him mega doses of rate controlling meds, they finally kick in when he goes to sleep, and everyone wonders why his HR is 30. You used a single dose of a drug, made the patient feel better, made the nurses feel better, and got your patient through the night completely stable. Using Precedex for a panic attack seems like an expensive overkill.

Again, based on what you said, it sounds like you did right by your patient. **** the Monday morning quarterbacking.

 

[DoubleBogey]

Agree with single dose bz - not crazy for tx of symptoms anxiety related. Precedex would be overkill for anxiety-related afib not related to withdraw in the ICU pts I tx at my home place (rural hospital). CCB vs BB for rapid afib (excluding HFrEF) or amio is another debate.

Pt isn’t intubated and no adverse event occurred = success in my mind.

 

[Psai]

I think you did just fine. Our surgeons are good but they don't know as much about physiology and critical care as they think they do. Sounds like this fellow would like a few middle of the night calls about the management of their patients since they enjoy being involved.

 

[cbrons]

Recently overnight in the ICU, 70 y/o s/p LUL lobectomy for adenocarcinoma, a fib, HTN, HLD. Came out of surgery in a fib with RVR 2 days prior in the 140s, w/ steady pressures. Hard to rate control, but manageable the past 2 days. At 3AM get a call, hes a. fib in the 160-170s pressure 120/60, received 1 x metop push during the day, 25 mg atenolol BID that day. At bedside patient is extremely anxious, excessively worried about his heart rate, however not fidgety or agitated. Adminstered 1 x 5mg metop does not budge. Patient unable to be consoled verbally, states hes having a panic attack.

Weighing options (haldol, ativan, precedex), I went with low dose ativan x 1 in the setting of his very fast heart rate (higher than age predicted) and didn't want to give haldol or QTc prolonging medications. I did this knowing full well the stigma against benzos (however, dose dependent) in the ICU setting and having read the literature. 5 minutes afterwards, patient calmed down, heart rate at 115, gave another IV metop 5mg, which brought his HR down to 100.

Next morning post call got reemed with a text from the CT fellow saying how could you use lorazepam!?! Looking back on it I probably should have used low dose precedex to calm him down, but I didn't think what I did was necessarily that bad and in this setting was effective. Thoughts?

Esmolol is ideal for post-surgical AFRVR

 

[AdmiralChz]

Well, you correctly surmised that the acute increase in HR was due to anxiety and you treated accordingly. PO seroquel is another popular ICU option.

In general, though, anti-arrhythmics like amiodarone, beta blockers like metoprolol and calcium channel blockers like diltiazem are your typical therapies for rapid a fib. If refractory, you can hit it old school with digoxin - just watch the K.

I wouldn’t reach for Precedex for anxiety, in this case. You can get some bradycardia (mostly with blouses, in my experience), but it’s quite sedating which isn’t exactly the goal for a post-op patient that should be advancing.

 

[leviathan]

Use an anxiolytic for anxiety if that is the source of their distress. If the distress is from delirium, that's a different story. Whoever reprimanded you might want to go back and read up a little a bit on pain sedation and agitation in the ICU.

 

[anbuitachi]

Don't think you did anything wrong. It's just a CT fellow no big deal. I would've used midazolam though