Back to the basic stuff (case discussion)

[anbuitachi]

lumbar fusion surgery L3-5, in 70 year old male in prone position, with history of htn, diabetes, cad
EKG sinus brady
Labs unremarkable

In middle of surgery with 1 hour left to surgery, patient develop rapid narrow complex tachycardia to 130s. Initially appeared irregular, but then regular. Couldnt definitely see P waves on the OR monitors with 5 lead ekg. otherwise nothing remarkable about surgery. No excess blood loss.

vagal maneuvers ineffective. 100mg of esmolol was given in span of few minutes with no change in rate at all. MAP > 65 entire time. Dilt ordered from pharmacy, estimated time to arrival 45 minutes.

What sequence of steps would you do in this situation?
How many of you would push adenosine in the prone position?

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[vector2]

lumbar fusion surgery L3-5, in 70 year old male in prone position, with history of htn, diabetes, cad
EKG sinus brady
Labs unremarkable

In middle of surgery with 1 hour left to surgery, patient develop rapid narrow complex tachycardia to 130s. Initially appeared irregular, but then regular. Couldnt definitely see P waves on the OR monitors with 5 lead ekg. otherwise nothing remarkable about surgery. No excess blood loss.

vagal maneuvers ineffective. 100mg of esmolol was given in span of few minutes with no change in rate at all. MAP > 65 entire time. Dilt ordered from pharmacy, estimated time to arrival 45 minutes.

What sequence of steps would you do in this situation?
How many of you would push adenosine in the prone position?

Put the pads on under the drapes and tell circulator to make sure crash cart is in the core. Send an abg, chemistry, mag, phos, trop, H&H. Not really panicking (don’t need adenosine or cardioversion just yet) since he’s got hemodynamically stable SVT. Call pharmacy back and see if you can get some verapamil and amiodarone up to the room any quicker than dilt. Start prophylactic neo gtt. Try metop 2.5-5mg just to make sure esmolol wasn’t a dud. If no effect, give 2.5 mg of verap at a time up to 10mg if pt has baseline normal EF. If can’t get verap, try your best to confirm it’s not WPW with concomitant afib and give amio 150. If gets unstable at any point, just synchronize cardiovert at 200 since he’s already under general anesthesia. No need to make everyone’s starfish quiver with an 8 second post-adenosine pause. Finish the surgery, get 12 lead, bedside echo, call cards.

 

[Planktonmd]

lumbar fusion surgery L3-5, in 70 year old male in prone position, with history of htn, diabetes, cad
EKG sinus brady
Labs unremarkable

In middle of surgery with 1 hour left to surgery, patient develop rapid narrow complex tachycardia to 130s. Initially appeared irregular, but then regular. Couldnt definitely see P waves on the OR monitors with 5 lead ekg. otherwise nothing remarkable about surgery. No excess blood loss.

vagal maneuvers ineffective. 100mg of esmolol was given in span of few minutes with no change in rate at all. MAP > 65 entire time. Dilt ordered from pharmacy, estimated time to arrival 45 minutes.

What sequence of steps would you do in this situation?
How many of you would push adenosine in the prone position?

Patient is hemodynamically stable, so keep on going with surgery, give Phenlyephrine if BP goes down which could help you return him to SR with reflex bradycardia. Verapamil bolus can be an option too. No reason to give Adenosine.
This might be sick sinus syndrome (brady at baseline) and likely the patient has paroxysmal Afib all the time.

 

[coffeebythelake]

In addition to what everyone else has said, I would also check w surgeon if they did anything at the time of the arrhythmia.

 

[Hork Bajir]

Agree with everything said. Fine to screw around and to break it, just gotta remember that anything you try risks making a stable situation devolve into an unstable one. FWIW if you’ve been practicing yoga you might be able to get a 12 lead under the drapes (questionable whether it’s with the acrobatics and likelihood of getting drool on your face)

Curious what ppl would be doing if we had the same scenario but a stable WCT instead?

 

[Planktonmd]

Agree with everything said. Fine to screw around and to break it, just gotta remember that anything you try risks making a stable situation devolve into an unstable one. FWIW if you’ve been practicing yoga you might be able to get a 12 lead under the drapes (questionable whether it’s with the acrobatics and likelihood of getting drool on your face)

Curious what ppl would be doing if we had the same scenario but a stable WCT instead?

This is where you need to look at the whole picture to come up with a reasonable plan of action:
If there is no P waves and you have reasons to think this might be VT (cardiac history), then you need to place pads on the patient, abort the surgery as quickly as possible and flip the patient supine.
If he becomes hypotensive while you are working on flipping supine you can try some Amiodarone.
If your clinical judgement is that this is likely an SVT with aberrant conduction then maybe you have more time, and if the patient remains stable you might still be able to finish the surgery.

 

[anbuitachi]

Put the pads on under the drapes and tell circulator to make sure crash cart is in the core. Send an abg, chemistry, mag, phos, trop, H&H. Not really panicking (don’t need adenosine or cardioversion just yet) since he’s got hemodynamically stable SVT. Call pharmacy back and see if you can get some verapamil and amiodarone up to the room any quicker than dilt. Start prophylactic neo gtt. Try metop 2.5-5mg just to make sure esmolol wasn’t a dud. If no effect, give 2.5 mg of verap at a time up to 10mg if pt has baseline normal EF. If can’t get verap, try your best to confirm it’s not WPW with concomitant afib and give amio 150. If gets unstable at any point, just synchronize cardiovert at 200 since he’s already under general anesthesia. No need to make everyone’s starfish quiver with an 8 second post-adenosine pause. Finish the surgery, get 12 lead, bedside echo, call cards.

any reason why metoprolol may work when a good dose of esmolol did nothing? both b1 selective blockers.

if the patient had moderate HF, would you wait for the dilt instead of going for verap? whats your preferred dosing for dilt?


you dont like 8 second adenosine pauses? it's kind of amusing watching it stop and then come back again


Anyway so we let the case proceed since he's stable. Surgeon informed and they ended up finishing in 40 minutes. BB didnt do anything. Did give phenyleprine but didnt anything to HR either. CCB didnt arrive before case finished. Didnt feel like breaking the crash cart just for adenosine/amiodarone. 12 lead EKG done in PACU showed A flutter. Cards consulted and TTE was normal and he ended up converting back to sinus brady with intermittent reversal to a flutter. He was placed on PO dilt and metoprolol.

 

[anbuitachi]

Agree with everything said. Fine to screw around and to break it, just gotta remember that anything you try risks making a stable situation devolve into an unstable one. FWIW if you’ve been practicing yoga you might be able to get a 12 lead under the drapes (questionable whether it’s with the acrobatics and likelihood of getting drool on your face)

Curious what ppl would be doing if we had the same scenario but a stable WCT instead?

i would need to be practicing yoga even to place pads on under the drapes in this prone patient on the spine table...

 

[drmwvr]

Surprised no one suggested dig...takes a while to work, but when B1, CCB and amio fail....Adenosine failure would lower suspicion threshold for atrial arrythmia tho...

 

[vector2]

any reason why metoprolol may work when a good dose of esmolol did nothing? both b1 selective blockers.

if the patient had moderate HF, would you wait for the dilt instead of going for verap? whats your preferred dosing for dilt?


you dont like 8 second adenosine pauses? it's kind of amusing watching it stop and then come back again


Anyway so we let the case proceed since he's stable. Surgeon informed and they ended up finishing in 40 minutes. BB didnt do anything. Did give phenyleprine but didnt anything to HR either. CCB didnt arrive before case finished. Didnt feel like breaking the crash cart just for adenosine/amiodarone. 12 lead EKG done in PACU showed A flutter. Cards consulted and TTE was normal and he ended up converting back to sinus brady with intermittent reversal to a flutter. He was placed on PO dilt and metoprolol.

Metoprolol is in every Pyxis, it’s safe, and there’s a small chance that its receptor interactions and affinity may vary enough to allow it to have an effect. In general, though, I think BB are almost always useless for SVTs compared to CCB.

If pt had non-decompensated moderate HF I would still give 2.5 of verap and then titrate future boluses very slowly while waiting for amiodarone instead of dilt drip. It’s not necessarily state of the art evidence based, but in the unit I don’t want to turn my back and then see the nurse who’s blindly following the HR has turned the dilt to 20 an hour on some guy with LVEF 30%.

Long story short, for a flutter or afib RVR I like an initial BB challenge (usually doesn’t work) then proceed immediately to verap 2.5-5 or dilt 5-10 slow IV push for immediate control and then start amio. Amio is extraordinarily safe and effective imo, not to mention the 150 mg IV load over 10 min can be given numerous times on top of the currently running maintenance gtt. We do have to be cognizant of heart block and severe brady upon conversion though bc the guy was already sinus brady at baseline.

 

[MirrorTodd]

I'd need to check our carts, but I know for sure we at least have amio stocked, fairly sure we stock Dilt in them, but I could be wrong. Is it common for the anesthesia carts to strictly have beta blockers and nothing else on the private practice side?

 

[Arch Guillotti]

Dilt ordered from pharmacy, estimated time to arrival 45 minutes.

This is a problem. There has to be a faster way to get it. You just have to figure out how bad you want it.

 

[anbuitachi]

This is a problem. There has to be a faster way to get it. You just have to figure out how bad you want it.

definitely not ideal. but it was 7pm and things really slow down after hours

 

[deleted162650]

i would need to be practicing yoga even to place pads on under the drapes in this prone patient on the spine table...

View attachment 312136

Think Michaelangelo painting the Sistine Chapel.

 

[anbuitachi]

Surprised no one suggested dig...takes a while to work, but when B1, CCB and amio fail....Adenosine failure would lower suspicion threshold for atrial arrythmia tho...

not a fan of dig, but then again b/c im not a fan i dont use it so im not experienced in using it. last time i used it was in the ICU as a resident back in the old days

 

[deleted697127]

i would need to be practicing yoga even to place pads on under the drapes in this prone patient on the spine table...

View attachment 312136

Lol thanks for the visual. I think we’ve all done spine cases. Make the surgeons step back, have the nurse lift the drapes, place one under axilla, and the other below the contralateral scapula. They don’t need to be in the perfect position but this is doable in an urgent situation.

 

[anbuitachi]

Lol thanks for the visual. I think we’ve all done spine cases. Make the surgeons step back, have the nurse lift the drapes, place one under axilla, and the other below the contralateral scapula. They don’t need to be in the perfect position but this is doable in an urgent situation.

thats definitely going to need yoga experience. the picture was to show what type of table we use. different centers use different setups, this one is harder to place in my opinion than some of the other setups.

 

[Lidolover]

Fluids ... either u had given too much or too little...

 

[deleted875186]

Dig will definitely not work fast enough, might as well just wait for the case or be done.

Dilt and verapamil, verapamil is more effective and less likely to cause hypotension.

Esmolol and metoprolol are equally crappy in rate controlling AF.

there is probably no situation in a GA case were I would give adenosine that I can think of. Either chemically rate control or cardiovery.

 

[deleted162650]

Dilt and verapamil, verapamil is more effective and less likely to cause hypotension.

Have a source/evidence on that?

I tend to think the opposite

 

[anbuitachi]

so it sounds like a lot of people here dont like adenosine.
any bad experiences?

 

[Planktonmd]

so it sounds like a lot of people here dont like adenosine.
any bad experiences?

I think most people don't enjoy seeing a patient in asystole in the prone position.

 

[anbuitachi]

I think most people don't enjoy seeing a patient in asystole in the prone position.

some people here make it sound like they dont like it in any position

 

[deleted126335]

some people here make it sound like they dont like it in any position

I love giving adenosine just for the reaction of the staff. Enhanced reaction effect if the patient is awake.

 

[IMGASMD]

I love giving adenosine just for the reaction of the staff. Enhanced reaction effect if the patient is awake.

Intern year, had a cardioversion done on someone who’s “relatively” healthy in icu, by a decent cardiologist. Lost pulse, that was it. He wasn’t unstable, just very difficult converting rhythm.

Ever since then, anyone messes with the tinker..... I get a little nervous. PTSD I suppose. So definitely no adenosine in prone position for me, unless absolutely necessary.

 

[anbuitachi]

Intern year, had a cardioversion done on someone who’s “relatively” healthy in icu, by a decent cardiologist. Lost pulse, that was it. He wasn’t unstable, just very difficult converting rhythm.

Ever since then, anyone messes with the tinker..... I get a little nervous. PTSD I suppose. So definitely no adenosine in prone position for me, unless absolutely necessary.

then i guess the question is if the case had hours to go, and you couldnt rate control it with anything, amio included, would you Cardiovert with pads on.. prone... or would you tell them to stop , flip supine, cardiovert. or would you just ride out the HR for hours until the end of the case..

 

[vector2]

then i guess the question is if the case had hours to go, and you couldnt rate control it with anything, amio included, would you Cardiovert with pads on.. prone... or would you tell them to stop , flip supine, cardiovert. or would you just ride out the HR for hours until the end of the case..

Cardiovert prone since odds of total asystole are pretty low. If after he is sinus brady but stable, give a bit of glyco. If does go asystole or symptomatic brady, transcutaneous pace for a couple min + glyco and/or ephedrine to see if he recovers his own rhythm. If still asystole or Mobitz type II or complete HB continue TCP, abort case and flip back over.

Have a source/evidence on that?

I tend to think the opposite

I find verapamil more effective and more likely to cause hypotension.

 

[deleted162650]

I find verapamil more effective and more likely to cause hypotension.

I’ve always though of Dilt as Verapamil Lite

 

[drmwvr]

I find verapamil more effective and more likely to cause hypotension.

I think the hypotension after a CCB in this setting comes in the context of prior attempted (aggressive) therapy with bb's, amio etc.... IME stuff like verapamil is a lot easier to manage by itself.

 

[anbuitachi]

BestBets: Which is the best calcium channel blocker for controlling the ventricular rate in patients with atrial fibrillation?

Small studies and all prior to 2006.

The three studies identified were remarkably concordant in their findings; there was no significant difference in terms of heart rate limitation, but verapamil therapy was associated with more symptomatic hypotension. This hypotensive effect of verapamil makes biological sense because Bohm and colleagues4, using human papillary muscle, found that it had nearly three times the negative inotropic effects of diltiazem.

Also noticed the third study say
" 3. There was no significant difference between any of the calcium channel blockers. However, they were all significantly better than digoxin "

 

[vector2]

I think the hypotension after a CCB in this setting comes in the context of prior attempted (aggressive) therapy with bb's, amio etc.... IME stuff like verapamil is a lot easier to manage by itself.

Verapamil is a relatively potent antihypertensive even in its own right. There’s a reason it used to be one of the top prescribed meds for HTN in the 80s and 90s before better meds with less cardiac depression came out.

 

[anbuitachi]

i guess thats why the neurointerventionalists give so much verapamil in their vasospasm cases. v for v

 

[abolt18]

Fluids ... either u had given too much or too little...

Yes, so you should definite give more fluids.... Or none.

 

[abolt18]

some people here make it sound like they dont like it in any position

While others LIKE it in any position!

 

[IMGASMD]

then i guess the question is if the case had hours to go, and you couldnt rate control it with anything, amio included, would you Cardiovert with pads on.. prone... or would you tell them to stop , flip supine, cardiovert. or would you just ride out the HR for hours until the end of the case..

I am chicken. I will turn the patient around then cardiovert. Little difficult to do chest compression prone, suspending on the table.

 

[deleted9493]

Ioban to the surgical field, drapes down, 12 lead EKG and CMP while I call intraop cardiology consult, Phenylephrine as needed while we wait.

Take 30 minutes to get some data, collaborate and figure out what the best course is. You are the patient’s advocate—don’t make them come back for repeat surgery, unnecessarily and don’t put them in harm’s way by assuming that because BP is stable, it will be fine.

 

[chocomorsel]

Intern year, had a cardioversion done on someone who’s “relatively” healthy in icu, by a decent cardiologist. Lost pulse, that was it. He wasn’t unstable, just very difficult converting rhythm.

Ever since then, anyone messes with the tinker..... I get a little nervous. PTSD I suppose. So definitely no adenosine in prone position for me, unless absolutely necessary.

Lost pulse and never got it back.

 

[MoMoGesiologist]

Patients go into AF/RVR all the time. You‘ve got a blood pressure. Only an hour left in the case. Give some Mg. Maybe amio bolus. Wait for dilt. HR is only in the 130s. Being prone does make this situation more complicated though...

If this happened in the ICU, it’ll be an hour before the nurse finds you to tell you, an hour before meds arrive from pharmacy, another hour before patient responds, etc. As long as you have a BP, you have time.

That being said, I don’t eff with heart blocks or ventricular arrhythmias; that can quickly become a crisis. TBH, don’t see as many SVTs, so not sure how they progress. Do they stay stable like afib pts or deteriorate to more lethal arrhythmias? Also, I’m more used to seeing SVT with HR 200s. HR <150s I usually think more atrial arrhythmias. What do y’all think?

 

[MoMoGesiologist]

Intern year, had a cardioversion done on someone who’s “relatively” healthy in icu, by a decent cardiologist. Lost pulse, that was it. He wasn’t unstable, just very difficult converting rhythm.

Ever since then, anyone messes with the tinker..... I get a little nervous. PTSD I suppose. So definitely no adenosine in prone position for me, unless absolutely necessary.

Great thanks. Now I’m scared.

 

[Hork Bajir]

Again, this is a stable situation. SVTs of all sorts are common under anesthesia, this is extremely unlikely to devolve spontaneously into an unstable situation- it might devolve when you start giving meds and treatments, though. If the patient is unstable, shock. If stable, tell the surgeon to hurry up, and resist the impulse to do anything stupid until the case is done and you can flip back over.

 

[IMGASMD]

Great thanks. Now I’m scared.

I am.

In all honesty, we (at least 90%of my partners) all think cardioversion as this nothing case. We give, what, a few cc of prop and call it a day. Until one day, you have a walking taking “relatively healthy” patient get shocked, and you’re the last face they see, ever. All you were there to do was to provide sedation.....

Sure there is intrinsic risk with everything we put patient through. Die during a routine cardioversion is fairly low on that list.

 

[IMGASMD]

Lost pulse and never got it back.

Yes. So he was very ded.

I was an intern, so washed my hands off pretty fast. But I remember, the cardiologist tried, my senior residents tried, even called my icu attending, came in to continue the code.

Never got anything back.

 

[chocomorsel]

Yes. So he was very ded.

I was an intern, so washed my hands off pretty fast. But I remember, the cardiologist tried, my senior residents tried, even called my icu attending, came in to continue the code.

Never got anything back.

Lesson learned for you. Rate control unless unstable. If you need that extra atrial kick trial of some amiodarone.

Our cardiologists in fellowship hated cardioverting anyone in the ICU. As iif they were on the case already and then patient became unstable. And they really hated digoxin. Which was fine with because we cardioverted anyway if needed. Have done it once on a stable patient whose rate was in the 150s and he was old and wasn’t responding to Ca or B blockers. And they had tried other drugs apparently which didn’t work or transiently worked. The cardioversion worked for a bit then he converted back. Never seen a patient flatline and code though from cardioversion.
Certainly never seen it w adenosine but I don’t like giving that drug unless I have to. I do get people around me who seem itchy to give it, but the flat line and ashen look don’t get me excited.

 

[anbuitachi]

Ioban to the surgical field, drapes down, 12 lead EKG and CMP while I call intraop cardiology consult, Phenylephrine as needed while we wait.

Take 30 minutes to get some data, collaborate and figure out what the best course is. You are the patient’s advocate—don’t make them come back for repeat surgery, unnecessarily and don’t put them in harm’s way by assuming that because BP is stable, it will be fine.

that wouldnt be 30 minutes where i'm at. that would be multiple hours. Stat CMP would take 1hr+ alone. Our stat ABG takes 30 minutes. Intraop cardiology consult would take hours.

Patients go into AF/RVR all the time. You‘ve got a blood pressure. Only an hour left in the case. Give some Mg. Maybe amio bolus. Wait for dilt. HR is only in the 130s. Being prone does make this situation more complicated though...

If this happened in the ICU, it’ll be an hour before the nurse finds you to tell you, an hour before meds arrive from pharmacy, another hour before patient responds, etc. As long as you have a BP, you have time.

That being said, I don’t eff with heart blocks or ventricular arrhythmias; that can quickly become a crisis. TBH, don’t see as many SVTs, so not sure how they progress. Do they stay stable like afib pts or deteriorate to more lethal arrhythmias? Also, I’m more used to seeing SVT with HR 200s. HR <150s I usually think more atrial arrhythmias. What do y’all think?

I agree but this isn't the ICU, it's the OR. lots of not stuff happen in the ICU that may not be the best. In the OR we have luxury of 1 anesthesiologist to 1 patient, or a few. I think just bc it happens in the ICU doesn't mean it's good or OK. With that said, because hes otherwise stable i wasn't too concerned. But still not a fan of leaving a old guy with CAD in HR of 130s for a hour.

Also what do you mean by SVT? SVT includes atrial arrhythmia

 

[WheezyBaby]

Non-gas perspective, just enjoy playing in these threads. Rate and lack of response to AVNB make me think more flutter than fib, though could be something infra-atrial but less likely with the age. Would feel stronger if there was minimal rate variability. I'd be curious the details surrounding his CAD. Since he's getting a fusion I imagine it's in a decent place, but I don't feel great about a 70 yo heart with CAD ticking away in the 130's, though could likely tolerate an hour if that's truly time to end of case. My inclination would be avoid any more BB/CCB, give a couple g of empiric mag, consider a dose of amio, reassess in 10 min, if persistent would lean toward flipping and trialing adenosine

 

[anbuitachi]

Non-gas perspective, just enjoy playing in these threads. Rate, age, and lack of response to AVNB make me think more flutter than fib, though could be something infra-atrial. Would feel stronger if there was minimal rate variability. I'd be curious the details surrounding his CAD. Since he's getting a fusion I imagine it's in a decent place, but I don't feel great about a 70 yo heart with CAD ticking away in the 130's, though could likely tolerate an hour if that's truly time to end of case. My inclination would be avoid any more BB/CCB, give a couple g of empiric mag, consider a dose of amio, reassess in 10 min, if persistent would lean toward flipping and trialing adenosine

wait you arent in anesthesiology but you dont like prone adenosine either?!

 

[WheezyBaby]

wait you arent in anesthesiology but you dont like prone adenosine either?!

All of my adenosine patients have a code cart at bedside and pads on. If you're prepping them with the expectation they may arrest, prone seems subideal . I was going to toss in that ICU has their own prone patients, but if I had to wager a guess flipping that patient population prior to an arrest isn't going to meaningfully affect their mortality!

 

[vector2]

. My inclination would be avoid any more BB/CCB,

I think you can def make the argument for no more BB after the esmolol fails and I like the idea of giving some empiric mag, but I've had plenty of pts in fellowship in both flutter and fib who've failed the initial lopressor boluses and then straight converted to NSR after one dose of 2.5mg verap IV.

 

[WheezyBaby]

I think you can def make the argument for no more BB after the esmolol fails and I like the idea of giving some empiric mag, but I've had plenty of pts in fellowship in both flutter and fib who've failed the initial lopressor boluses and then straight converted to NSR rhythm after one dose of 2.5mg verap IV.

I've seen it before as well with additional doses of either CCB/BB although I can't comment specifically on verapamil due to lack of experience. I'm just anxious about what the HR is going to look like if he converts with the baseline Brady

 

[vector2]

I've seen it before as well with additional doses of either CCB/BB although I can't comment specifically on verapamil due to lack of experience. I'm just anxious about what the HR is going to look like if he converts with the baseline Brady

Indeed, although the baseline rate could also be a problem if he converts with amio as well. With this pt best not to do anything too provocative pharmocologically until the pads are on and you have pacing and cardioversion capability.