Cancelling a Case in Academia, #54: New Onset Afib

[Coastie]

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92 yo female with no pmhx except htn (takes 25 metoprolol qd) comes in for a cysto resection of a bladder tumor.

On the table, tachy in 140s, irreg irreg. HTN to 180/100, 12 lead shows afib, prev. undx. Lady is completely asymptomatic.

Attending cancels on the spot, gets primary team to get a cards consult.

Thoughts?

 

[Planktonmd]

92 yo female with no pmhx except htn (takes 25 metoprolol qd) comes in for a cysto resection of a bladder tumor.

On the table, tachy in 140s, irreg irreg. HTN to 180/100, 12 lead shows afib, prev. undx. Lady is completely asymptomatic.

Attending cancels on the spot, gets primary team to get a cards consult.

Thoughts?

A fib in a 92 Y/O is as common as sinus rhythm!
She is already NPO, on the OR table and the procedure is going to take 15 minutes, so I don't see why you can't give her a beta blocker and get it done.

 

[apma77]

new a-fib in the 140s range..elective case...cancel or delay until cardiologist gives his input

you do the case..she goes into unstable RVR ...you are fu#K#D my friend

your attending made the right call

 

[Planktonmd]

new a-fib in the 140s range..elective case...cancel or delay until cardiologist gives his input

you do the case..she goes into unstable RVR ...you are fu#K#D my friend

your attending made the right call

She is 92, what do you think the cardiologist is going to do??
Why do you think your anesthetic is going to put her in "unstable RVR"?

 

[militarymd]

92 yo female with no pmhx except htn (takes 25 metoprolol qd) comes in for a cysto resection of a bladder tumor.

On the table, tachy in 140s, irreg irreg. HTN to 180/100, 12 lead shows afib, prev. undx. Lady is completely asymptomatic.

Attending cancels on the spot, gets primary team to get a cards consult.

Thoughts?

Call him a pu ss y

 

[New2Midwest]

Cancel the case-if the lady throws a clot from her LA to her cortex in that 15 minutes, you are cooked...

 

[Bertelman]

She is 92, what do you think the cardiologist is going to do??

Maybe get her HR under control? Check for reversible causes of AFib? r/o a clot in her atria?

If the attending made the wrong call, I think many of us would like to know why, and how we support that argument when we take the oral boards.

 

[Planktonmd]

Maybe get her HR under control? Check for reversible causes of AFib? r/o a clot in her atria?

If the attending made the wrong call, I think many of us would like to know why, and how we support that argument when we take the oral boards.

All the things you mentioned are good and should be done, the only question is the timing, do we need to do all of them before this minor procedure?
For the oral boards the answer is absolutely yes.
For the real world practice: Probably not because this is a 92 y/o patient who's only problem is that we witnessed her asymptomatic episode of Afib because she was unlucky enough to be under our care at that moment.
She got up early, got dressed, had nothing to eat or drink, had to beg somebody to drive her to the hospital and wait for her, she has been waiting on a rock solid stretcher for 5 hours, she had a nurse poke her 5 times until she finally got an IV in her hand.
She also has continuous hematuria and she needs her bladder tumor fulgurated to stop the blood loss, which will take 15 minutes.
I say, give a beta blocker, do the procedure, then ask the cardiologist to see her.

 

[Bertelman]

All the things you mentioned are good and should be done, the only question is the timing, do we need to do all of them before this minor procedure?
For the oral boards the answer is absolutely yes.
For the real world practice: Probably not because this is a 92 y/o patient who's only problem is that we witnessed her asymptomatic episode of Afib because she was unlucky enough to be under our care at that moment.
She got up early, got dressed, had nothing to eat or drink, had to beg somebody to drive her to the hospital and wait for her, she has been waiting on a rock solid stretcher for 5 hours, she had a nurse poke her 5 times until she finally got an IV in her hand.
She also has continuous hematuria and she needs her bladder tumor fulgurated to stop the blood loss, which will take 15 minutes.
I say, give a beta blocker, do the procedure, then ask the cardiologist to see her.

Thanks.

 

[Consigliere]

All the things you mentioned are good and should be done, the only question is the timing, do we need to do all of them before this minor procedure?
For the oral boards the answer is absolutely yes.
For the real world practice: Probably not because this is a 92 y/o patient who's only problem is that we witnessed her asymptomatic episode of Afib because she was unlucky enough to be under our care at that moment.
She got up early, got dressed, had nothing to eat or drink, had to beg somebody to drive her to the hospital and wait for her, she has been waiting on a rock solid stretcher for 5 hours, she had a nurse poke her 5 times until she finally got an IV in her hand.
She also has continuous hematuria and she needs her bladder tumor fulgurated to stop the blood loss, which will take 15 minutes.
I say, give a beta blocker, do the procedure, then ask the cardiologist to see her.

Now that's the type of thinking you need in private practice! Bravo!

 

[urge]

You shouldn't be doing elective cases in patients like the one you talk about. I'm amazed at why did the patient make it as far as the OR. Should have been canceled in holding and cardiology consulted. Was it you fault for pushing the pt without talking to your attending? He did the right thing. It takes more balls to cancel the case with a bitching surgeon than doing it.

 

[coprolalia]

Had a short case like this recently. Patient wasn't on the monitor in the holding area. When I got him to the room and hooked him up, looked like simple tachycardia in the low 100's. By the time the case was done, he was in the low 130's with irregular R-R intervals. We got a 12-lead in the PACU -> new-onset a-fib. Guy didn't feel a thing. No other adverse events during the case.

Sent him to the ED. They converted him with 20mg of IV Cardizem and sent him home.

-copro

 

[militarymd]

You shouldn't be doing elective cases in patients like the one you talk about. I'm amazed at why did the patient make it as far as the OR. Should have been canceled in holding and cardiology consulted. Was it you fault for pushing the pt without talking to your attending? He did the right thing. It takes more balls to cancel the case with a bitching surgeon than doing it.

may be so...and perhaps you have 3 of them....but it takes only 2 BIG balls filled with testosterone to do the right thing.....push the propofol.

 

[deleted126335]

.

 

[urge]

may be so...and perhaps you have 3 of them....but it takes only 2 BIG balls filled with testosterone to do the right thing.....push the propofol.

Well, let's see. Pushing metoprolol, propofol and phenylephrine is really easy. If pt does well, fine. If pt craps out, call cardiology(or ICU, or the morgue). That's all very easy to do. In contrast, telling a pushy surgeon, with whom you will have to work every day, to crawl back to the hole the came from because his case is not going, well, that's not as easy.

 

[militarymd]

Well, let's see. Pushing metoprolol, propofol and phenylephrine is really easy. If pt does well, fine. If pt craps out, call cardiology(or ICU, or the morgue). That's all very easy to do. In contrast, telling a pushy surgeon, with whom you will have to work every day, to crawl back to the hole the came from because his case is not going, well, that's not as easy.

Depends on who you are.....

 

[urge]

Depends on who you are.....

True. Gray hair helps.

 

[Milhouse Van Houten]

UNEQUIVICALLY, the STANDARD OF CARE is to work up new onset Afib. ALWAYS. feel free to go to the OR without a work up, but if something bad happens, you are BEYOND *****D. The new Miller book delineates these guidelines, and specifically brings this point up. The preop anesthesia attending at my institution says he has served as an expert witness multiple times for these exact cases, and everytime the anesthesiologiest is TOAST. DON'T DO IT.

that being said, what happens in private practice is very different. efficiency, appeasing surgeons, and making money are paramount. you don't want to be the guy known as the wussy who cancels cases. ABSOLUTELY WE SHOULDN'T DO THIS CASE, but would we anyway--that's the question.

 

[militarymd]

UNEQUIVICALLY, the STANDARD OF CARE is to work up new onset Afib. ALWAYS. feel free to go to the OR without a work up, but if something bad happens, you are BEYOND *****D. The new Miller book delineates these guidelines, and specifically brings this point up. The preop anesthesia attending at my institution says he has served as an expert witness multiple times for these exact cases, and everytime the anesthesiologiest is TOAST. DON'T DO IT.

that being said, what happens in private practice is very different. efficiency, appeasing surgeons, and making money are paramount. you don't want to be the guy known as the wussy who cancels cases. ABSOLUTELY WE SHOULDN'T DO THIS CASE, but would we anyway--that's the question.

that load is so foul, I can smell it through my computer screen.

 

[Planktonmd]

UNEQUIVICALLY, the STANDARD OF CARE is to work up new onset Afib. ALWAYS. feel free to go to the OR without a work up, but if something bad happens, you are BEYOND *****D. The new Miller book delineates these guidelines, and specifically brings this point up. The preop anesthesia attending at my institution says he has served as an expert witness multiple times for these exact cases, and everytime the anesthesiologiest is TOAST. DON'T DO IT.

that being said, what happens in private practice is very different. efficiency, appeasing surgeons, and making money are paramount. you don't want to be the guy known as the wussy who cancels cases. ABSOLUTELY WE SHOULDN'T DO THIS CASE, but would we anyway--that's the question.

I am having trouble understanding your advice:
Should we or shouldn't we do it?
😕

 

[Planktonmd]

I am having trouble understanding your advice:
Should we or shouldn't we do it?
😕

Or maybe we should do it only if we are greedy ignorant private practice anesthesiologists?

 

[huktonfonix]

Arrhythmias considered as an active cardiac condition under the 2007 ACC/AHA guidelines include afib with uncontrolled ventricular rate >100. I would cancel pending evaluation and treatment.

 

[mille125]

UNEQUIVICALLY, the STANDARD OF CARE is to work up new onset Afib. ALWAYS. feel free to go to the OR without a work up, but if something bad happens, you are BEYOND *****D. The new Miller book delineates these guidelines, and specifically brings this point up. The preop anesthesia attending at my institution says he has served as an expert witness multiple times for these exact cases, and everytime the anesthesiologiest is TOAST. DON'T DO IT.

that being said, what happens in private practice is very different. efficiency, appeasing surgeons, and making money are paramount. you don't want to be the guy known as the wussy who cancels cases. ABSOLUTELY WE SHOULDN'T DO THIS CASE, but would we anyway--that's the question.

lord

 

[huktonfonix]

What people have failed to mention is that you have to take the tone of your group into account as well. If youre not sure whether or not you would have the backing of your group, ask a partner. While I agree that you dont want to be known as "the guy who always cancels", the "cowboy" label in a more conservative group can be just as damaging to your chances of making partner.

 

[numbmd]

Whatever happened to talking?

"Excuse me Dr. Seamen, but take a look at this... Looks like your patient has a new onset of A fib".

Urologist looks at monitor, tilts his head to the side, just like my Labrador, and says,"Gee what do you want to do?"

"Well can she wait to get checked out? Or does she need to go today?"

Two possible answers come next. Yes or No. If the answer is no, then you didn't cancel the case, you both did. If it is yes, then tell him to just jot down a note why she can't wait, and it somewhat forces your hand now, making it either an urgent or emergent case.

Either way you involved Dr. Seamen, and he's happy because he's involved.

Besides, I hardly ever cancel a case. Surgeons hate to hear that their case is cancelled. Sometimes I "delay" a case, maybe even til another day. In reality, I hardly even "delay"cases either.

No decision is ever in a vacuum, and sometimes you have to pick your battles carefully. But it is important to start the discussion in the right way to make it easy to come to the right decision.

 

[DrN2O]

80M hospitalized w newly diagnosed lung ca, otherwise no significant PMH. Scheduled for VAT pleurodesis. The night before surgery, had some chest pain, and STAT EKG showed AFIB no RVR. Serial trop x2 barely positive but no bump. What do you do when you see the pt in pre-op?

 

[Planktonmd]

80M hospitalized w newly diagnosed lung ca, otherwise no significant PMH. Scheduled for VAT pleurodesis. The night before surgery, had some chest pain, and STAT EKG showed AFIB no RVR. Serial trop x2 barely positive but no bump. What do you do when you see the pt in pre-op?

This is different, new onset of angina (chest pain) with chemical evidence of ischemia (elevated troponin) is unstable angina, the Afib is not the issue here, unstable angina needs to be addressed before surgery.

 

[maceo]

that load is so foul, I can smell it through my computer screen.

tell your lawyer that when you are writing out a check with a lot of zeros to the plaintiff tough guy

 

[militarymd]

tell your lawyer that when you are writing out a check with a lot of zeros to the plaintiff tough guy

Fu ck.....is that all you people can worry about? Writing a check to someone.

Well...I have a really fu ck in high priced lawyer who I pay a lot of fuc kin money to already....

So you know what....I say "fu ck you" to the plainififf.

 

[toughlife]

are we done with this case yet? Be a physician and take care of business. Rate control that shizznit and let's get the case done.

 

[mille125]

Fu ck.....is that all you people can worry about? Writing a check to someone.

Well...I have a really fu ck in high priced lawyer who I pay a lot of fuc kin money to already....

So you know what....I say "fu ck you" to the plainififf.

i would hate to see you say fu ck you to your career

 

[huktonfonix]

are we done with this case yet? Be a physician and take care of business. Rate control that shizznit and let's get the case done.

Just dont use that answer for your boards.

 

[huktonfonix]

This is different, new onset of angina (chest pain) with chemical evidence of ischemia (elevated troponin) is unstable angina, the Afib is not the issue here, unstable angina needs to be addressed before surgery.

playing devils advocate....how is this any different than the Afib with RVR? Both are classified as active cardiac conditions requiring evaluation and treatment prior to noncardiac surgery. Now you could argue that you as a perioperative physician had evaluated the afib, determined it to be otherwise benign, treated it with rate control, and then went ahead with the case. Just playing it out from an oral boards perspective.

 

[Planktonmd]

playing devils advocate....how is this any different than the Afib with RVR? Both are classified as active cardiac conditions requiring evaluation and treatment prior to noncardiac surgery. Now you could argue that you as a perioperative physician had evaluated the afib, determined it to be otherwise benign, treated it with rate control, and then went ahead with the case. Just playing it out from an oral boards perspective.

The difference here is clear: Chest pain.
AFIB in a 92 year old getting a cystoscopy is not the same as unstable angina before thoracic surgery.

 

[militarymd]

i would hate to see you say fu ck you to your career

been there ...done that....still got a job.

 

[maceo]

are we done with this case yet? Be a physician and take care of business. Rate control that shizznit and let's get the case done.

cancel the ELECTIVE case.. you are not a cardiologist... let someone better than you take care of it. and move on with the next case..

 

[toughlife]

This is different, new onset of angina (chest pain) with chemical evidence of ischemia (elevated troponin) is unstable angina, the Afib is not the issue here, unstable angina needs to be addressed before surgery.

ditto. this is a different beast. This patient gets a cards consult.

 

[toughlife]

Just dont use that answer for your boards.

we know well by now that the academic dogma they are teaching us in residency and real life are two different things.

Some of these so called academic attendings are obstructionists to the nth degree when it comes to finding excuses to delay cases. Seen it with my own eyes.

 

[toughlife]

Just dont use that answer for your boards.

Of course. For the boards, you play their game.

 

[dhb]

cancel the ELECTIVE case.. you are not a cardiologist... let someone better than you take care of it. and move on with the next case..

😱

A-fib for 90 y/o is like breathing...

 

[huktonfonix]

The difference here is clear: Chest pain.
AFIB in a 92 year old getting a cystoscopy is not the same as unstable angina before thoracic surgery.

No disagreement on that point. My point was, in the unlikely adverse event, how do you defend proceeding with elective surgery when faced with an ACC/AHA designated "active cardiac condition" (afib with RVR >100). Do you say that you evaluated and treated the afib then decided to proceed with the surgery? That may be a valid argument since the guidelines dont say it needs to be a cardiologist that evaluates and treats.

 

[Planktonmd]

No disagreement on that point. My point was, in the unlikely adverse event, how do you defend proceeding with elective surgery when faced with an ACC/AHA designated "active cardiac condition" (afib with RVR >100). Do you say that you evaluated and treated the afib then decided to proceed with the surgery? That may be a valid argument since the guidelines dont say it needs to be a cardiologist that evaluates and treats.

Although the AHA guidelines are important they are not the bible and you as a physician should be able to use your judgment and decide what's best for your patient.
There are many reasons why I would proceed with the surgery on the 92 Y/O with an asymptomatic episode of Afib on the OR table before a cysto, but if I was taking the oral boards I would not say that to the examiner, I would say: This is not an emergent surgery so I would delay the case and get a cardiology consult. This the safest way to answer but it's not really what I would do in real life.

 

[Lonestar]

If I had to take the old woman to the OR, i would control her HR and proceed with the case as long as her BP is well maintained.

Now if she was on the table with a HR >110s and BP < 90/50 then I would most likely delay the surgery until she is optimized.

 

[maceo]

😱

A-fib for 90 y/o is like breathing...

no its not!

 

[9french]

The original posted case is absolutely one that should be cancelled. The attending did the right thing.

First, this is not an urgent case. No harm will come to the patient by delaying the case.

Second, A-fib is not always benign. Approximately 5% of the time it is caused by a serious underlying condition such as P.E. or MI. Would anyone take a patient to the O.R. for a TURBT who is actively infarcting or actively throwing a P.E.? A 92 y.o. may not c/o CP depending on her other medical conditions. Non-cardiac surgery and general anesthesia is associated with a high mortality rate in patients with a recent MI, up to six weeks out.

Third, this is not stable AF. The patients H.R. is 140. This needs to be stabalized. I submit that this stabalization should not be done on the O.R. table. There are too many variables for this being a safe place to push the metoprolol, cardizem, dig, amiodarone, etc. A quick example of why not to do this is that at 140, with no atrial kick, her CO is decreased. How much, we do not know. With fluid absorbtion from the cysto, plus IVF, what defense would you have if she goes into acute CHF and develops pulmonary edema? This is not an academic hypothetical, but rather something you will see sometime in your career.
In short new-onset af is not benign until proven so. It is, dare I say, cavalier, to proceed with this case.

 

[periopdoc]

The original posted case is absolutely one that should be cancelled. The attending did the right thing.

A quick example of why not to do this is that at 140, with no atrial kick, her CO is decreased. How much, we do not know.

Really? With a blood pressure of 180/100 we know that her CO is decreased? Not saying I disagree with you overall, but are you sure her CO is decreased?

-pod

 

[Tenesma]

92 yo w/ a-fib w/ RVR....

unlikely to pop a clot... not worried about that

the rest of her vitals are OK... not too worried - doubt MI or PE

would do the case, i'd have metoprolol in one hand and a defibrillator in the room...

 

[9french]

Really? With a blood pressure of 180/100 we know that her CO is decreased? Not saying I disagree with you overall, but are you sure her CO is decreased? -pod

Blood pressure is dependent on both SVR and CO. I've taken care of plenty of patients with low CO and hypertension. But you are correct, at 140, even with a decreased stroke volume, her CO may be normal. However, it also may not be.

A 92 yo heart is often time stiff, i.e. at least some impaired relaxation. The decreased filling time plus lack of atrial kick has a high likelihood to lead to decreased stroke volume when compared to baseline. Of course, my assumption in this particular patient may be incorrect. Nonetheless, it would be prudent to fully work up her new onset AF.

 

[9french]

92 yo w/ a-fib w/ RVR....

unlikely to pop a clot... not worried about that

the rest of her vitals are OK... not too worried - doubt MI or PE

would do the case, i'd have metoprolol in one hand and a defibrillator in the room...

It is a fallacy to be reassured by normal vitals that she is not undergoing an MI or P.E.

Normal vitals in no way exclude either a PE or MI. ST elevation or new onset LBBB are, of course, the classic signs of a STEMI, but a NSTEMI may present with much less specific findings including AF.

In this patient, she does not even have normal vitals. She is profoundly tachycardic and hypertensive. The most common ECG change in a PE is tachycardia (Yes, I realize that tachycardis is very non-specific and even potentially meaningless in AF).

For me, what it comes down to, is that if I'm concerned enough about the patient that I am going to bring a defibrillator in the room for an elective case, I am going to be concerned enough to make sure the patient is medically optimized prior to going back.

 

[9french]

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