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

[Coastie]

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Never posted the follow up.

She got 2 mg of IV metoprolol.

Went down to around 110 on the rate, and BP of 130/80.

Still got cancelled by attending.

Remember, afib purely asymptomatic.

Still cancel the case?

 

[huktonfonix]

Shes responding to the metoprolol and has stable vitals. Why not give some more, stabilize her heart rate, then proceed? Assuming this should be a short procedure with minimal fluid shift then she should be fine. fluid absorption should be minimal with few venous sinuses and a short case. just ask the surgeons to use the minimal height/pressure possible if youre concerned about fluid absorption.

 

[militarymd]

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 .

She's not dying from hypoperfusion...whatever her CO is...high, low, normal.....it's enough.

push the propofol.....otherwise she might die before she's ready for surgery...and you and MORE importantly, your hospital, just lost a piece of the pie.

 

[Bertelman]

I'll have to find one of those masturbating smilies!

 

[Laurel123]

This woman is 92 and is in afib. I agree with the above poster that said that it is probably just being NPO, a little dehydrated and disrupted from her usually schedule that threw her 92 year old heart into Afib. If you cancel the case and send her the cardiology, they convert her, send her on her merry way, what is the chance that she will show up in Afib the next time she has surgery? I would say that is likely.

Our goals for surgery is to have a patient optimized. And at 92, just being alive and functional is pretty much as optimal as you are going to get.

Well, all that being said, I am still not sure I would proceed. The chance of something bad happening while getting a 15 minute procedure under complete monitering is about the same as the chance of something bad happening while she gets up in the morning for her daily bowel movement (no monitering at all! ) But because she is 92 years old, the chance of bad stuff happening during either of these 'procedures' is pretty high. Thus, if something bad happens during the procedure or in the post-op period, her pre-op vital signs would give people an opportunity to point the finger at you.

Also, being in private practice, I have been in similar situations, where the surgeon is more than happy to cancel the case. I don't know how much reimbursement is recieved for a cystoscopy, but I remember a couple of months ago when we canceled I think it was a small upper extremity ortho case (trigger finger or removal of hardware or something) for RVR Afib in a very old woman. Clinically, we believed that she would probably be fine and we wouldn't cause her more stress and risk than a car ride on the freeway. However, after meeting the family, we got the feeling that they didn't grasp the fact that this patient was in her 90's and she really could suffer mortality or morbidity at any time in her life and we believed that if anything happened to her at all during the perioperative period, they would pin it on us. So the surgeon was happy to pawn the patient off to cardiology.

 

[Tenesma]

9FRENCH

no where did i say that her vitals EXCLUDED PE or MI

but i doubt PE or MI... PEs and MIs in 92 year olds usually don't present with HYPERTENSION.

i bet she has a good working (and likely stiff) heart since she is able to generate those pressures.

i'd just slow her down a bit (which would likely drop her pressure a bit).

I think we (anesthesiologists) forget that we are doctors as well, and perfectly able to manage a borderline patient without having to yell for cardiology on a regular basis - especially in a 92 year old... the fact that she is breathing and pink means she is optimized in my book.