Intraop new onset afib

[hotdogz]

Hi there, I just had a quick question...
What does everyone think of intra op new onset afib and whether or not the case should be canceled or continued? In my group, there have been few instances where new onset afib developed during intermediate type procedures (hip, other ortho) and consulting with the cardiologist, they recommended continuing the case and just rate controlling. What does the current literature, academia, and private practice have to to say about this. Should we rate control and finish surgery as quick as possible. Also, what if this happens first thing when we hook patient up to monitor or during pre-op holding. Should we just rate control and proceed or just cancel and work up patient. Thanks guy, look forward to hearing your thoughts.

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[Sonny Crocket]

Intra op I have has this happen and tend to rate control and refer to medicine/cards afterwards. Pre op you have to ask yourself is this case elective, urgent or emergent and go from there.

 

[urge]

I would continue.

Regarding a fib in holding, I would cancel if it is new onset. Proceed if paroxysmal a fib.

 

[Planktonmd]

So if they had already made incision you want them to stop and come back another day?

 

[Laryngophed]

I'm just a student and but thinking about the question, I think I would ask myself 3 questions. I welcome any correction and education to this thinking. 1) Are there any changes in hemodynamic status with this new-onset a fib? If they are stable and just fibbin' away, I don't know that that is a good reason to stop an operation. Any chance they have a clot hiding in the LA appendage? Not likely from a fib since it is new onset (as best we can tell)? Do they need cardioversion? If they are hemodynamically stable, and can be rate controlled, probably not. If they can't be rate controlled, or if their pressure bottoms out, or they give some other indication of hypoperfusion (I'm especially thinking of patients who are dependent on atrial kick for ventricular filling) then maybe. But would a cardioversion mean stopping a procedure?

New question I hope you guys can help me with, what agent are you going to use to rate control them in the OR? Esmolol or labetalol, relatively quick on, quick off beta blockers? Calcium channel blocker? Call cards and ask about starting an amiodarone drip? Thanks for your input, and I'd appreciate any critiques you have on my thought process above.

 

[HollywdAnesth]

I had many a'attending freak out during residency over "new" onset a-fib intra op/pacu. Every single time the cardiologist would come down and just tell us to keep the rate controlled. The overwhelming majority of cases of a-fib are not due to ischemia or mitral stenosis. I don't have any data or papers to back this up.
I just rate control and recommend to the surgeon that a cardiologist should stop by at some point.

 

[Idiopathic]

there is usually a cause of atrial fibrillation (stress, catecholamines, electrolytes, volume shifts, pain, ischemia, acidosis, etc) that should lead you to further investigate the patient's condition. in the preoperative setting, its probably best to delay an elective case when presented with new-onset atrial fib, but the case by case management should be handled by the provider at the bedside, and the decision to cancel an ongoing case is not one that is made lightly. barring hemodynamic instability and the prospect of a long case, i probably allow the surgeon to continue if we are already underway, but these rules are not hard and fast. sometimes you get "a feeling" and that isnt always reflected in the literature or the guidelines

i think that most of us would NOT attempt to electrically cardiovert, because I (we) almost always suspect paroxysmal a-fib, and these patients are probably at higher risk of LA clot. With that said, rate controlling agents and electrolyte correction (another thing you should consider) often have stabilizing effects and the patient may chemically convert. I think if this happens, it is fine. i would try to get a cardiologist to see this patient before leaving the hospital to set up follow up for echo, anticoagulation, etc. if the fib is short and transient/does not return, use your best judgement much in the same way you would assess cardiac risk in the first place.

if this arrhythmia comes with instability/significant hypotension, then the board answer (and usually the real life one) is to cardiovert urgently.

 

[Sufenta]

I did cancel a minor elective procedure recently, but she was new onset w hemodynamically stable RVR. I did rate control her. My rationale was she might be having ischemia.

 

[Impromptu]

If the patient with intraoperative is still getting enough blood and oxygen to the vital organs, I would continue the case. If it is an old person with critical stenosis or some other problem like that, then consider other options.

 

[nap$ter]

it

Hi there, I just had a quick question...
What does everyone think of intra op new onset afib and whether or not the case should be canceled or continued? In my group, there have been few instances where new onset afib developed during intermediate type procedures (hip, other ortho) and consulting with the cardiologist, they recommended continuing the case and just rate controlling. What does the current literature, academia, and private practice have to to say about this. Should we rate control and finish surgery as quick as possible. Also, what if this happens first thing when we hook patient up to monitor or during pre-op holding. Should we just rate control and proceed or just cancel and work up patient. Thanks guy, look forward to hearing your thoughts.

it's a grey zone in the literature. the decision to proceed or abort has to be individualized to the pt/procedure.

in the vast majority of these instances the pt is stable and asymptomatic with a low chads score and i have proceeded with a periop cards referral for what usually winds up as an outpt afib workup - which is almost always negative.

 

[Bostonredsox]

Most all of you gas guys do tee right? If they develop fib right in front of you intraop, that is to say pt is already intubated and asleep, and your not sure if it's paroxysml, stick the tee probe in and see if there's clot in the LAA or LV. If there isn't then I can safely cardiovert them postop while there still nicely sedated without anticoagulating them for three weeks and we just saved the pt three weeks of rivaroxaban and an awake cardioversion.

If it develops in front of you preop, well I guess it depends on the case right? An elective hernia, guess it could be postponed. But most of these cases are going to be pts with underlying parox fib who happened to flip into fib from SR preop. Rate control them intraop and well work them up post op.

 

[Mman]

intraop new onset afib equals cardiology consult prior to going home for the usual workup, in PACU if outpatient or on floor if inpatient. Abort the case? Please. There is more risk in cancelling the case part way through and placing them through a 2nd anesthetic than just finishing what you started with rate control.