Intraoperative A fib

[Mman]

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double post

 

[Noyac]

Yes my case went entirely too long. The pt was a very poor candidate. It was a cluster F*ck from the get go. We had a locums anesthesiologist here and she refused to do the case (she's no dummy) and this pt had been seen and cleared by anesthesia prior to surgery due to medical optimization and pt understanding. I was asked to do the case last minute and since I'm a cowboy I guess, I got bitten in the arse for it. The pt did fine and his renal mass was removed but the urology douchebag is a new grad that absolutely sucks. I have been in practice for over 10yrs and I have never had a case go to peer review. This one did! But it went to view for pt selection issues. Not my issue. I guess my record could still be considered clean

 

[nimbus]

My next question is why is it okay to chemically cardiovert without TEE screening?

Just trying to make sense of this.

 

[deleted162650]

The key is duration of AFib right? If acute onset and less than 48H duration then supposedly not enough time for thrombus formation and
OK to cardiovert w/o TEE. If greater than 48H or chronic intermittent AF then TEE advised.

 

[Laryngophed]

The key is duration of AFib right? If acute onset and less than 48H duration then supposedly not enough time for thrombus formation and
OK to cardiovert w/o TEE. If greater than 48H or chronic intermittent AF then TEE advised.

And I think one of the arguments I've heard not infrequently (in the ICU and on the floor, particularly in patients with chronic cardiac or pulmonary insults, is that we may see a rhythm change to afib, but we have no clue what happened before the tele monitor is on.

 

[Ezekiel2517]

The key is duration of AFib right? If acute onset and less than 48H duration then supposedly not enough time for thrombus formation and
OK to cardiovert w/o TEE. If greater than 48H or chronic intermittent AF then TEE advised.

yah, if AF > 48 hrs most recommend to have cardioversion postponed until three weeks of AC or have TEE done. Problem is if pt is unstable. "Unstable" is open to interpretation by a lot of people.
If < 48 hrs, I know some docs who still want to anticoagulate before cardioverting and some who just go ahead.

 

[cleansocks]

For stable new Afib, I check ABG, replenish magnesium and calcium, correct K if ABG suggests it, slowly give amiodarone boluses x 2 and start amio drip.

If they're hypotensive I'll give pressors that slow heart rate and fluids. I'll consider cardioversion but haven't needed it.

I've found amio helps quite a bit with even rate control. Theoretically it has all 4 classes of anti-arryhtmic mechanisms including beta and calcium channel blocking properties.

My understanding is that amio's Vd is very high and therefore giving a lot of the drug slowly is useful. Slowly is key.

 

[dhb]

Fun facts:
"Amiodarone is fat-soluble, and tends to concentrate in tissues including fat, muscle, liver, lungs, and skin. This confers a high volume of distribution (5000 liters in a 70 kg adult) and a long half-life.
Amiodarone exhibited multi-compartmental pharmacokinetics with a mean apparent plasma terminal elimination half-life of 58 days (range 15 to 142 days) for Amiodarone and 36 days (range 14 to 75 days) for the active metabolite (DEA)"

 

[Vaporized]

I was just in icu for 2 months. It was not a cardiac icu FWIW. Based on attending preference we would use either metoprolol or cardizem to rate control people in RVR. I found that CCB always worked better, just an observation. I'm assuming storage reasons are why it cannot be stored in room because I would use it over metoprolol for rate control and labetalol over metoprolol for BP.

 

[Noyac]

Fun facts:
"Amiodarone is fat-soluble, and tends to concentrate in tissues including fat, muscle, liver, lungs, and skin. This confers a high volume of distribution (5000 liters in a 70 kg adult) and a long half-life.
Amiodarone exhibited multi-compartmental pharmacokinetics with a mean apparent plasma terminal elimination half-life of 58 days (range 15 to 142 days) for Amiodarone and 36 days (range 14 to 75 days) for the active metabolite (DEA)"

Your classic.

Nice

 

[fakin' the funk]

Let's say you are doing a case and your pt goes into A fib.

What's your treatment approach?

What if your pt has had A fib in the past and is scheduled for a long case. Do you do anything to prevent it from occurring?

Assuming BP stable (almost always is)
Amio 150mg over 10 minutes. Maybe 75 over 10, then the rest over another 20 if the BP is marginal.

 

[deleted682700]

Yes my case went entirely too long. The pt was a very poor candidate. It was a cluster F*ck from the get go. We had a locums anesthesiologist here and she refused to do the case (she's no dummy) and this pt had been seen and cleared by anesthesia prior to surgery due to medical optimization and pt understanding. I was asked to do the case last minute and since I'm a cowboy I guess, I got bitten in the arse for it. The pt did fine and his renal mass was removed but the urology douchebag is a new grad that absolutely sucks. I have been in practice for over 10yrs and I have never had a case go to peer review. This one did! But it went to view for pt selection issues. Not my issue. I guess my record could still be considered clean

You need to throw that transplant surgeon under the bus. Why did the douche bag take so long? Hope your peer review process is not like a kangaroo sham court. Anesthesiologists need to get involved in meetings and educate other specialities as to why it's a shared responsibility. Ask that dumb surgeon how he would hydrate without killing of the remaining kidney?

 

[pgg]

There are bad fast surgeons and good fast surgeons, and there are bad slow surgeons, but there are no good slow surgeons.

Slow surgeons are a menace.

 

[Terminalextubation]

Hi, PGY1 here...
This was touched on a little, but how do you systematically workup the AFib (or flutter or SVT) in the OR?
After establishing the patient is stable and pushing a rate/rhythm controlling agent, I assume next step is to see if there is a history of arrhythmia.
I would say most important thing is to rule out MI, PE, pH problem, electrolyte derangement. Do you essentially run through the H's and T's (even though this isn't ACLS)?

 

[Planktonmd]

Hi, PGY1 here...
This was touched on a little, but how do you systematically workup the AFib (or flutter or SVT) in the OR?
After establishing the patient is stable and pushing a rate/rhythm controlling agent, I assume next step is to see if there is a history of arrhythmia.
I would say most important thing is to rule out MI, PE, pH problem, electrolyte derangement. Do you essentially run through the H's and T's (even though this isn't ACLS)?

If the patient is stable and you are able to control the rate, all you need to do is to continue to manage your patient like any other patient under anesthesia.
Make sure you are OK with volume replacement and that your anesthetic is adequate.

 

[Khaan]

Depends, if they are normotensive and rate controlled, I likely wouldn't do anything. If in rvr, titrate b blockers. Hypotensive then amiodarone.
New onset with no prior history and they're tanking, consider cardioversion.

Would you be worried about furthering hypotension from amiodarone, or would it be a null issue d/t rhythm control correcting the BP?

 

[Noyac]

Would you be worried about furthering hypotension from amiodarone, or would it be a null issue d/t rhythm control correcting the BP?

I little concerned but if you are using amio then hypotension is probably already an issue. You will need to deal with it either way. On another note, the cardizem will drop BP pretty good too.

 

[sleepallday]

Would you be worried about furthering hypotension from amiodarone, or would it be a null issue d/t rhythm control correcting the BP?

Concerned, yes. And I may have to treat the hypotension separately but my hope is that controlling the rhythm will fix the BP.