New onset A-flutter and elective surgery

[sigrhoillusion]

Wanted some people's opinions on what you would do with a patient who presented for elective surgery and they had a-flutter with no prior history of it.

Would it matter if they had a pre-op EKG showing flutter vs. finding out when you hooked them up to the monitor in the OR?

Would you proceed or delay the case? What if the flutter occurred after induction but before the surgery started? Does the type of surgery matter? Type of anesthesia?

I'm keeping this kind of open ended and vague cause I wanted to get people's opinions and thoughts on newly diagnosed arrhythmias and providing anesthesia before I give my own opinions. Doesn't have to be flutter, could be a-fib or WPW or whatever rhythm you can think of. Well besides asystole...

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[dhb]

Undiagnosed rythm alteration gets to see cards and postpone surgery.
Acute a fib or flutter after induction i'll try to convert and proceed would wake up and cancel if hemodynamically unstable (probably shock him before wake up).

 

[Mman]

giving cardiology a call. Sinus rhythm is a good thing for cardiac function. If this is truly new in this patient, they need some sort of minimum evaluation and probable cardioversion (could be pharmacologic) prior to an elective surgery.

 

[Noyac]

Depends on the surgery
Depends on the rhythm
Is it stable or unstable
But for the most part, delay the case. Get cards involved.

 

[vector2]

Pretty much any previously undiagnosed arrhythmia (including PVCs) gets canceled cause it could be a sign of previously undiagnosed structual heart disease or ischemia. Now say a patient with a history of PAF s/p ablation who had been in sinus but happens to be in asymptomatic rate controlled fib that morning...I would probably slap a probe on in preop real quick and make sure lv/rv/valve function, atrial size, and pa pressures are consistent with prior studies and then proceed.

 

[nlax30]

I agree in that certainly any newly found arrhythmia should be evaluated first and the case cancelled. If the patient shows up and is found to be in afib/aflutter I would guess that they were relatively asymptomatic from it and you really wouldn't know when it began unless they had a recent/previous EKG. Certainly in that case with afib/flutter of unknown duration I would not suggest cardioversion (unless unstable of course) as they need some further work-up and risk of stroke assessed.

Someone with known paroxysmal afib who then goes back into afib I would say just rate control and continue.

 

[YadaYadaNext]

Elective procedure - new onset arrhythmia = cancel case - unless you have VERY recent ECHO/stress/cath telling you everything you want to know.

I'd check electrolytes, replace, and call cardiology. Would probably give a few grams of magnesium empirically.

If UNSTABLE, obviously cardiovert.

However I most likely would not cardiovert a STABLE patient at this point (even though it would probably benefit the patient). Have no idea of duration(>48 hours?). I might be more inclined to cardiovert if I threw a probe down and confirmed a clean LAA. - would give 2 grams of mag and maybe even some KCl while the lytes are cooking prior to shock. Even with a clean LAA, I've seen cardiology anticoagulate for 2 weeks, then cardiovert, and 6 more weeks of AC.

All in all, not worth it for the anesthesiologist to shock and cause a CVA just to save the patient an outpatient conscious sedation and DCCV.

 

[BLADEMDA]

Wanted some people's opinions on what you would do with a patient who presented for elective surgery and they had a-flutter with no prior history of it.

Would it matter if they had a pre-op EKG showing flutter vs. finding out when you hooked them up to the monitor in the OR?

Would you proceed or delay the case? What if the flutter occurred after induction but before the surgery started? Does the type of surgery matter? Type of anesthesia?

I'm keeping this kind of open ended and vague cause I wanted to get people's opinions and thoughts on newly diagnosed arrhythmias and providing anesthesia before I give my own opinions. Doesn't have to be flutter, could be a-fib or WPW or whatever rhythm you can think of. Well besides asystole...

I see this weekly. The posts above are correct but in reality 95% of all new A. fibs in the elderly can be rate controlled. That said, I did have a patient with new onset A.Fib in the O.R. who couldn't tolerate the anesthetic. The loss of the atrial kick left the patient hemodynamically unstable. I placed lines in the patient and started Levophed.
The combo of Diltiazem and Amiodarone did convert him to NSR about 2 hours into his PACU stay. He got a Cards work-up then came back for his surgery a few days later.

If the A. fib happens after induction I do the case (unless unstable as described above) with rate control. If I see new onset A.fib or A. Flutter prior to induction I "delay" the case for a Cardiology consult/work-up. I believe this is our current standard of care in the USA.

http://anaesthetics.ukzn.ac.za/Libr..._management_for_non-cardiac_surgery.sflb.ashx

 

[Noyac]

Why would anyone cardiovert this pt short of severe decompensation due to rhythm?

Get cards involved.

 

[Mman]

Pretty much any previously undiagnosed arrhythmia (including PVCs) gets canceled cause it could be a sign of previously undiagnosed structual heart disease or ischemia.

I'm sorry, did you just say you cancel a case for PVCs? WTF? Everyone gets PVCs, even 20 year old ASA 1 patients.

 

[sigrhoillusion]

OK now that I've gotten some responses I'll go into a little more detail.

78yo patient coming in for skin graft/hand reconstruction after dog bite. Patient otherwise "healthy" and denied any medical problems except for remote history of breast CA s/p mastectomy many years ago. But otherwise no other issues. Goes to our pre-op center a few days before surgery and seen by anesthesia. They get the above history a few labs, CXR and EKG and send patient on her way.

Morning of surgery I briefly look through my cases. This was an afternoon case but I have two rooms and numerous regional blocks to do with residents so I try to get some of the electronic pre-ops done so I can quickly confirm history and get consent when the time comes and do blocks/get patient in OR. So I get to this patient's chart quick check her stdies and see EKG from pre-op center with the above mentioned rhythm, a-flutter 2:1 conduction at 150bpm and go "Hmmmmmmm" don't remember anything about that. No notes from cards, just a note that EKG was confirmed and patient cleared for surgery.

I talk to surgeon and some colleagues and show them the EKG. With no history I'm thinking this patient should have cardiology see them.

So it's like 6 hours before her surgery, but being the good samaritan I am, I call this patient up and ask her if anyone had talked to her about the EKG. No.
Has she ever seen cardiology? No.
PCP? Nope, moved recently and hasn't seen a PCP in a while.
Any symptoms? Not really, but she does say she occasionally gets palpitations.

So no primary to see, the fact that she is on the phone and otherwise symptomatic makes me happy that she didn't die yet. That being said I don't want her to wait to come in only for me to tell her that we're not doing the case and have cardiology see her. So I reassure her and tell her to come to the ED. I then call ED attending and give him a heads up and go about the rest of my day.

ED attending calls me a few hours later that the patient has arrived. I find a minute to go down to ED and sure enough repeat EKG shows same rate and she's on the monitor taching away. No symptoms. Labs sent. I say hello, again thank her for coming in and then go about the rest of my day.

So stalking the chart the following day, it appeared all her lab work was OK. Cardiology saw her that day. They attempted to rate control and started her on esmolol and heparin infusions. She ended up going for TEE/cardioversion later in the day. TEE showed EF 40% with vegetations on her MV so no cardioversion. ID consulted and started on abx.

Haven't looked in a few days, but I feel I did the right thing. I rembember there was a thread about arrhythmias a while ago and it seemed like a lot of people (especially PP) would just push on. As Blade said, 90% of the time you can rate control and move on as most tolerate it. But as he also mentioned there are a few that crump. So yes me being the pathetic academic (and rhyming master...) I "postponed" the case. Things to think about is what if I didn't have an EKG before hand, or what if I got a prelim EKG and it showed this rhythm, or what if when I got her on the table she was taching away at 150bpm with no EKG prior? I'd probably postpone and have cards see her. Obviously if she had a history and was on meds I would probably push on. And if it happened after induction and she tolerated it, I'd try to rate control and push on and then have cards see post-op.

Another thing I was wondering is what if you had a-flutter EKG from a few days prior but don't know this until she shows up and you get a repeat and she's in NSR? What do you do? Do the H+P/ROS and then hope she doesn't flip back into a-flutter? Cards post-op? Cards pre-op?

However, with the info I had pre-op and the complete lack of history and ability to go to a PCP I felt I made the right choice especially in an elective case. The bigger question is what was the point of her going to the pre-op center...? You'd think the whole point was to filter out these patients and prevent them from showing up the DOS only to be postponed/canceled because of information we had gathered. I was pretty pissed. The surgeon is a good guy, but if I was him, I'd be pissed too.

You can all now proceed to laugh at me for calling a patient at home and acting like an internal medicine intern... 🤣

 

[BLADEMDA]

S#%t happens. If they show up on the day of surgery in NSR I do the case. I typically give low dose metoprolol IV during the case to keep them in NSR. Esmolol if needed for induction to avoid tachycardia.

As for seeing patients in preop clinic that doesn't guarantee anything. I could come in with 4+ mets for a lap chole but still have an MI in the O.R. There are no guarantees on anything but we do follow the guidelines and protocols. There simply isn't any way to predict things that can happen to human beings especially new onset A. Fib (which is quite common). All we can do is prepare for the worst and hope for the best. Fortunately, that strategy usually works out.

Sh@t Happens.

 

[BLADEMDA]

 

[sigrhoillusion]

S#%t happens. If they show up on the day of surgery in NSR I do the case. I typically give low dose metoprolol IV during the case to keep them in NSR. Esmolol if needed for induction to avoid tachycardia.

As for seeing patients in preop clinic that doesn't guarantee anything. I could come in with 4+ mets for a lap chole but still have an MI in the O.R. There are no guarantees on anything but we do follow the guidelines and protocols. There simply isn't any way to predict things that can happen to human beings especially new onset A. Fib (which is quite common). All we can do is prepare for the worst and hope for the best. Fortunately, that strategy usually works out.

Sh@t Happens.

Well obviously S%&T happens... that's not really the point. The point is shouldn't we limit the chances for S%$T to happen? Obviously any patient can go into an arrhythmia, but if you have a patient in new one, wouldn't it be best to postpone? If you do have a pre-op clinic shouldn't it be used to prevent cases like this? Like if you were working at a pre-op clinic and you got this EKG. What would you do? Would you work it up, or just say, "stay NPO for surgery and if something goes wrong S%&T happens, anesthesia will deal with it"

Like I said, if this was post-induction I see if the patient tolerates it, rate control and hopefully worst case cardiovert. That is the definition of S%&T happening. Not sure if it's the same as having information, acknowledgin/disregarding it, hoping nothing happens and then if S%&Y happens deal with it.

 

[ambiturner]

Who staffs the pre-op clinic? Even if they don't read the EKGs, don't they at least check the vitals? They need to get some feedback on this one, what a joke.

In a more general sense, I would cancel for new afib/flutter if for no other reason to ensure the change doesn't represent a new event.

 

[deleted162650]

See, crap like this is exactly why I don't bother to even look at preop EKGs.

 

[sigrhoillusion]

Who staffs the pre-op clinic? Even if they don't read the EKGs, don't they at least check the vitals? They need to get some feedback on this one, what a joke.

In a more general sense, I would cancel for new afib/flutter if for no other reason to ensure the change doesn't represent a new event.

I know there's at least an anesthesiologist and APNs, and occasionally resident with them. To be honest I've never been over there so not sure how exactly it's run. But from the sounds of it, it's similar to the one we had in residency. Surgeons send certain patients (or all of them for some specialties..........) for pre-op clearance. Initial pre-eval done by nurses. Then pre-ops, labs, EKGs, CXRs and other things are verified by MD. MD then sees patients and gets anesthesia consents and tells patients if they need anything else before surgery. Sometimes the patient only gets labs/imaging and don't have a chane to physically be seen.

In the original case patient was seen, but EKG was not read that day. However, it was read prior to surgery, verified and patient was OKed for procedure with no further intervention. When I talked to him after all of this he said that he had seen EKG but since it was day before surgery he figured if there were any concerns whoever was managing patient would cancel (which I thought was the point of pre-op testing...) . He also stated that he would have done the case and just rate controlled patient, which would be nice, but again per her chart, cardiology has been unsuccessful with and appears to have started dig loading her. Again, the fact that this elderly patient has been fluttering away for at least 4-5 days now without symptoms makes me feel that she'd tolerate the procedure, but that being said, not worth it to find out in an elective procedure.

 

[sigrhoillusion]

See, crap like this is exactly why I don't bother to even look at preop EKGs.

Regardless of EKG, you'd hook her up to the monitors and you'd be staring at a-flutter at 150 prior to starting. Then what? No prior history. Start asking questions? Push on with the propofol? Give esmolol?

 

[Mman]

Haven't looked in a few days, but I feel I did the right thing. I rembember there was a thread about arrhythmias a while ago and it seemed like a lot of people (especially PP) would just push on. As Blade said, 90% of the time you can rate control and move on as most tolerate it. But as he also mentioned there are a few that crump. So yes me being the pathetic academic (and rhyming master...) I "postponed" the case.

Hey now, I'm in a pure PP setting and try not to cancel anything if I can help it, but even I said I'd cancel for new a-flutter and have them see a cardiologist. That's not a PVC.

Now if the patient was in NSR on the preop EKG and ended up going into a-flutter after induction, well then I'd probably still do the case if they were otherwise stable and it was minor enough. But starting the case when you know it's going on? That's a whole bigger ball of wax. And that's not just academic teaching point to cancel it. That's the real world PP answer also.

 

[deleted162650]

Regardless of EKG, you'd hook her up to the monitors and you'd be staring at a-flutter at 150 prior to starting. Then what? No prior history. Start asking questions? Push on with the propofol? Give esmolol?

Fist off - that was sarcastic. If I hook her up to monitors in the OR and see AF @ 150 then I'm still gonna postpone surgery 9 times outta 10 unless it's something really minor like a carpal tunnel. She pops into it right after induction but before incision then it gets a little harder to cancel. If I see this in the preop bay, then she for sure bought herself a cards workup before proceeding with an elective case. While it's likely benign, there's always the chance it's due to some underlying badness. And, you have no idea how long this has been going on for. Anything you do to try to rate control her has the potential to convert her which has the (albeit small) chance to send clots hurdling towards her brain. Let's say you are a family doc and you see this pt in clinic for the first time and discover she's in AF at 150 - what you gonna do? You're gonna call up your cards buddy and probably send her to the hospital right?

Your preop clinic team needs a , and the dipsh*t who said:

if there were any concerns whoever was managing patient would cancel

Needs to get taken out back and before getting fired - that kind of stupidity is dangerous to have around the hospital.

 

[Southpaw]

You did the right thing for your patient. Don't feel bad, or guilty, or whatever. New onset atrial flutter prior to induction of Anesthesia is pretty straightforward --> off to cardiology. I'm in private practice and without a doubt would do the same as you did.

 

[vector2]

I'm sorry, did you just say you cancel a case for PVCs? WTF? Everyone gets PVCs, even 20 year old ASA 1 patients.

As others have said, it depends on the patient and the procedure. No one here is talking about a 20 yr old asa 1, but if the pt is 75yo hypertensive and is having new onset frequent PVCs (2-3 per sweep) it's something that's needs to be worked up. Sure, maybe it's just the mag is low, but I wouldnt underestimate the probability of frequent PVCs being sentinel ischemia in someone with other risk factors.

 

[Robotic Wis-Hipple]

This reminds me of one of the preop clinics my program had, not so much an actual preop and triage/optimize goal as it was a collect info and do nothing with it going thru the motions kind of thing. Because of that the Surgeons don't buy in because they're still seeing cases delayed or at best having talks about delaying with the attending of record the morning off. Why should a surgeon send a patient for preop "clearance" if nothing is being done preemptively by the people running the clinic?

 

[sigrhoillusion]

This reminds me of one of the preop clinics my program had, not so much an actual preop and triage/optimize goal as it was a collect info and do nothing with it going thru the motions kind of thing. Because of that the Surgeons don't buy in because they're still seeing cases delayed or at best having talks about delaying with the attending of record the morning off. Why should a surgeon send a patient for preop "clearance" if nothing is being done preemptively by the people running the clinic?

My thoughts exactly. Preop clinic should be a way of screening certain patients in order to optimize them for surgery. Problem is half of them go a few days before surgery so even if anything is found there's no time to do anything about it. The other half probably have no reason to go in the first place. Then we tend to get a bunch of unnecessary labs/imaging on people.

In this case this patient was "healthy" with no symptoms however she hadn't seen a doctor in a long time. So outside of her age the surgeon might not have had any reason to send her to the clinic. So it might have ended up where she got bypassed and ended up in the OR anyways. The fact that she went, we had the info and would have let her starve all day was a complete ball dropper. That attending should try out for a WR position for the Eagles...

 

[Mman]

As others have said, it depends on the patient and the procedure. No one here is talking about a 20 yr old asa 1, but if the pt is 75yo hypertensive and is having new onset frequent PVCs (2-3 per sweep) it's something that's needs to be worked up. Sure, maybe it's just the mag is low, but I wouldnt underestimate the probability of frequent PVCs being sentinel ischemia in someone with other risk factors.

I dunno, most old patients have PVCs too. I'm also not sure what you mean by "2-3 per sweep". Are you referring to a patient in the OR hooked up to continuous EKG monitoring? Because that's kinda late in the game to cancel a case for PVCs. Are you talking about 2 or 3 PVCs on the preop 12 lead EKG? I mean at what point in the process are you finding these PVCs and caring about it? I mean if the person comes in complaining of new DOE or unstable angina and also has a lot of PVCs, sure get them worked up. But if it's your average 70 year old with DM and HTN that has had various cardiac workups over the last decade and they've got some PVCs there is no reason to postpone a case IMHO.

 

[Noyac]

I didn't read all the responses. I'm feeling lazy today.
But as a rule I don't see a pt that meets criteria for an ECG until the ECG is done when I am in the period clinic.
Therefore, I would have seen this ECG as all of this DOS crap would have been avoided.

 

[Ignatius J]

Different but similar question, I think we can all agree that non-rate-controlled a-fib/a-flutter should be delayed for work-up.

What about new onset rate-controlled a-fib? I spoke with a cardiologist about this one time who said all he would do is ensure rate control and "clear for surgery." I actually see patients that have had just this done all the time.

Intermediate and high risk surgery still get cancelled but I've done cysto and hand cases in rate-controlled new-onset a-fib. Especially in November and December- you screw with a patient's deductible and push them to the new year and you can be in for a world of pain.

So....rate-controlled, new-onset a-fib. What is your plan of action?

 

[chocomorsel]

Different but similar question, I think we can all agree that non-rate-controlled a-fib/a-flutter should be delayed for work-up.

What about new onset rate-controlled a-fib? I spoke with a cardiologist about this one time who said all he would do is ensure rate control and "clear for surgery." I actually see patients that have had just this done all the time.

Intermediate and high risk surgery still get cancelled but I've done cysto and hand cases in rate-controlled new-onset a-fib. Especially in November and December- you screw with a patient's deductible and push them to the new year and you can be in for a world of pain.

So....rate-controlled, new-onset a-fib. What is your plan of action?

What do you mean rate controlled? As in, the patient has seen a cardiologist who's started him on a B Blocker and some Coumadin and possibly done an echo?
Or is it you rate controlling it in pre op after you've discovered it?

 

[Ignatius J]

What do you mean rate controlled? As in, the patient has seen a cardiologist who's started him on a B Blocker and some Coumadin and possibly done an echo?
Or is it you rate controlling it in pre op after you've discovered it?

He comes in with heart rate of 80 in a-fib that he doesn't know about.

 

[dhb]

I can't believe there is still a debate about this. It's as clear cut as it comes...

 

[anbuitachi]

Didn't read entire thread but if you have QI I would report this. Ridiculous this patient didn't get screened out w a hr of 150

 

[Direct Laryngoscopy]

I recently had a 78 yo with a PMhx of hTN and DM who came in a week prior for hypoglycemia and rhabdo. He was developed flutter and facial drooping and was found to have an embolic CVA "most likely." Carotid study showed severe dz and he was booked for a CEA. Cards evaluated him and opined EP study could be done later on. One cardiology note did note a TEE should be done to evaluate for LAA thrombus.

I cancelled the case because the pt's HR was in the 130s, but I couldn't understand why they wouldn't get a TEE in a Pt with a CVA associated with new onset a flutter. I told both the medicine and surgical teams a TEE would be appropriate and was ordered the same day. The pt was actually in the cath lab to get the TEE when the vascular surgeon called down to cancel the TEE. My question is in a case like this would you have still proceeded with the CEA if no TEE was done? What about controlled fib/flutter? I don't have a reason why the surgeon is deadset against a TEE?


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[chocomorsel]

He comes in with heart rate of 80 in a-fib that he doesn't know about.

New onset Afib, I would get a cardiologist to look at him. R/O ischemia, take a look at chambers and valves, get on proper meds.
See what you got to work with before you go into the OR and stress him out.

 

[chocomorsel]

I recently had a 78 yo with a PMhx of hTN and DM who came in a week prior for hypoglycemia and rhabdo. He was developed flutter and facial drooping and was found to have an embolic CVA "most likely." Carotid study showed severe dz and he was booked for a CEA. Cards evaluated him and opined EP study could be done later on. One cardiology note did note a TEE should be done to evaluate for LAA thrombus.

I cancelled the case because the pt's HR was in the 130s, but I couldn't understand why they wouldn't get a TEE in a Pt with a CVA associated with new onset a flutter. I told both the medicine and surgical teams a TEE would be appropriate and was ordered the same day. The pt was actually in the cath lab to get the TEE when the vascular surgeon called down to cancel the TEE. My question is in a case like this would you have still proceeded with the CEA if no TEE was done? What about controlled fib/flutter? I don't have a reason why the surgeon is deadset against a TEE?


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Screw that. I would tell the surgeon to find a different anesthesiologist. Really?

 

[nlax30]

I recently had a 78 yo with a PMhx of hTN and DM who came in a week prior for hypoglycemia and rhabdo. He was developed flutter and facial drooping and was found to have an embolic CVA "most likely." Carotid study showed severe dz and he was booked for a CEA. Cards evaluated him and opined EP study could be done later on. One cardiology note did note a TEE should be done to evaluate for LAA thrombus.

I cancelled the case because the pt's HR was in the 130s, but I couldn't understand why they wouldn't get a TEE in a Pt with a CVA associated with new onset a flutter. I told both the medicine and surgical teams a TEE would be appropriate and was ordered the same day. The pt was actually in the cath lab to get the TEE when the vascular surgeon called down to cancel the TEE. My question is in a case like this would you have still proceeded with the CEA if no TEE was done? What about controlled fib/flutter? I don't have a reason why the surgeon is deadset against a TEE?

What would a TEE change? That patient needs anticoagulation regardless of whether or not there's a thrombus in the LA appendage. I guess only thing is would the case have been cancelled if there was a thrombus? Plus if his CVA was on the side of the carotid stenosis then that's probably the culprit and not the flutter.

Slightly different scenario, but it's not infrequently that I get a TEE request from Neurology on a patient that either has a history of afib or recently diagnosed afib. My question to them is then what is it going to change? If I don't find a thrombus I am recommending anticoagulation, if I do find a thrombus I'm recommending anticoagulation.

But you do cases all the time I'm sure on patients who have known controlled afib who then come off anticoagulation for surgery so not every patient is getting a TEE in the OR, right?

 

[Mman]

What would a TEE change? That patient needs anticoagulation regardless of whether or not there's a thrombus in the LA appendage. I guess only thing is would the case have been cancelled if there was a thrombus? Plus if his CVA was on the side of the carotid stenosis then that's probably the culprit and not the flutter.

Slightly different scenario, but it's not infrequently that I get a TEE request from Neurology on a patient that either has a history of afib or recently diagnosed afib. My question to them is then what is it going to change? If I don't find a thrombus I am recommending anticoagulation, if I do find a thrombus I'm recommending anticoagulation.

But you do cases all the time I'm sure on patients who have known controlled afib who then come off anticoagulation for surgery so not every patient is getting a TEE in the OR, right?

with recently diagnosed a-fib, aren't you checking for a clot to see if you can safely cardiovert them? If you don't find a thrombus, you cardiovert them now. If you do, you anticoagulate first.

 

[nlax30]

with recently diagnosed a-fib, aren't you checking for a clot to see if you can safely cardiovert them? If you don't find a thrombus, you cardiovert them now. If you do, you anticoagulate first.

Yea certainly if they have not been on anticoagulation (or at least less than 3 weeks of it). In the above case it seemed like they were asking for a TEE just to take to surgery which I didn't get. Plus, in the setting of surgery and acute CVA I can't anticoagulate right away anyway so even so I wouldn't cardiovert that patient and so a TEE at that time isn't going to change what I do.

But yea, if you're planning on cardioverting and they have not been on anticoagulation then certainly take a look first.

 

[Arch Guillotti]

If you do, you anticoagulate first.

Unless the surgery isn't entirely elective.