Post Op A FIb

[Noyac]

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Yesterday, I was in a case at the end of the day and the pacu nurses and surgeon didn't want to bother me (critical point in case, C2-T3 fusion) so they called the hospitalist who was seeing this pt b/4 surgery and was taking her after surgery. She was 91 yo. and just got finished with a lap chole. No real heart history 🙄 but after emergence she went into a fib in the pacu. Vitals were stable but HR was 120's. The anesthesiologist was gone by now.

So my question is, how do you guys like to treat new onset a fib with stable vitals? The hospitalist sent his nurse practitioner who ordered a 12 lead (we had already done that) and cosigned his order. Thanks, that was helpful.😱 I know the ACLS protocol which gives you many options, so whats your favorite?

I got to the pacu about 30 minutes later and saw this. I took over and she converted. I was a little put back at the lack of urgency on the hospitalists part and the NP. The surgeon was present the whole time until he saw I got involved and things were improving HR wise. I know as anesthesiologists we like to see immediate results.

 

[BLADEMDA]

Yesterday, I was in a case at the end of the day and the pacu nurses and surgeon didn't want to bother me (critical point in case, C2-T3 fusion) so they called the hospitalist who was seeing this pt b/4 surgery and was taking her after surgery. She was 91 yo. and just got finished with a lap chole. No real heart history 🙄 but after emergence she went into a fib in the pacu. Vitals were stable but HR was 120's. The anesthesiologist was gone by now.

So my question is, how do you guys like to treat new onset a fib with stable vitals? The hospitalist sent his nurse practitioner who ordered a 12 lead (we had already done that) and cosigned his order. Thanks, that was helpful.😱 I know the ACLS protocol which gives you many options, so whats your favorite?

I got to the pacu about 30 minutes later and saw this. I took over and she converted. I was a little put back at the lack of urgency on the hospitalists part and the NP. The surgeon was present the whole time until he saw I got involved and things were improving HR wise. I know as anesthesiologists we like to see immediate results.

HR control. B-Blockers vs. Cardizem drip. I usually try a little esmolol and check the response. If BP stable and HR goes down then I consider Metoprolol I.V. I don't find Digoxin offers a whole lot but usually in my elderly patients I add this after reconfirming the K level.

I know verapamil has been mentioned by another poster but I usually stick with B-blockers and/or Cardizem with excellent results. Cardizem drip works fine but it is nice when I get rate control out of 2-3 mg of Metoprolol I.V.
It makes things easy for everyone. I have used Esmolol drips and Cardizem drips but prefer the latter because I can CAREFULLY add B-Blockers on top on the Cardizem drip if needed.

I don't usually prescribe more "aggressive" A. Fib meds because rate control is my priority. I let the Cardiologists consider the bigger guns after they see the patient. But, if unstable A.Fib then every option is considered.

I have many peer reviewd articles on the subject. I used to be more rigid in my approach (e.g. esmolol infusion over cardizem drip because of slightly better rate control) but found that a "flexible" approach seemed to be just as good or better and was easier to maintain after the patient left PACU.

Blade

 

[Intubate]

I agree with beta blockers or dilt. I use metoprolol because thats what I've always used (1 mg at a time). I also always send electrolytes (its not high yield, but sometimes its the culprit) and rule them out with enzymes (a somewhat unlikely presentation for ischemia).

 

[milrisome]

Agree with above. Use dilt or metoprolol. Usually once you get rate control (in my experience) they will convert on their own, if it truly is new onset. These people are probably going in and out of Afib all the time and the surgical/anesthetic stress pushes them into it. Just need to control rate until the stress subsides.

I agree with looking for a cause but you would probably know about it before surgery. I assume there wasn't much bleeding with a lap chole but probably good to look into that.

 

[BLADEMDA]

Agree with above. Use dilt or metoprolol. Usually once you get rate control (in my experience) they will convert on their own, if it truly is new onset. These people are probably going in and out of Afib all the time and the surgical/anesthetic stress pushes them into it. Just need to control rate until the stress subsides.

I agree with looking for a cause but you would probably know about it before surgery. I assume there wasn't much bleeding with a lap chole but probably good to look into that.

After my years of experience the subgroup to look out for is the following:

Elderly patient with history of HTN and PAC's on the EKG. These patients seem to have a higher incidence of A.FIB in the Perioperative period.

The studies show that good rate control and the majority will convert on their own to NSR.

Blade

 

[Noyac]

Here is my approach.

Verapamil.

This pt was given digoxin 0.5 mg with no results. When i entered the PACU her HR was 120's . I grabbed some verapamil and gave her 2.5 mg. Her HR quickly came down to 85 and she was still in a. fib. I was happy with that HR so I stopped there. About 20 minutes later she converted.
I also have used the B blockers but have found verapamil to be a little better. Not of caution, don't use the ca channel blocker and B blocker together. Too much cardiac depression. But you guys all know that already.

I was just curious as to how others treated the occasional a. fib.

 

[Planktonmd]

Here is my approach.

Verapamil.

👍

I am a strong believer of Verapamil.

 

[BLADEMDA]

👍

I am a strong believer of Verapamil.

Please provide peer reviewed studies backing up that statement. There are many showing Esmolol infusion or Cardizem Infusion is the way to go. Would you like the references?

Blade

 

[Planktonmd]

Please provide peer reviewed studies backing up that statement. There are many showing Esmolol infusion or Cardizem Infusion is the way to go. Would you like the references?

Blade

No I don't want the references!
No one said that Esmolol and Diltiazem don't work but I think that they are more suitable for use in the ICU.
The advantage of Verapamil ,as you know, is that it has a longer half life and you don't need an infusion, this ,in my humble opinion, makes it more suitable for our purposes.
On the other hand Verapamil is in no way a perfect drug and it can be a lethal weapon in the wrong hands, it can trigger V Fib in WPW syndrome, it potentiates the AV blockade caused by other antiarrhythmics(including Digoxin and Beta blockers), and it's a potent negative inotrop.
So, I say : in the right hands, and in the right patient, Verapamil is a wonderful drug, and I don't have the " peer reviewed studies backing up that statement".
😀

 

[BLADEMDA]

No I don't want the references!
No one said that Esmolol and Diltiazem don't work but I think that they are more suitable for use in the ICU.
The advantage of Verapamil ,as you know, is that it has a longer half life and you don't need an infusion, this ,in my humble opinion, makes it more suitable for our purposes.
On the other hand Verapamil is in no way a perfect drug and it can be a lethal weapon in the wrong hands, it can trigger V Fib in WPW syndrome, it potentiates the AV blockade caused by other antiarrhythmics(including Digoxin and Beta blockers), and it's a potent negative inotrop.
So, I say : in the right hands, and in the right patient, Verapamil is a wonderful drug, and I don't have the " peer reviewed studies backing up that statement".
😀

The studies show that the INFUSIONS result in a spontaneous conversion to NSR in the majority of cases. The B-Blockers have a higher spontaneous conversion than the Ca Channel blockers. Thus, Verapamil may NOT be best choice considering the fact that Metoprolol is available I.V. and is longer acting than Esmolol. So, using the same logic as you I humbly state that Metoprolol is a better choice for those wishing to avoid an infusion.

That is the approach I use routinely. Metoprolol I.V. (after esmolol test dose on HR and BP) for new onset A.fib. After this drug I start an infusion of either Cardizem (no bolus) or Esmolol. I have encountered new onset A.Fib many times in my career and have NEVER had any major cardiac depression with the Metoprolol plus Cardizem drip. But, I have seen severe bradycardia after 10-15 minutes on the cardizem drip which quickly resolved after stopping the infusion. In those cases (two) of severe bradycardia due to the combination of Metoprolol plus Cardizem the infusion was restarted at a very low rate in one patient and NOT needed again in the second.

Blade

 

[jetproppilot]

Here is my approach.

Verapamil.

This pt was given digoxin 0.5 mg with no results. When i entered the PACU her HR was 120's . I grabbed some verapamil and gave her 2.5 mg. Her HR quickly came down to 85 and she was still in a. fib. I was happy with that HR so I stopped there. About 20 minutes later she converted.
I also have used the B blockers but have found verapamil to be a little better. Not of caution, don't use the ca channel blocker and B blocker together. Too much cardiac depression. But you guys all know that already.

I was just curious as to how others treated the occasional a. fib.

As I posted previously, Noy, I like verapamil in this scenerio as well.

Not convinced that beta blockers are superior to calcium channel blockers treating supraventricular tachydysrhythmias with rapid ventricular response.

Diltiazem infusion is the en vogue calcium channel treatment for supraventricular tachydysrhythmia intervention....but after eleven years of high volume practice, I've learned that doctors gravitate to the newest stuff,, sometimes casting aside older, less marketable, albeit just as effective, or even superior, interventions.

Hell, I've been guilty.

A'int no hottie verapamil drug reps-with-augs-sportin'-around-the-operating-room....

hmmmmmmm

takes a little sense to realize that its THE BENJAMINS are at work here.

Verapamil may achieve what you want clinically.

Ain't no blond drug rep hottie with 34 C's gonna bring you shrimp fettucini touting the efficacy of a drug with no profit margin-power!!!

Point being,

LOOK TO SOME OF THE RECENT (albeit nonprofitable) PAST FOR GREAT CLINICAL PROBLEM SOLVING TECHNIQUES.

And keep this in mind for the rest of your career.

Cuz hottie drug reps will come and go.

BUT VERAPAMIL WILL KEEP ON WORKIN'

BLADE has gone with the hottie diltiazem approach.

With papers supplied by hottie to support such intervention.

I'm telling you, in BLADE FASHION (i.e. IN MY 87 YEARS OF EXPERIENCE, but seriously,with ELEVEN YEARS OF HIGH VOLUME PRACTICE,,

verapamil will probably work well for you here.

no hottie diltiazem drug rep is gonna say that.

 

[sdn1977]

As I posted previously, Noy, I like verapamil in this scenerio as well.

Not convinced that beta blockers are superior to calcium channel blockers treating supraventricular tachydysrhythmias with rapid ventricular response.

Diltiazem infusion is the en vogue calcium channel treatment for supraventricular tachydysrhythmia intervention....but after eleven years of high volume practice, I've learned that doctors gravitate to the newest stuff,, sometimes casting aside older, less marketable, albeit just as effective, or even superior, interventions.

Hell, I've been guilty.

A'int no hottie verapamil drug reps-with-augs-sportin'-around-the-operating-room....

hmmmmmmm

takes a little sense to realize that its THE BENJAMINS are at work here.

Verapamil may achieve what you want clinically.

Ain't no blond drug rep hottie with 34 C's gonna bring you shrimp fettucini touting the efficacy of a drug with no profit margin-power!!!

Point being,

LOOK TO SOME OF THE RECENT (albeit nonprofitable) PAST FOR GREAT CLINICAL PROBLEM SOLVING TECHNIQUES.

And keep this in mind for the rest of your career.

Cuz hottie drug reps will come and go.

BUT VERAPAMIL WILL KEEP ON WORKIN'

BLADE has gone with the hottie diltiazem approach.

With papers supplied by hottie to support such intervention.

I'm telling you, in BLADE FASHION (i.e. IN MY 87 YEARS OF EXPERIENCE, but seriously,with ELEVEN YEARS OF HIGH VOLUME PRACTICE,,

verapamil will probably work well for you here.

no hottie diltiazem drug rep is gonna say that.

You are ONE funny guy😉! You've got these drug reps figured out. Gosh - I could have had a career there - I've got the legs.....just not those other "qualities" (no worries - I agree completely!!!, altho diltiazem & esmolol are pretty old school. Are you still getting lunch out of that??).

Couple of points - first, there is more than one way to skin a cat - lots of ways to covert this pt. But, some points to consider - is your lady going to the ICU? - she's gotta go with an esmolol or diltiazem drip. Unfortunate, but practical considerations are - are there beds there? Sometimes not, although this fusion at this age might have needed to spend a night there no matter what. But....a drip changes the nurse😛t ratio even if she was going to her reserved ICU bed.

That's not to say the previous verapamil conversion might not have bought her an ICU reservation as well - there is a possible likelyhood she could go back into a fib hours later (no - don't have the studies at hand) even after verapamil conversion.

But, getting her converted before discharge from PACU without a drip in place does definitely change staffing ratios. Not sure that is a good therapeutic reason, but we all have to live with the economics....

 

[OB1🤙]

Alternatively, you could go with the dilt if the pharma-sloot wore a low-cut top last time she came around, but stick with the verapamil if she went conservative. Amounts to a coin flip. You could probably even randomize a trial that way...

I kid, I kid. Seriously, those pharma floozies have no place in our hospitals. In my married opinion, of course. Your mileage may vary.

 

[Planktonmd]

The studies show that the INFUSIONS result in a spontaneous conversion to NSR in the majority of cases. The B-Blockers have a higher spontaneous conversion than the Ca Channel blockers. Thus, Verapamil may NOT be best choice considering the fact that Metoprolol is available I.V. and is longer acting than Esmolol. So, using the same logic as you I humbly state that Metoprolol is a better choice for those wishing to avoid an infusion.

That is the approach I use routinely. Metoprolol I.V. (after esmolol test dose on HR and BP) for new onset A.fib. After this drug I start an infusion of either Cardizem (no bolus) or Esmolol. I have encountered new onset A.Fib many times in my career and have NEVER had any major cardiac depression with the Metoprolol plus Cardizem drip. But, I have seen severe bradycardia after 10-15 minutes on the cardizem drip which quickly resolved after stopping the infusion. In those cases (two) of severe bradycardia due to the combination of Metoprolol plus Cardizem the infusion was restarted at a very low rate in one patient and NOT needed again in the second.

Blade

I have to say that Metoprolol is definitely safer than Verapamil but in no way more effective!
and since you are talking about long acting beta blockers, I have a suggestion for you:
Try Atenolol IV for this indication you will realize how weak Metoprolol is.

 

[BLADEMDA]

I have to say that Metoprolol is definitely safer than Verapamil but in no way more effective!
and since you are talking about long acting beta blockers, I have a suggestion for you:
Try Atenolol IV for this indication you will realize how weak Metoprolol is.

The study showed esmolol Infusion was superior to Diltiazem. I don't have any peer reviewed evidence for Metoprolol/Atenolol vs. verapamil. I am EXTRAPLATING that since the infusion of B-blockers is superior to Ca channel blockers than that would apply to long lasting drugs of the same class as well. I have no opinion of atenolol vs. metoprolol so I can't comment on the superiority of the EXACT B-blocker. I choose metoprolol for safety and my familiarity with the drug.

Again, please produce peer reviewed evidence for the superiority of Ca channel blockers. My ancedotal experience agrees with the literature.

Curr Med Res Opin. 2003;19 (5):376-382

Anesthesiology 1998 Nov;89 (5):1052-1059





Blade

 

[Intubate]

Steering clear of the CCB vs B blocker debate (I have said that I use metoprolol, but just because that's what I use), I'd like to go back briefly to the case. It said she got digoxin first-- what's up with that? I think most cardiologists would agree that dig has no role in conversion or control of acute afib (and not much of a role anywhere else either). Do you guys use this routinely?

 

[Laurel123]

Steering clear of the CCB vs B blocker debate (I have said that I use metoprolol, but just because that's what I use), I'd like to go back briefly to the case. It said she got digoxin first-- what's up with that? I think most cardiologists would agree that dig has no role in conversion or control of acute afib (and not much of a role anywhere else either). Do you guys use this routinely?

Personally, I am a fan of the esmolol small boluses, and then when shown effective, titrate in some metoprolol.

I remember as in intern in medicine, that we would use digoxin often. I think that internists were concerned about the negative inotropic effect of BB and CCB, as well as the vasodilating effects of the CCB, so when the patient had low/normal blood pressure but basically stable, with rapid rate afib, they would use digoxin. But I haven't used digoxin since my intern year.

Another drug we use for rapid a-fib is amiodarone, if the patient has low ejection fraction.

 

[Planktonmd]

The study showed esmolol Infusion was superior to Diltiazem. I don't have any peer reviewed evidence for Metoprolol/Atenolol vs. verapamil. I am EXTRAPLATING that since the infusion of B-blockers is superior to Ca channel blockers than that would apply to long lasting drugs of the same class as well. I have no opinion of atenolol vs. metoprolol so I can't comment on the superiority of the EXACT B-blocker. I choose metoprolol for safety and my familiarity with the drug.

Again, please produce peer reviewed evidence for the superiority of Ca channel blockers. My ancedotal experience agrees with the literature.

Curr Med Res Opin. 2003;19 (5):376-382

Anesthesiology 1998 Nov;89 (5):1052-1059





Blade

Blade,

You keep saying the same thing and citing irrelevant data!
I am not talking about Diltiazem vs. Esmolol, All Beta blockers are NOT EQUAL and all Calcium Channel blockers ARE NOT EQUAL EITHER!
Can you produce a study showing that Esmolol or Diltiazem are superior to Verapamil??????
You are basically offering your ANECDOTAL experience and I am telling you mine.
What you are doing is not wrong but what I am advocating is valid and works, if you know what you are doing.
Beta blockers work best when the A fib is cathecolamine induced, which is very common in post-op patients but there are other factors involved too, and sometimes you need to suppress the AV conduction which can be done using different classes of drugs, one of these classes is calcium channel blockers namely Diltiazem and Verapamil.
So It's good to know all the alternatives and then decide how you want to proceed based on your knowledge and experience.

 

[bigtuna]

This is a very non-urgent situation for rate control. Mild tachycardia, asymptomatic, normal BP. The indication for IV meds at all is questionable, certainly contiuous IV infusion is questionable.

I think you are more likely to get in trouble by pushing large amounts of IV beta blocker or CCB in a 90 year old. Little old ladies with diastolic dysfunction are the one subgroup of patients most likely to develop hypotension or CHF when given these meds.

If you really want to get the rate normal before pt leaves the PACU then give some low dose IV metoprolol, dilt, verapamil and then start on scheduled oral (or low dose IV if unable to take po). It is true that most patients will spont convert to NSR but that is not proven to be due to the BB or CCB.

The general consensus among cardiologists that I've talked to is the the hypotenion caused by the commonly used meds is verapamil>dilt>metoprolol.

 

[jetproppilot]

Alternatively, you could go with the dilt if the pharma-sloot wore a low-cut top last time she came around, but stick with the verapamil if she went conservative. Amounts to a coin flip. You could probably even randomize a trial that way...

I kid, I kid. Seriously, those pharma floozies have no place in our hospitals. In my married opinion, of course. Your mileage may vary.

HAHAHAHAHAHAHAHAHAHAHAHAHAHAHAH


i think i just pee peed on myself

 

[BLADEMDA]

Blade,

You keep saying the same thing and citing irrelevant data!
I am not talking about Diltiazem vs. Esmolol, All Beta blockers are NOT EQUAL and all Calcium Channel blockers ARE NOT EQUAL EITHER!
Can you produce a study showing that Esmolol or Diltiazem are superior to Verapamil??????
You are basically offering your ANECDOTAL experience and I am telling you mine.
What you are doing is not wrong but what I am advocating is valid and works, if you know what you are doing.
Beta blockers work best when the A fib is cathecolamine induced, which is very common in post-op patients but there are other factors involved too, and sometimes you need to suppress the AV conduction which can be done using different classes of drugs, one of these classes is calcium channel blockers namely Diltiazem and Verapamil.
So It's good to know all the alternatives and then decide how you want to proceed based on your knowledge and experience.

Fine. You have the last word. But, I recommend those uncertain as to the best course of action read the PUBLISHED literature on the subject. There are many good studies and I have listed two.

Blade

 

[Noyac]

Steering clear of the CCB vs B blocker debate (I have said that I use metoprolol, but just because that's what I use), I'd like to go back briefly to the case. It said she got digoxin first-- what's up with that? I think most cardiologists would agree that dig has no role in conversion or control of acute afib (and not much of a role anywhere else either). Do you guys use this routinely?

Dig was ordered by the hospitalist since it was his pt prior to the surgery and was going back to his service and since I was in a case and the anesthesiologist that did the case was not available.

 

[Planktonmd]

Fine. You have the last word. But, I recommend those uncertain as to the best course of action read the PUBLISHED literature on the subject. There are many good studies and I have listed two.

Blade

Ok,

Thank you for giving me the last word.

I would like to emphasize for " those uncertain to the best course of action" that the 2 studies you have provided compare Esmolol to Diltiazem, and none of them mentions Verapamil, so they are slightly irrelevant.

Here are the links to these 2 studies if anyone is interested.
http://www.anesthesiology.org/pt/re...y150216StQTxr1Rc!1152499061!181195629!8091!-1

http://www.ingentaconnect.com/content/libra/cmro/2003/00000019/00000005/art00002

 

[cubs3canes]

During my cards month, my attending was an EP guru. So we attempted chemical conversion on all of our patients.

We started with a CCB (verapamil) most of the time. The heart rate would be controlled, but still in a.fib.

Then we would try ibutilide. Look it up. Give 4mg of Mg and measure Mg before you give it. Then connect the code cart because they still can go into torsades. The data shows that all most no one will go into torsades when you pre-dose with Mg.

then Ibutilide 1mg IV over 10 minutes. Wait about 15 minutes and they will convert. It worked everytime. You can re-dose in 30 minutes, but after that...get the EP guy to shock them

Cubs

 

[BLADEMDA]

During my cards month, my attending was an EP guru. So we attempted chemical conversion on all of our patients.

We started with a CCB (verapamil) most of the time. The heart rate would be controlled, but still in a.fib.

Then we would try ibutilide. Look it up. Give 4mg of Mg and measure Mg before you give it. Then connect the code cart because they still can go into torsades. The data shows that all most no one will go into torsades when you pre-dose with Mg.

then Ibutilide 1mg IV over 10 minutes. Wait about 15 minutes and they will convert. It worked everytime. You can re-dose in 30 minutes, but after that...get the EP guy to shock them

Cubs

Your treatment with Ibutilide is associated with increased risk to the patient.
Why not leave that decision to the Cardiologist?

The studies show "little difference between a rate control strategy and a strategy to restore/maintain sinus rhythm. Regardless of the strategy, a majority of patients will be in NSR after two months."

The study showed 91% conversion to NSR in the rate control group compared to 96% in the anti-arrhythmic arm.

I don't think the extra risk warrants an AUTOMATIC jump to Ibutilide in the PACU.

Blade

 

[cubs3canes]

You are correct blademd. I would leave it to the cardiologists.

However, I just wanted to add another drug to the mix. There is more to a.fib than rate control. (however, it is all that I care about).

Cubs

 

[Doc13]

qUICK question, this patiently likes paroxysmal afib, but if not noticed for a while and it is <48 hrs since onset, why not just cardiovert him if echo shows no clot hangin in the heart and if hes still in afib after whatever slowing agent you have chosen?

 

[Planktonmd]

qUICK question, this patiently likes paroxysmal afib, but if not noticed for a while and it is <48 hrs since onset, why not just cardiovert him if echo shows no clot hangin in the heart and if hes still in afib after whatever slowing agent you have chosen?

Sure, if the A fib does not respond to medications and the patient remains hemodynamically stable the cardiologist is most likely going to attempt cardioversion later.
If the patient becomes hemodynamically unstable because of the A fib then you go straight to cardioversion.

 

[ZA_Gasman]

What worries me about this is that we don't know for sure that she is not having paroxysmal AF. Surely a "reasonably" high percentage of 91y olds have AF, and without a clear idea of what is really going on, I'd be quite cautious about jumping in and welding her heart. She's stable, so I'd be tempted to load (carefully) with Amiodarone, and if that doesn't work in the short term (hours) I'd get an echo, and if no clot, consider elective cardioversion.

The point someone made earlier about 'lytes is well made. Yield on an electrolyte screen is lousy, but you'd feel like a right t*t if one missed something obviously and easily correctable. Might also be wasting time with the defib if the K+ is all wrong.....