Scary a-fib case...

[sevoflurane]

After last night I have a new found respect for esmolol.

So this guy is a 78 y/o, cad, cabg x 4, DM, h/o a-fib, admitted for respiratory failure secondary to r. sided pna. Dude has recently been treated with chemo for large cell ca. of the left lung (patient is a smoker). Been on 25 mcg of levophed for hypotension 2nd to unknown cause... likely sepsis (also neutropenic).

I get called to see this guy cause he's in rapid a-fib with a ventricular response of 170bpm. Get an ekg, which confirms this.
B.P. is 78/40. Trops were negative eralier in the day.
I look at his flows and see that he has been getting plenty of fluids (7-8 liters in the last 24hrs). He's making plenty of urine (80-100 cc per hour). I transduce his cvp and his sitting at 12-14mmhg. So I think to myself... ok.. this guy is not hypovolemic.

I check his lytes... all look good. Time to treat his a-fib. He has soft pressures and I assume that part of it is due to the fact that he has lost his atrial kick and he has an EF of 38%. My co-residnet and I choose not to cardiovert. He's been in a-fib >48 hours and is coagulopathic (also h/o apical apendage clot). We take it easy and give him 5 of cardizem. Nothing. Give him another 5 and he comes down to the 150's but his sbp actually goes down to 70/50 (diastolic actually went up). We call our upper level and she says push another 5. We do and he looses a bit more systolic. She gets called stat and leaves us managing the patient as his pressures go back up to 75ish/40ish...

I say, hey... maybe he's not liking the levophed and that's the cause of his a-fib... Wean him down to 20 mcgs and see what he does.... Not a good idea. Pressures drop down again. After kicking it back up we come up with another plan.... Let's dig load this dude. It may take some time, but we may be able to break his rate this way. 15 minutes later he's going at 170 bpm and still hypotensive.

The next phase scared the living crap out of me. We are thinking this guys oxygen supply/demand is not looking good. Most recent trop now .1. Let's bring out the wonder drug... breviblock! I knew he was a smoker and had lung ca, but we agreed that since he had been so tachy we could try a test dose and see if he responded. He's now on 40 of levophed with minimal response in pressures- this is after trying to switch him over to phenylephrine. He didn't like that either.

He had great lung mechanics on the vent and had peak pressures of 16. He's 90kg's and we ask for 10mg as a test dose, keeping in mind that his bolus should have been 45mgs. I telll the nurse give it slowly over 5 minutes and I start taking care of another patient who started to crash in another pod. 10 minutes later, my co-resident calls over and says he needs my help. I walk in the room and his pressures are 40/20. Knee jerk kick up his levo to 60 mcgs. Take a look at his peak pressures and they are still 16. Bronchospasm? likely not. I heard no wheezes, but I couldn't feel a pulse. Scary sh$t.
As we push the code bells for PEA, we give 1 mg of epi. Takes about 3 minutes + chest compressions to bring up his pressures to 180/90. Longest three minutes of my life.

Now what the hell happened here? Esmolol is like one of my favorite drugs, and I really didn't think this was the cause (especially with 10 mgs), but the temporal relationship is hard to ignore. In a two and half hour period we had given 15 mgs of Diltiazem and 125 mics of dig. and 10 of esmolol- appropriately small doses due to his low B.P.

So... he goes back to his pathologic rhythm. 75/45 with a-fib going at 165 bpm. At this juncture we decided to cardiovert... 50, 100, 200, 300 j. The guy didn't break... and we decided to wait it out and continue to dig load him. I left him this morning with unstable vitals....

Now I know this guy has been circling the drains for a couple of days now but I felt like I was between a rock and a hard place. Should I have pushed some amio and complicate things even more? maybe we should have paced him. Cardiology fellow agreed with our resusication.

Any thoughts??? Noy, jet, UT, mil...

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[Laryngospasm]

Amiodarone would have been worth a try.

 

[Noyac]

Well you know I think these people should be left alone to do what it is they are trying to do - Die. But it is hard to not respond and we don't usually like to let them get their way on our watch. So, If I were in your shoes from the start, I would have had a stick of neo and pushed it to see if he got any response (decreased HR and increased BP). I would have then gone to Esmolol right away at 40 mg bolus. I don't usually worry about airway response with esmolol b/c its so short acting and any bad effects usually go away in 10 minutes if they are going to occur. And esmolol is not as likely to cause bronchospasm. Some of you guys may have other experiences with the drug. The cardizem usually works well, but as you found out it doesn't always do the trick. Another trick that I use from time to time is neostigmine. A bolus of this 1-2mg will slow the rate. Just don't forget to tell the RN to put a chucks pad under his ass.
Personally, I think this is a bad situation that will not have a chance at any good outcome. Why do we prolong these cases?

 

[Gator05]

I've heard of verapamil working better than dilt, but sounds like the last thing you wanted was a neg chronotrope.

Did you consider inotropic support?

 

[augmel]

I would argue for earlier cardioversion. There are risks as you mentioned, but a 78 y/o tach'n along at 170 is much worse than a 40/50/60 year old doing the same. That and the hypotension and I would have had the pads on and shocking before giving any drugs. Sounds like it wouldn't have worked anyhow in this case. I think then dig and amio would be up next.

 

[augmel]

Well you know I think these people should be left alone to do what it is they are trying to do - Die.

Ok THIS is actually my first thought. But if you gotta do something, then the cardioversion thing.

 

[cloud9]

He's been in a-fib >48 hours and is coagulopathic (also h/o apical apendage clot).

I thought this made shock cardioversion a no-no? Or is this one of those grey areas (i.e. benefit vs potential consequences)? Unless I missed it, no mention of heparin or coumadin.

 

[augmel]

I thought this made shock cardioversion a no-no? Or is this one of those grey areas (i.e. benefit vs potential consequences)? Unless I missed it, no mention of heparin or coumadin.

It is a relative containdication. It is not mentioned above, but I would hope that a guy with cancer and a-fib would have some anti-coagulation on board. My point was just that a old guy with heart rate of 170 and hypotension is in the process of dying. He is just this side of a full arrest, so in my mind, the theoretic risk of embolism is secondary to saving what myocardium and renal cells he has left.

 

[sevoflurane]

I thought this made shock cardioversion a no-no? Or is this one of those grey areas (i.e. benefit vs potential consequences)? Unless I missed it, no mention of heparin or coumadin.

I didn't mention it, but he was on a heparin gtt.

Levophed is an inotrope.

We thought long and hard about cardioversion. If he hadn't had a recent TEE which showed a nice size clot we would have cardioverted early. How often can we not rate control patients? In my experience, not often. I don't know if it would have made a difference though. He ended up getting zapped anyways. Is knowing that he had a clot in his heart a contraindication to cardioversion in a hemodynamically unstable patient... I don't know actually. But I would be it is a relative contraindication as mentioned above.

I really did want to push amio, but with three other agents on board i felt I might be complicating things. If he had come down, I wouldn't have known which agent did it dig, cardizem or amio. On the other hand if his rate had come down and not known what agent did it, I would have taken that for sure.

I just looked at his x-ray. Looks like he flashed. I don't know what came first though. Pulmonary edema then arrest or arrest then pulmonary edema. Doesn't really fit though. His lung mechanics were pretty benign and his lungs sounded ok.

 

[cubs3canes]

I thought this made shock cardioversion a no-no? Or is this one of those grey areas (i.e. benefit vs potential consequences)? Unless I missed it, no mention of heparin or coumadin.

Last time I checked this is not a gray area. You basically have to see them go into a. fib or have a good record of a normal rate within 48 hours in order to go to the shock without anti-coagulation first.

 

[Idiopathic]

Last time I checked this is not a gray area. You basically have to see them go into a. fib or have a good record of a normal rate within 48 hours in order to go to the shock without anti-coagulation first.

I guess the bone of contention is the fact that the A-fib c RVR is going to kill him ultimately, and the cardioversion is a potential way to get him out of it. Is the px better off in a-fib with awful pressures and occasional PEA(!) than with cardioversion?

 

[augmel]

If he hadn't had a recent TEE which showed a nice size clot we would have cardioverted early.

I really did want to push amio, but with three other agents on board i felt I might be complicating things. If he had come down, I wouldn't have known which agent did it dig, cardizem or amio.

Ah. I thought that was a remote hx of clot. If I knew there was current/recent clot, I would be more tempted to at least try pushing drugs once or twice. I agree that once you start a couple drugs, you are better off sticking with them and increasing doses than loading with even more AV blocking agents. You really are screwed in this situation, especially if the patient has a bad outcome. You get criticized for shocking if he throws an embolism, you get criticized for not shocking if he arrests.

I had a similar patient I saw overnight on cross-cover. He eventually got rate controlled when he went from 160 to 120 to 80 to 40 to 0 in about a minute. We had tried to shock him without success, tried amio, tried dig, then he just wore out and died. I remember the cardiologist emphasizing that 80 y/o's cannot go for long with that kind of tachycardia. Left an impression on me.

 

[jetproppilot]

Well you know I think these people should be left alone to do what it is they are trying to do - Die. But it is hard to not respond and we don't usually like to let them get their way on our watch. So, If I were in your shoes from the start, I would have had a stick of neo and pushed it to see if he got any response (decreased HR and increased BP). I would have then gone to Esmolol right away at 40 mg bolus. I don't usually worry about airway response with esmolol b/c its so short acting and any bad effects usually go away in 10 minutes if they are going to occur. And esmolol is not as likely to cause bronchospasm. Some of you guys may have other experiences with the drug. The cardizem usually works well, but as you found out it doesn't always do the trick. Another trick that I use from time to time is neostigmine. A bolus of this 1-2mg will slow the rate. Just don't forget to tell the RN to put a chucks pad under his ass.
Personally, I think this is a bad situation that will not have a chance at any good outcome. Why do we prolong these cases?

To be honest, Noy, when I read the first sentence of your post I thought it was kind of harsh....I mean, we're doctors, right? We're The Wolf . We fix problems.

But, I'm wrong. And you are right.

This is a no-win situation.

And all your clinical suggestiona are top-notch.

The best we can do.

As are the other posts.

Drugs. Consider shocking. Risks/benefits considered by the physician of said interventions.

Nice thread with keen responses.

Thats all we can do.

Not every patient lives. Especially old dudes with major arrhythmia issues.

Maybe its time for this dude to check out.

 

[Noyac]

To be honest, Noy, when I read the first sentence of your post I thought it was kind of harsh....I mean, we're doctors, right? We're The Wolf . We fix problems.

But, I'm wrong. And you are right.

This is a no-win situation.

And all your clinical suggestiona are top-notch.

The best we can do.

As are the other posts.

Drugs. Consider shocking. Risks/benefits considered by the physician of said interventions.

Nice thread with keen responses.

Thats all we can do.

Not every patient lives. Especially old dudes with major arrhythmia issues.

Maybe its time for this dude to check out.

Your right WOLF, we fix problems. But there are some problems wew can't fix and as you said, "not every patient lives."

 

[VentdependenT]

Maybe when I'm constipated next time ill hit myself up with a mg of neostigmine, grab a cigarette and something to read and let the healing begin.

thanks for the suggestion noy

 

[TheSandMan]

Your right WOLF, we fix problems. But there are some problems wew can't fix and as you said, "not every patient lives."

Playing devils advocate, I was watching a re-run of scrubs and they made a good point. I can't remember the exact phrase, but essentially Dr Cox said something to the effect - we can't save everyone, but we try our best so that when we have someone we can save, we're sharp and ontop of our game

 

[needadvice]

latex allergy?

 

[militarymd]

Playing devils advocate, I was watching a re-run of scrubs and they made a good point. I can't remember the exact phrase, but essentially Dr Cox said something to the effect - we can't save everyone, but we try our best so that when we have someone we can save, we're sharp and ontop of our game

Isn't that what residency is for?

There are cases that I describe as "rearranging deck chairs on the titantic".....and I had one today.

80 something demented vasculopath with non-healing foot ulcer....other leg amputated already. CHF, low EF, can't tell what rhythm she has on ECG....chronic hypotension....80/40 all the time.

Scheduled for fem pop.....arrghhh!!!!

No matter what I do...her survival is measured in months.

 

[jetproppilot]

Scheduled for fem pop.....arrghhh!!!!

No matter what I do...her survival is measured in months.

And this is (one of many areas) where our US healthcare system is going wrong.

Someone, somewhere, needs to have the power to say

NOPE.

 

[cchoukal]

.

 

[Noyac]

Isn't that what residency is for?

There are cases that I describe as "rearranging deck chairs on the titantic".....and I had one today.

80 something demented vasculopath with non-healing foot ulcer....other leg amputated already. CHF, low EF, can't tell what rhythm she has on ECG....chronic hypotension....80/40 all the time.

Scheduled for fem pop.....arrghhh!!!!

No matter what I do...her survival is measured in months.

I'm pretty sure that my surgeons would not have brought this case to the OR.

 

[jetproppilot]

I'm pretty sure that my surgeons would not have brought this case to the OR.

we have one that would have.

and he is the least deft of the vascular surgeons I work with.

 

[Noyac]

And this is (one of many areas) where our US healthcare system is going wrong.

Someone, somewhere, needs to have the power to say

NOPE.

And here's another.
My partner gets a ruptured AAA suprarenal at 4am and when the pt gets to the OR his pH is 6.9?, he's blue sat-ing in the low 80's, and tubed on 100%. I don't know all the particulars but he was a 70yo, obese, CAD, COPD, etc etc. The x-clamp time was around 3 hrs. When the pt arrived in the ICU he had received many units of PRBC's. FFP and plts plus around 30 liters of fluid. His ph was normal and h/h as well. He obviously progressed to ARDS and acute renal failure. After a few weeks in the ICU, his airway pressures were normal and his kidney were functional. The family then decided that enough was enough and pulled the plug. He must have had a large Life INs Policy.
We go through all this and then as things start to improve, the family pulls the rug out from under your feet.

 

[jetproppilot]

And here's another.
My partner gets a ruptured AAA suprarenal at 4am and when the pt gets to the OR his pH is 6.9?, he's blue sat-ing in the low 80's, and tubed on 100%. I don't know all the particulars but he was a 70yo, obese, CAD, COPD, etc etc. The x-clamp time was around 3 hrs. When the pt arrived in the ICU he had received many units of PRBC's. FFP and plts plus around 30 liters of fluid. His ph was normal and h/h as well. He obviously progressed to ARDS and acute renal failure. After a few weeks in the ICU, his airway pressures were normal and his kidney were functional. The family then decided that enough was enough and pulled the plug. He must have had a large Life INs Policy.
We go through all this and then as things start to improve, the family pulls the rug out from under your feet.

Your partner shouldve knelt down and picked up the plug, plugged it back into the wall, knelt down again to grab his ankle-holstered .45 Glock, and capped the family.

 

[Noyac]

we have one that would have.

and he is the least deft of the vascular surgeons I work with.

Did he happen to come from BR?
WE had one there that was fired and fits your discription, a hack.

 

[jetproppilot]

Did he happen to come from BR?
WE had one there that was fired and fits your discription, a hack.

No.

He's been at this hospital forever.

CEAs, fem-pops, all are major productions with ACTS needed, endless drama reminiscent of past ER episodes...blood loss.....

he brings Greenfield filters to the OR for placement...

and we place the central-access wire before he can do the case.....( )...uhhhhhh.....we just did 90% of the case for you.......hahahahahahhahahahahahahaha

 

[sdn1977]

sevoflurane - I've been thinking about your case for a few days & I'll give you a pharmacological perspective - which is only one aspect. But...since you asked about drugs.....

If I understand what happened & your timing...this guy has a-fib w/ a rapid ventricular response & low pressure. You give diltiazem x 3 over...???? amt of time - a short period I'd guess. Then you give dig 0.125mg. Fifteen min later you give esmolol...and things go south...

Ok - a few thoughts. First...dig & esmolol given concurrently or in a VERY short time frame have a documented interaction. Esmolol increases the digoxin blood level by 10-20% (varies w/studies).

Your dig dose was 125mcg & its hard to evaluate it based on what you gave since we don't know renal function or ht. Dig is dosed on IBW (not the actual 90kg) so if he was between a 5.5' - 6' man (IBW 64-78kg - 70kg is good, not accounting for renal function) his loading dose would be 640-780mg - giving the 1/2 the dose initially then following q 4-8 h for full digitalization. So...your first dose might have been approx 300mcg (practially 250mcg).

Your conservative choice of 125mcg seems all good, except after esmolol, the digoxin blood level would be closer to an original dose of 138-150mcg (again...depending on ht). Still within normal limits....if that were the only drug you gave. But...it wasn't and the timing of when these drugs were given & peaked may have become an issue.

Diltiazem IV has a half life of 3.4hr & has linear kinetics. You gave digoxin 30-45 min later, with a higher than expected blood level due the the esmolol, which followed 15 min later...and now you have all three peaking at the same time which may have been a cause for the bad stuff you ended up with.

But...this is just a drug perspective on what happened which can't be taken out of the context of all the other bad stuff the folks here already alluded to. But...try not to give esmolol with digoxin if you can help it.

 

[Noyac]

sevoflurane - I've been thinking about your case for a few days & I'll give you a pharmacological perspective - which is only one aspect. But...since you asked about drugs.....

If I understand what happened & your timing...this guy has a-fib w/ a rapid ventricular response & low pressure. You give diltiazem x 3 over...???? amt of time - a short period I'd guess. Then you give dig 0.125mg. Fifteen min later you give esmolol...and things go south...

Ok - a few thoughts. First...dig & esmolol given concurrently or in a VERY short time frame have a documented interaction. Esmolol increases the digoxin blood level by 10-20% (varies w/studies).

Your dig dose was 125mcg & its hard to evaluate it based on what you gave since we don't know renal function or ht. Dig is dosed on IBW (not the actual 90kg) so if he was between a 5.5' - 6' man (IBW 64-78kg - 70kg is good, not accounting for renal function) his loading dose would be 640-780mg - giving the 1/2 the dose initially then following q 4-8 h for full digitalization. So...your first dose might have been approx 300mcg (practially 250mcg).

Your conservative choice of 125mcg seems all good, except after esmolol, the digoxin blood level would be closer to an original dose of 138-150mcg (again...depending on ht). Still within normal limits....if that were the only drug you gave. But...it wasn't and the timing of when these drugs were given & peaked may have become an issue.

Diltiazem IV has a half life of 3.4hr & has linear kinetics. You gave digoxin 30-45 min later, with a higher than expected blood level due the the esmolol, which followed 15 min later...and now you have all three peaking at the same time which may have been a cause for the bad stuff you ended up with.

But...this is just a drug perspective on what happened which can't be taken out of the context of all the other bad stuff the folks here already alluded to. But...try not to give esmolol with digoxin if you can help it.

SDN, can you repeat that but veeerryy slllowwwllyy.

Its great to have your input here but come on, we're just a bunch of dumb anesthesiologists. We give somethng and nothing happens immediately so we give more and then we give something else and again and again.

Generally, I give Dig until they start to see and aura and then stop. Oh, wait, they can't see when they are under GA. Ok nevermind.

Seriously, great stuff SDN.

 

[sdn1977]

SDN, can you repeat that but veeerryy slllowwwllyy.

Its great to have your input here but come on, we're just a bunch of dumb anesthesiologists. We give somethng and nothing happens immediately so we give more and then we give something else and again and again.

Generally, I give Dig until they start to see and aura and then stop. Oh, wait, they can't see when they are under GA. Ok nevermind.

Seriously, great stuff SDN.

I can explain some (only some!) stuff after the fact.....but you guys can actually keep us alive, even when you don't know what is causing us to try to die! Sevoflurane is a great example of that in this case (btw...did your pt die? - just curious...)

That is why we trust you!

And...oh....that aura thing......too much dig

 

[jetproppilot]

sevoflurane - I've been thinking about your case for a few days & I'll give you a pharmacological perspective - which is only one aspect. But...since you asked about drugs.....

If I understand what happened & your timing...this guy has a-fib w/ a rapid ventricular response & low pressure. You give diltiazem x 3 over...???? amt of time - a short period I'd guess. Then you give dig 0.125mg. Fifteen min later you give esmolol...and things go south...

Ok - a few thoughts. First...dig & esmolol given concurrently or in a VERY short time frame have a documented interaction. Esmolol increases the digoxin blood level by 10-20% (varies w/studies).

Your dig dose was 125mcg & its hard to evaluate it based on what you gave since we don't know renal function or ht. Dig is dosed on IBW (not the actual 90kg) so if he was between a 5.5' - 6' man (IBW 64-78kg - 70kg is good, not accounting for renal function) his loading dose would be 640-780mg - giving the 1/2 the dose initially then following q 4-8 h for full digitalization. So...your first dose might have been approx 300mcg (practially 250mcg).

Your conservative choice of 125mcg seems all good, except after esmolol, the digoxin blood level would be closer to an original dose of 138-150mcg (again...depending on ht). Still within normal limits....if that were the only drug you gave. But...it wasn't and the timing of when these drugs were given & peaked may have become an issue.

Diltiazem IV has a half life of 3.4hr & has linear kinetics. You gave digoxin 30-45 min later, with a higher than expected blood level due the the esmolol, which followed 15 min later...and now you have all three peaking at the same time which may have been a cause for the bad stuff you ended up with.

But...this is just a drug perspective on what happened which can't be taken out of the context of all the other bad stuff the folks here already alluded to. But...try not to give esmolol with digoxin if you can help it.

uhhhhhhh.......

this is why I come to this forum.

Thanks for the BEYOND INFORMATIVE post, dude/dudette.

 

[Idiopathic]

sevoflurane - I've been thinking about your case for a few days & I'll give you a pharmacological perspective - which is only one aspect. But...since you asked about drugs.....

If I understand what happened & your timing...this guy has a-fib w/ a rapid ventricular response & low pressure. You give diltiazem x 3 over...???? amt of time - a short period I'd guess. Then you give dig 0.125mg. Fifteen min later you give esmolol...and things go south...

Ok - a few thoughts. First...dig & esmolol given concurrently or in a VERY short time frame have a documented interaction. Esmolol increases the digoxin blood level by 10-20% (varies w/studies).

Your dig dose was 125mcg & its hard to evaluate it based on what you gave since we don't know renal function or ht. Dig is dosed on IBW (not the actual 90kg) so if he was between a 5.5' - 6' man (IBW 64-78kg - 70kg is good, not accounting for renal function) his loading dose would be 640-780mg - giving the 1/2 the dose initially then following q 4-8 h for full digitalization. So...your first dose might have been approx 300mcg (practially 250mcg).

Your conservative choice of 125mcg seems all good, except after esmolol, the digoxin blood level would be closer to an original dose of 138-150mcg (again...depending on ht). Still within normal limits....if that were the only drug you gave. But...it wasn't and the timing of when these drugs were given & peaked may have become an issue.

Diltiazem IV has a half life of 3.4hr & has linear kinetics. You gave digoxin 30-45 min later, with a higher than expected blood level due the the esmolol, which followed 15 min later...and now you have all three peaking at the same time which may have been a cause for the bad stuff you ended up with.

But...this is just a drug perspective on what happened which can't be taken out of the context of all the other bad stuff the folks here already alluded to. But...try not to give esmolol with digoxin if you can help it.

More like this. Seriously, this stuff keeps me coming back.

 

[sdn1977]

I think about the pharmacology of the cases you guys post a lot, but I rarely respond - just brain teaser stuff for me.

But....this one...well...sevoflurane spoke of "the wonder drug - breviblock" and "esmolol one of my favorite drugs"....& what do my kids say.....I didn't want him to "hate the player". Esmolol, diltiazem & dig (well...maybe not dig so much) are great drugs....it is sometimes just the combination & in this case the timing that confounds things.

You guys do give me stuff to think about - for sure!

 

[jetproppilot]

I think about the pharmacology of the cases you guys post a lot, but I rarely respond - just brain teaser stuff for me.

But....this one...well...sevoflurane spoke of "the wonder drug - breviblock" and "esmolol one of my favorite drugs"....& what do my kids say.....I didn't want him to "hate the player". Esmolol, diltiazem & dig (well...maybe not dig so much) are great drugs....it is sometimes just the combination & in this case the timing that confounds things.

You guys do give me stuff to think about - for sure!

Yeah, well, do us all a favor, SDN.

And post what you consider third-grade-pharmacology-stuff on this board.

We'll all benefit from your knowledge.

Just think about it as your contribution to the group of critical care physicians that may be taking care of you during your appendectomy one day....

 

[foshizzo]

Originally Posted by jetproppilot
we have one that would have.

and he is the least deft of the vascular surgeons I work with.
**********************************************

Q. Why are coffins nailed shut?

A. To keep the vascular surgeons out.

 

[jetproppilot]

Originally Posted by jetproppilot
we have one that would have.

and he is the least deft of the vascular surgeons I work with.
**********************************************

Q. Why are coffins nailed shut?

A. To keep the vascular surgeons out.

HAHAHAHHAHAHAHAHAHAHHAHAHAHAHAHAHAHAHAHAHAHHAHA

now thats some funny s hit....

 

[sevoflurane]

sevoflurane - I've been thinking about your case for a few days & I'll give you a pharmacological perspective - which is only one aspect. But...since you asked about drugs.....

If I understand what happened & your timing...this guy has a-fib w/ a rapid ventricular response & low pressure. You give diltiazem x 3 over...???? amt of time - a short period I'd guess. Then you give dig 0.125mg. Fifteen min later you give esmolol...and things go south...

Ok - a few thoughts. First...dig & esmolol given concurrently or in a VERY short time frame have a documented interaction. Esmolol increases the digoxin blood level by 10-20% (varies w/studies).

Your dig dose was 125mcg & its hard to evaluate it based on what you gave since we don't know renal function or ht. Dig is dosed on IBW (not the actual 90kg) so if he was between a 5.5' - 6' man (IBW 64-78kg - 70kg is good, not accounting for renal function) his loading dose would be 640-780mg - giving the 1/2 the dose initially then following q 4-8 h for full digitalization. So...your first dose might have been approx 300mcg (practially 250mcg).

Your conservative choice of 125mcg seems all good, except after esmolol, the digoxin blood level would be closer to an original dose of 138-150mcg (again...depending on ht). Still within normal limits....if that were the only drug you gave. But...it wasn't and the timing of when these drugs were given & peaked may have become an issue.

Diltiazem IV has a half life of 3.4hr & has linear kinetics. You gave digoxin 30-45 min later, with a higher than expected blood level due the the esmolol, which followed 15 min later...and now you have all three peaking at the same time which may have been a cause for the bad stuff you ended up with.

But...this is just a drug perspective on what happened which can't be taken out of the context of all the other bad stuff the folks here already alluded to. But...try not to give esmolol with digoxin if you can help it.

Nice job SDN, keep 'em coming-

Esmolol and Dig... that's great stuff. Exactly what I've been trying to get out of this post.

A quesiton: would you expect all three drugs to peak roughly at the same time and have a sudden onset? To me, that doesn't really sound likely although possible. Often when I use cardizem I see a response pretty quickly. Dig on the other hand is very variable depending on Ca+, K+, protein binding, etc. The timing between the dig and the esmolol was about an hour, maybe a little less. Is this interaction possible in this time frame?

We did think of giving him 250 mcg of dig, but we thought we'd take it easy since he just had a wiff of cardizem a little earlier. Since we were using three drugs we thought of giving lower doses of everything (includiung test dose esmolol). This is why I like to stick to one drug if I can... but if it's not working, you have to try something else. Gotta get something in between the supply-demand relationship.

Using the retroscope, our team thinks that this guy acutely decompensated from his sepsis (now growing lots of gn nlf bugs from many places-surely pseudomonas). The abg at the time of the code was 7.08. In his already fragile state and with a low ph, his a-fib probably got the best of him. He had been running rampid for hours likely in an acidotic state. Sepsis/septic shock, asidocis, a-fib and some cardiodepressants might have been the magic formula for this guy to code- I don't really know.

BTW, this guy is doing much better now. His a-fib came down after turning off his levophed (accomplished by lots of crystalloids, 2u prbc's, stress dose roids, cardizem gtt, full dig load). He's off the cardizem drip and we'll start diurising sometime in this week. Here is for hoping this guy makes it out of the unit

 

[sdn1977]

Nice job SDN, keep 'em coming-

Esmolol and Dig... that's great stuff. Exactly what I've been trying to get out of this post.

A quesiton: would you expect all three drugs to peak roughly at the same time and have a sudden onset? To me, that doesn't really sound likely although possible. Often when I use cardizem I see a response pretty quickly. Dig on the other hand is very variable depending on Ca+, K+, protein binding, etc. The timing between the dig and the esmolol was about an hour, maybe a little less. Is this interaction possible in this time frame?

We did think of giving him 250 mcg of dig, but we thought we'd take it easy since he just had a wiff of cardizem a little earlier. Since we were using three drugs we thought of giving lower doses of everything (includiung test dose esmolol). This is why I like to stick to one drug if I can... but if it's not working, you have to try something else. Gotta get something in between the supply-demand relationship.

Using the retroscope, our team thinks that this guy acutely decompensated from his sepsis (now growing lots of gn nlf bugs from many places-surely pseudomonas). The abg at the time of the code was 7.08. In his already fragile state and with a low ph, his a-fib probably got the best of him. He had been running rampid for hours likely in an acidotic state. Sepsis/septic shock, asidocis, a-fib and some cardiodepressants might have been the magic formula for this guy to code- I don't really know.

BTW, this guy is doing much better now. His a-fib came down after turning off his levophed (accomplished by lots of crystalloids, 2u prbc's, stress dose roids, cardizem gtt, full dig load). He's off the cardizem drip and we'll start diurising sometime in the this week. Here is for hoping this guy makes it out of the unit

First off - glad to see your pt is better!

I'll try to address all you comments - first the esmolol (because you like it ) & its a really crazy drug - IMO. Yeah - an hour between dig & esmolol is basically concurrent. Its funny though....dig has no effect on esmolol kinetics & esmolol has little effect on dig blood levels when dig is at steady state - so what's the mechanism???? No one really knows. Esmolol has funny metabolism - it is metabolized by esterases (most think its arylesterase) principally in the cytosol of erythrocytes. So..some postulate it has to do with the initial binding of digoxin to blood proteins - RBC's being one of them, but later at steady state, this is less of an influence - that is just speculation though.

Now...the diltiazem...you guys have so much more experience with this than I, but my experience is the dose for temporary control of vent rate w/a fib is between 0.15-0.25mg/kg - again using the 70kg wt (altho not so critical here) you gave just 0.07mg/kg - less if you use closer to the actual wt...so you really did just give a wiff. (Out of curiousity...why did you give such a low dose?) Also...for this purpose (tachyarrhythmia as opposed to bp control)...there is some evidence to suggest you wait for 15 min to allow the full effect to occur on AV conduction. So...by the second dose you are starting to see an effect (you should - you're about at 0.14mg/kg using IBW) & by dose 3, I get confused....you lowered the levophed...perhaps because that was the cause of the a fib??? & the pressure dropped - as you would expect in addition to the diltiazem....which just might now be working on the AV node (remember - it takes about 15 min to evaluate the full effect) which would be 15 min AFTER the last dose since you essentially loaded in 5min increments.

But...things got complicated by giving 2 more drugs (I'm not sure dig was an actual complicator, but...) which might have lowered the guys ability to sustain his bp.

Acidosis also will shift the metabolism & protein binding of drugs all over the place & we don't even want to speculate on his renal perfusion & what that might have done to drug levels.......

Now that we know this guy has sepsis on top of all the other bad stuff you described....eh...the drugs are only one part of the whole thing and from the outside looking in - I'm not sure doing anything else, from a drug perspective alone, would have changed what you experienced. Unless you are giving just one drug in a healthy pt - the drugs can NEVER be taken out of context of the clinical situation.

You did a great job saving this guy! I wish I could give you more definitive answers...but too many variables. This guy lived another day....good job!

 

[cloud9]

First off - glad to see your pt is better!

I'll try to address all you comments - first the esmolol (because you like it ) & its a really crazy drug - IMO. Yeah - an hour between dig & esmolol is basically concurrent. Its funny though....dig has no effect on esmolol kinetics & esmolol has little effect on dig blood levels when dig is at steady state - so what's the mechanism???? No one really knows. Esmolol has funny metabolism - it is metabolized by esterases (most think its arylesterase) principally in the cytosol of erythrocytes. So..some postulate it has to do with the initial binding of digoxin to blood proteins - RBC's being one of them, but later at steady state, this is less of an influence - that is just speculation though.

Now...the diltiazem...you guys have so much more experience with this than I, but my experience is the dose for temporary control of vent rate w/a fib is between 0.15-0.25mg/kg - again using the 70kg wt (altho not so critical here) you gave just 0.07mg/kg - less if you use closer to the actual wt...so you really did just give a wiff. (Out of curiousity...why did you give such a low dose?) Also...for this purpose (tachyarrhythmia as opposed to bp control)...there is some evidence to suggest you wait for 15 min to allow the full effect to occur on AV conduction. So...by the second dose you are starting to see an effect (you should - you're about at 0.14mg/kg using IBW) & by dose 3, I get confused....you lowered the levophed...perhaps because that was the cause of the a fib??? & the pressure dropped - as you would expect in addition to the diltiazem....which just might now be working on the AV node (remember - it takes about 15 min to evaluate the full effect) which would be 15 min AFTER the last dose since you essentially loaded in 5min increments.

But...things got complicated by giving 2 more drugs (I'm not sure dig was an actual complicator, but...) which might have lowered the guys ability to sustain his bp.

Acidosis also will shift the metabolism & protein binding of drugs all over the place & we don't even want to speculate on his renal perfusion & what that might have done to drug levels.......

Now that we know this guy has sepsis on top of all the other bad stuff you described....eh...the drugs are only one part of the whole thing and from the outside looking in - I'm not sure doing anything else, from a drug perspective alone, would have changed what you experienced. Unless you are giving just one drug in a healthy pt - the drugs can NEVER be taken out of context of the clinical situation.

You did a great job saving this guy! I wish I could give you more definitive answers...but too many variables. This guy lived another day....good job!

Others have said it, thank you so much for posting here. This has been extremely informative and, with time constraints as they are, has been very "high yield" and useful information. Very appreciative!!

 

[sevoflurane]

First off - glad to see your pt is better!

I'll try to address all you comments - first the esmolol (because you like it ) & its a really crazy drug - IMO. Yeah - an hour between dig & esmolol is basically concurrent. Its funny though....dig has no effect on esmolol kinetics & esmolol has little effect on dig blood levels when dig is at steady state - so what's the mechanism???? No one really knows. Esmolol has funny metabolism - it is metabolized by esterases (most think its arylesterase) principally in the cytosol of erythrocytes. So..some postulate it has to do with the initial binding of digoxin to blood proteins - RBC's being one of them, but later at steady state, this is less of an influence - that is just speculation though.

Now...the diltiazem...you guys have so much more experience with this than I, but my experience is the dose for temporary control of vent rate w/a fib is between 0.15-0.25mg/kg - again using the 70kg wt (altho not so critical here) you gave just 0.07mg/kg - less if you use closer to the actual wt...so you really did just give a wiff. (Out of curiousity...why did you give such a low dose?) Also...for this purpose (tachyarrhythmia as opposed to bp control)...there is some evidence to suggest you wait for 15 min to allow the full effect to occur on AV conduction. So...by the second dose you are starting to see an effect (you should - you're about at 0.14mg/kg using IBW) & by dose 3, I get confused....you lowered the levophed...perhaps because that was the cause of the a fib??? & the pressure dropped - as you would expect in addition to the diltiazem....which just might now be working on the AV node (remember - it takes about 15 min to evaluate the full effect) which would be 15 min AFTER the last dose since you essentially loaded in 5min increments.

But...things got complicated by giving 2 more drugs (I'm not sure dig was an actual complicator, but...) which might have lowered the guys ability to sustain his bp.

Acidosis also will shift the metabolism & protein binding of drugs all over the place & we don't even want to speculate on his renal perfusion & what that might have done to drug levels.......

Now that we know this guy has sepsis on top of all the other bad stuff you described....eh...the drugs are only one part of the whole thing and from the outside looking in - I'm not sure doing anything else, from a drug perspective alone, would have changed what you experienced. Unless you are giving just one drug in a healthy pt - the drugs can NEVER be taken out of context of the clinical situation.

You did a great job saving this guy! I wish I could give you more definitive answers...but too many variables. This guy lived another day....good job!

SDN,

I really like having you guys either on rounds or just a phone call away. You guys are an excellent resource, help a lot and are a great safety net in the hospital. Cheers brother!

Oh.. on your quesiton about the low cardizem "wiff"- It was his low B.P. In a stable dude with rapid a-fib and systolics above 140 I usually push around 15-20mg (unless they are real skinny and below average height).