September FY23

[A Schutter]

This Months article is submitted by Dahlia Rouchon, CRNA it is titled "Perioperative Atrial Fibrillation" It is an excellent review of AFib and management options.

Here is the article link

Questions for discussion:
1. What are the anesthesia considerations for Afib RVR?What are the treatment options?

2. Have you had a patient go into Afib RVR? What treatment did you use and was it successful?

[Kelly Rechtin]

1) Anesthesia considerations for AFib with RVR include looking at other vital signs (BP and O2 sat) to see how patient is tolerating this increase in HR. May need to support these while also treating the HR. Treatment options include beta blockers and calcium channel blockers. If pt cannot tolerate these lines of treatment- amiodarone. In WPW, use procainamide.

2) Yes- Used beta blockers (esmolol then metropolol if needed) with success.

[Wai-Ling Lo]

1. What are the anesthesia considerations for Afib RVR? What are the treatment options?
The main consideration is whether the pt is hemodynamically stable or not. If not, rate control is important. Treatment includes identifying the triggers (e.g. anemia, hypovolemia, ischemia, light anesthesia) and rectify them; drug treatment includes esmolol, metoprolol, diltiazem and amiodarone; for hemodynamically unstable pt, synchronized cardioversion is warranted and consider anticoagulation if needed. In post op setting, for A fib more than 24-48 hours, pt will need TEE to rule out LAA thrombus prior to conversion.

2. Have you had a patient go into Afib RVR? What treatment did you use and was it successful?
Yes. I have tried fluid, deepened anesthesia, esmolol, metoprolol, diltiazem and amiodarone (it really depends on the case and situation). I am usually successful in controlling the ventricular response but not always successful in converting pt back to sinus rhythm.

[sjsimmons]

1. What are the anesthesia considerations for Afib RVR? What are the treatment options?

If the atrial fibrillation (AF) is discovered in the preoperative area, the provider should first consider if the arrhythmia is a new or long-standing. If there is suspicion that it is new, the anesthesia and surgical team should consider postponing the procedure and referring the patient for investigation of potential cardiopulmonary disease. If the AF is long-standing, the rate is well-controlled, and the patient is hemodynamically stable, the surgery may proceed.

If AF with RVR develops during a surgical procedure, the anesthesia provider should first consider the patient’s hemodynamic status. As atrial contraction (atrial kick) contributes 20% of left ventricular stroke volume, the presence of AF could lead to a reduction in cardiac output with ultimate hemodynamic instability.

Treatment should include rate control with beta antagonists (such as metoprolol) and calcium channel blockers (such as diltiazem or verapamil). According to this article, beta antagonists are preferred in patients with myocardial ischemia and hyperthyroidism. If the patient becomes unstable, the anesthesia provider should consider cardioversion.

2. Have you had a patient go into Afib RVR? What treatment did you use and was it successful?

Although I have never had a patient go into AF with RVR while providing anesthesia, I frequently had ICU patients go into AF with RVR after cardiac surgery. If the patient was stable, we treated with an amiodarone infusion. According to the article, amiodarone is the second line of treatment when beta or calcium antagonists are not a suitable intervention. Amiodarone will slow AV conduction and decrease ventricular rate, thus increasing the chance of a patient converting to sinus rhythm.

[Anne McNulty CRNA]

(1) what are the anesthesia considerations for Afib RVR? What are the treatments?

(1) What are the anesthesia considerations for afib/RVR? Treatments? The major consideration is the patients hemodynamic stability. Prolonged afib/rvr can result in end organ damage if not treated. If the afib is long standing , rate control should be achieved before undergoing surgery. Embolic risks should be addressed before surgery and patient specific decisions made. A great example of this is untreated sleep apnea that we see in so many patients. Treatments include identifying triggers during the intra-op period, such as hypo/hypervolemia, light anesthesia , ischemia,etc. Treatment include beta blockade, calcium channel blocker, amiodarone and cardioversion.

(2) I have memory of many patients going into afib/rvr during the intra-op period. I recall tourniquet release as a trigger of Afib in many ortho cases. I have treated with beta blocker and calcium channel blockers. I recall having an elderly ortho-trauma patient that we used intra-op TEE to monitor cardiac status. Always check electrolytes and Magnesium is frequently administered.

[aileenm4]

1. considerations include issues with hemodynamics as patients can lose 20% of their SV and decrease their CO. Treatment should be quick as long term ubtreated Afib can lead to atrial dilation, stretch and remodeling and this vicious cycle is hard to terat. treatments include rhythm control strategy and or rate control strategy with medications like antiarrythmics, anticooagulation meds, ablation

2. I have not had a patient with Afib in pediatrics ever. this is not a disease or rhythm of peds patients.

[Soo-Ok Kim]

1. What are the anesthesia considerations for Afib RVR?What are the treatment options?
A-fib/RVR can cause hemodynamic instability since it reduces CO by 20%. Depending on the timing of A-fib and the rate of A-fib, the treatment/approach can be individualized. If stable with rate control, the surgical procedure can be proceeded with the existing medical management. Rate control can be achieved with beta blockers and CCB. if not achieved, amoidarone can be used for the higher possibility of rhythm conversion. Cardioversion can be considered for unstable A-fib with the confirmation of no thrombus by TEE.

2. Have you had a patient go into Afib RVR? What treatment did you use and was it successful?
I have had a patient with new finding of A-fib with controlled HR at the beginning of colonoscopy. Since pt was healthy and CHADVASC score 0 and it was low risk procedure, the procedure was completed as planned. Pt was consulted to communicate with PMD for further recommendation for A-fib treatment.

[kels]

1.) Afib RVR that is new in preop requires further investigation into reasons for the afib and the possibility of cancelling the case. If the afib rvr happens in the or rate control is important. Beta blockers can help with rate control . Other medications that can be used with new onset afib rvr include calcium channel blockers and amiodarone . unstable afib rvr may require a cardioversion

I have not had a pt go into a fib rvr

[nanci]

Questions for discussion:
1. What are the anesthesia considerations for A fib RVR? What are the treatment options? Anesthesia considerations are determination if the A fib is new onset or unknown onset and if the patient is on long-term anticoagulation which can lead to bleeding during the operative time period. Maintaining hemodynamic status also an important consideration as it is the rapid ventricular rate that induces hemodynamic instability. If sinus rhythm and hemodynamics are not stabilized management can be made by medications such as beta blockers or calcium antagonists. Amiodarone can also be used to help slow rhythm. Electrical cardioversion can also be used when hemodynamics are unstable.

2. Have you had a patient go into A fib RVR? What treatment did you use and was it successful? I have not yet had a patient go into a fib with RVR.

[kelseyleonard]

1. What are the anesthesia considerations for Afib RVR?What are the treatment options?

Anesthesia considerations include first identifying if the pt is hemodynamically stable. If not stable ie hypotensive, altered mental status etc, the pt can be given beta blockers or calcium channels or cardioverted if necessary. If the patient is stable, it is helpful to understand the triggering agent and determine if that can be reversed. if sustained afib, rate control will need to be established and anticoagulation discussed depending on the pts CHADVASC score.



2. Have you had a patient go into A fib RVR? What treatment did you use and was it successful?

I had a pt go into afib RVR shortly after induction, prior to incision. The pt was hypotensive and was treated with esmolol and phenylephrine. BP was stabilized however since we had not yet started the case, the decision was made to abort and have a cardiology work up prior to undergoing any further anesthesia.

[jswitzman]

Pts with Afib often have other co-morbities including HTN, Valve disease, reduces EF, CHF, OSA. Maintaining hemodymics under anesthesia is very important. Beta blockers can be helpful as can a
Remifentanyl drip to keep hr low and possibly prevent RVR

[jswitzman]

Pts with Afib often have other co-morbities including HTN, Valve disease, reduces EF, CHF, OSA. Maintaining hemodymics under anesthesia is very important. Beta blockers can be helpful as can a
Remifentanyl drip to keep hr low and possibly prevent RVR