[London88]

I am sure that most SRNAs and all CRNAs know that anesthesia is usually 99% relaxation and 1% sheer terror. Where I work it is 80% relaxation and 20% sheer terror because we do primarily cardiac anesthesia. It would be great if the CRNAs and SRNAs can share some of their moments of terror in the OR. I will start by discussing my case from Yesterday. We induce a pt for an AVR repair. Pt has a hx of Afib, EF30%, +3 MR. We use a high dose narcotic technique and pavulon as MR. Pt goes into a rapid AFib 180s, B/P tolerating this for the moment. I suggest brevibloc to my attending, he decides on 150 of amiodarone. He gives it and next minute we are still in a rapid AFIB with a MAP of 38. Now seemed like a beautiful time to do a DL. I had the ETT tube in within seconds. B/P is tolerable but we are still in a rapid Afib. Again I suggest brevibloc he goes for the Digoxin. Digoxin is good but we are trying to break the arrythmia now and not 30-40 mins down the road. Finally he gives in and gives the brevibloc and low and behold within seconds we are in an Afib in the one teens. We were playing the little game of because you suggested it I will do something different. I like the guy as we get on great but he is notorious for playing these little games whereas with the other attendings it is not even an issue as they go with whoever has the best idea.

[Pete495]

Sounds like your attending was going for breaking the AFIB, not necessarily decreasing the heart rate. Although, I think Amiodarone is the first choice, I am thinking that in people who have chronic AFIB, the amiodarone is mostly ineffective, and you were probably right to suggest brevibloc, and at least stable him out by decreasing the heart rate. Honestly, amiodarone would have been my first choice as an anti arrhythmic, if it was new onset AFIB. Digoxin would have been my last choice, esp. immediately before heart surgery, w/ all the Potassium issues?

On your moments of terror subject, here is one I had happen a couple wks ago.

Didn't think it would ever happen, ever!? Well, all the stupid s%&t happened in one day. First case of the day was a TVH. checked the machine like I usually do, and everything was looking good, Pipeline pressure 50psi, and O2 cylinder 1800, good flow on flowmeters. 02 cylinder closed by me. CRNA rechecked to make sure everything was copacetic, saw the same reading on the O2 tank. I'm pretty sure he closed it, but did not recheck him.

About 10 minutes into the case after the patient is hooked up, pipeline pressure starts to fall, 30, 20, to zero. Alarm didn't go off until very late in the game, but it didn't matter. After wetting my pants, we switched to the O2 cylinder, and disconn. from wall. sorry, no pressure or gas there either. Okay, so I'll try medical air, but that's a no go too, cuz the machine must have some interlock that shuts down after the fail safe kicks in. Had to call stat for a new O2 tank, and anyone who knew what the heck was going on. Was baggin the patient manually through the machine temporarily on room air. never sufferred any deleterious consequences. sat. was 96 and above the whole time.

One of the connections mid line between the wall and the machine was cracked/loose a little bit. Everything appeared fine at the beginning, I think cuz everthing was fine. Then something freaky happened, and the connection came loose or something, and so the machine wasn't gettin any air so it went to the cylinder (which was supposedly closed), but maybe it was a faulty valve, and it wasn't shut tight all the way.

In any case, the pt. suffered no dire consequences, but even after we restored pipiline pressure, and put on a new O2 tank, the machine would alarm Reverse Flow, and Threshold Low. I know what they mean, but wasn't sure what it all added up to. Had our coordinator look at the machine. He adjusted the soda lime, said sometimes they need redistributed.

Any comments welcomed.

[MmacFN]

man.

I dont even know what to say except good job trying to be an advocate for the patient, you were right other provider was wrong.

[Focker]

London88, would verapamil be another alternative in the case of rapid afib?

[London88]

Verapamil would have been okay. I look at the fact that because we are under anesthesia it better to give a drug that has a short half-life, such as brevibloc or verapamil. You may have to chase it with some neo but it does not last as long. We have not yet made incision and by the time they do their prep and all the rest for surgery we are not going to be making incision for another 45 mins so you will be chasing your B/P. Amidarone is a good drug but I prefer to wait until we are on bypass to slam in the 150mg because of the hypotension. This particular surgeon likes amiodarone to be given to all his heart pts. Most of the time we start the amiodarone infusion and then give the 150 bolus when we get on bypass. Remember these are cardiac pts who are already compromised. There are many ways to skin a cat in the OR but some ways are better than others. I hope we can continue to engage in more clinical discussion as there is a lot learn from this. Next time I will discuss the pt who went asystole after a spinal.

[rayman]

If you are going to be loading up with amiodarone anyway I can understand giving that a shot. However, with that rate of 180 and the hypotension I think you made a great call. Brevibloc would be preferable for all the reasons you listed. Of course it is easy for me to say that sitting here in my recliner with time to think about it...lol. Much more difficult with it happening in front of you and trying not to **** yourself. Good job and great teaching point, thanks.

[Pete495]

I am also wondering why they didn't to a mitral valve repair also w/ 3+ MR? Ablation therapy also seems appropriate while you were in the OR with the history of chronic AFIB. Did the AFIB happen after you pushed the drugs or was it while you were intubating? In any case, if it was chronic, I would treat the heart rate, not the AFIB.

Quite honestly, I've given amiodarone A LOT, and I haven't seen as much hypotension as I have with the Beta Blockers. Afterall, one of the primary effects of beta blockade is to bring down the blood pressure. In my opinion and clinical experience, you will get less hypotension w/ the amiodarone.

Would anybody else use dig in this case?

good post.

[rayman]

Hey London, you said the HR came down after the brevibloc...what happened with that map of 38? Shouldn't it have gone up with better ventricular filling, starling, etc?

[London88]

The MAP when up when I intubated him. a DL is very stimulating and is a good way to bring the B/P up . By the time I got done intubating the B/P was okay but we still had the HR issue. Many times pts who have MR or AR have Afib owing to the increased volume. So an ablation in this situation is not warranted what he needs is a new valve. Thank you for correcting me on the MR it was aortic regurgitation and not mitral regurge. As far as amiodarone goes the loading dose should be given over 10 mins unless you are doing CPR etc. It is a matter of picking your poison both the amiodarone and brevibloc will cause hypotension. I would not have given amiodarone first but like I said it was not a bad choice. As far as the good old verapamil i have not used it in ages. It been about ten yeras since I have given IV verapamil. Geez I don't know if we even have it in our draw.

[herseyjh]

I would go with the brevibloc. You can slow the rate and get yourself out of the woods. The bad news is once you have given a beta blocker switching to a Ca blocker might get you into problems. I have seen people do it but mixing the two with get you into trouble.