[zacarias]

Last night was a shift and a half!!! I had one guy who was old, sick and kept getting sicker. He's an 81 y/o DNR with pulmonary fibrosis, often comes in with SOB due to AF with RVR. Well, I had him last night, he was in SR in the 80s but converts to Rapid AF 140s at 2030. He also has pneumonia mind you (which probable precipitated the former). To note is he's often in and out of afib and is on coumadin.

The hospitalist orders a dilt gtt. I start the gtt at 5ml/hr and doesn't do a thing. His pressure barely is acceptable. I up him to 10 eventually. Nothing. I wait awhile, call the hospitalist and he says try a fluid bolus! Well, this guy's been getting 100cc/hr because they thought he was pretty dry when he came in. He doesn't seem like he's in failure but it's hard to tell as his he does have lower left. He's has pulm fibrosis and I think some atelectasis. His sats are in the mid 90s 5L.

After the fluid bolus, his urine output picks up and his bp goes to 110/50 so yippee I can go up to 15ml/hr on the dilt gtt! Doesn't budge his rate at all. Lab calls and says we have a + blood cx (gram neg rods). Great...well looks like we might have sepsis. It's like almost 5am now. I call the hospitalist back and he's not sure if he wants to try amiodarone. Then he calls back and says why not so we start him on an amio gtt!! I'm running around trying to find the special filter when day shift comes. I give them report and stay late and start the amio gtt and get vitals because while I am not required to stay, I realized I was leaving a busy load for day shift.

By the time I left, 20 min into the amio, the guy was still 130-155 afib. The guy's like refractory to everything. Have any of you guys had this type of experience? Have you had a pt on a dilt AND amio gtt at the same time on your tele unit?

[gr8rnpjt]

At this point sometimes I have had cardiologist order IV dig q8h x 3 doses, then switch to po.

[zacarias]

This guy was already on dig and his dig level was 1.1.

[ark-two]

Had a gut who's hr was around 150 on amio @ 33 ml/hr. Tried dig IV and cardioversion. He was also a-fib. Had COPD. Amio did not touch his hr except around noon he would slow to the 80's afib and slowly rebound to the 140-150 throughout the day. We cardioverted him. I was really surprised they did it. He was in afib for a couple days before the cardioversion. He went directly to SR hr 70's. We sent him out of the unit. From what the floor nurses said, he went back into afib, but was rate controlled.

[zacarias]

Wow, it sounds like that guy was even refractory to amiodarone. But for people that are chronically in and out of afib (or have had afib for a while), cardioversion seems like it would only help for a small period of time. I think the guys whose rates don't come down are pretty sick to begin with anyway.

[ark-two]

The cardioversion helped for about a week and then he converted back to afib, but it was more rate controlled. Guess they are going to coagulate him. Don't know what happened, since he left and went to rehab. What ever happened with your patient?

[intra-aortic]

I work in CCU and had a pt who went into rapid a-fib. Got orders for dilt and amio gtss. Worked like a charm. Approximately 3 hours, she converted back to sinus. I run both gtts at the same time, starting with 5ml of dilt and I believe 27ml/hour of amio. I eventually had to go up on dilt to 15ml. But I was glad that it only took abour three hours to convert back.....If not I would have had a very busy night.

[SEOBowhntr]

In all actuality, the A-Fib is probably related to hypoxia, and in pt.'s with moderate to severe Hypoxia, often times you cannot correct the rhythm problem without correcting the hypoxia. Also, even though some people are nervous about it, you may be best off to use Lopressor on such a pt. even w/ his poor lung status. Remembering that the increased O2 demand of that Tachycardic heart is only potentiating the problem. Also IV Lopressor seems to be less likely to cause the severe bronchospasm that you get w/ PO Lopressor. Rate control is the objective here, and keep in mind that Digoxin, even IV Dig, is slow acting, therefore, it really isn't an overly effective drug in rate control under emergent or urgent situations. And w/ known Pulmonary Fibrosis, Cordarone is certainly not an overly good option, w/ the damage it is known to cause to lung tissues. Unfortunately, for such a patient, maybe comfort care would be the best option.


Doug

[zacarias]

Good info Doug. An update, is that this patient did die two days later. His body couldn't take it. His + blood cx revealed pseudomonas.

[cateccrn]

I have seen pt.s who would only respond to 20mgs of Diltiazem, and others who needed the Amnio as well. Just have to keep trying what works with the ones who arent cardioversion or Corvert candidates. Lopressor can be a tricky thing in this case, due to the guy's hypotension. Rate control is your
goal, but Ive seen Lopressor cause some hairy complications.