Afib question

[Sugarcoma]

I am an RN of 6 months. Cardiac and Tele are probably my weakest areas. I work on a general surgical floor and had a patient with sustained tachycardia (up to 158) for over an hour. My previous assessment revealed a regular normal heart rate, when I listened to her again it reminded me of listening to a newborns heart. A stat EKG revealed A-fib with RVR, pt. with no hx of a-fib. When it continued, I called a rapid response for assessment.

The team basically walked in and walked out as pt. was stable and converted to NSR shortly. Spent the whole night listening to the tele mon go off as HR jumped up and several times pt. jumped into A-fib again. The docs did nothing, no meds etc. despite the fact that it was happening fairly frequently. When I gave report (to a VERY experienced RN, whom I trust implicity) she told me something needed to be done for this pt. I told her what happened with the rapid and she was also confused.

Here are my questions.

I know that bradycardia is o.k. unless symptomatic, though I still always call docs when it occurs if it sticks around. Same with PVC's, if they are happening frequently. The docs don't exactly appreciate this quality in me (draw lytes, let me know if k needs to be replaced, if not don't call again) With A-fib I learned that pt.s need to be coagulated due to the risk of possibly throwing a clot. Even if this rhythm is not sustained, if they are popping in and out of it regularly for long period of times wouldn't this still be a risk for them?

When do you wait and watch as opposed to calling the doc? If pt has no hx of a-fib and is suddenly a-fib on monitor wouldn't you at least call to report the change? I fear I am developing a reputation as an over-reactor with the residents on our floor. One even told me I was neurotic (in a nice way), this has led to some hesitancy for me to call a doc, but I never let that stop me. I was taught in school if you don't know call someone who does. If I can't get the answer from another RN on the floor, i call a doc.

[highlandlass1592, BSN, RN]

Sometimes, you just need to resort to brass tacks. Try something along these lines:

"I'm sorry that you need to come back so often for something as ridiculous as an asymptomatic rapid AF, but unfortunately, the protocol here requires that I notify you for the change in rhythm. Further, if you don't respond, then I'm forced to call your senior (the higher resident, or the first's doctor's boss); if your senior also fails to respond, then I'll have to call the attending cardiologist at home. If you don't like that, then I would suggest when you're promoted to director of clinical medicine, please keep those dislikes in mind, and change the god damn policy so that us poor nurses don't have to bother the poor residents with such 'meaningless' things. I mean, it's really a waste of our time too, you know. But until then, when I call, I expect you to be here. Oh, and btw, if you don't show up; don't worry, you can read all about it in the chart; ie. who I called, how many times I called, how many minutes elapsed, what was ordered, et cetera; and have a nice day."

Advice to the OP. Don't worry about it. Stick to your guns. You already have a license, so you need to protect it. A medical resident doesn't have a license yet, and is still in training. Whether he or she passes their training in large part, depends on how they conduct themselves on the floor during their residency. Your job is to protect the patient, not the medical resident. Frankly, their convenience or work load isn't even on my radar. Sometimes, these "doctors" forget that we don't work for them. Sure, we will follow their medical orders, but we work for the hospital in delivery of care to the hospital's patients. Ultimately, my employer makes the rules. If the rules are to call the MD for a rhythm change, then that's what I will do; the resident's likes or dislikes are not my concern. We are not there to make friends; just do your jobs. Period.

Further, from your follow up post, the patient sounds like a train wreck to being with. Someone with such an extensive history, in new onset Rapid AF, really belongs back in a telemetry setting, regardless if they were asymptomatic or not, IMHO.

Not sure where you come up with that a resident isn't a licensed professional. They most certainly do have a license, hence the ability to prescribe.

[highlandlass1592, BSN, RN]

Hey guys thanks for the quick replies!

Additional info: 81 years old with a cardiac hx, 2 previous stemi's, CAD, stents x 3. Pt. appeared asymptomatic but was hard to tell. Was just d/c from SICU and extubated that day. Pulse ox was normally low 90's, lungs wheezy and sounded full of "gunk" and had DOE, and that never really changed.

Rate was controlled at times but would then jump up and stay in high 140's. episodes lasted 5-15 minutes with 4 that lasted over an hour. Pt. was sleeping and no LOC changes and appeared quite bothered by me (can't you just let me sleep).

What scared me the most is that in the first 1 1/2 hours that I had pt. feet and legs were expanding before my eyes. In my initial assessment I noted +1 pitting, right before I called the team it was easily +2 and probably closer to +3. Pt. was getting NO fluids at the time and I have NEVER seen anyone blow up that fast. Plus pt got 40 of lasix IVP 2 hours before my receiving them! That was my main reason for calling the rapid.

I will add that pts. edema did not get any worse for the remainder of my shift even when .9 was added (suspected dehydration).

P.S. Havin, thanks for pointing out my error (coagulated), for some reason I cannot edit it.

Some things to think about with the info you added:

If this is the first time this has happened with this patient, they may not necessairly anti-coagulate right away. They may try to get him to convert chemically. With his cardiac hx, I'm not sure he hasn't done this before. I'm not looking at his history nor am I looking at any of his home meds right now. I'm guessing with his cardiac dz, he may be on a beta-blocker like Metoprolol. Beta-blockers can be great for rate control, frequently we may just give an extra dose to see if this will "tweak" them to get that rhythm to calm down. There is also the availability of Amiodarone as well. You can give either IV bolus or po bolus of Amio...but remember, Amio hangs around for about 21 days post-administration...and with a CHF hx, you need to be looking at liver function as well (right-sided heart failure will really mess with your liver, so if you're looking to start Amio, LFT's are always a good idea). As the patient was asymptomatic, you do have time to look at different treatment options..such as Metop, Amio, Calcium-channel blockers such as cardizem, etc. Really, tx is going to depend upon physician preference at your facility.

Electrolyte disturbance, which has already been mentioned, definitely could play a role in this type of patient. K+ of course, should be checked but Magnesium as well...and calcium could be depleted so it wouldn't be bad to check a Ca+ level as well. In our cardiac surgery population, we run a bit higher levels of K and Mag. It can reduce cardiac irritability.

Another area to consider, since I believe you said he was post-op, is he taking all of his home meds? It definitely sounded like he may be having a CHF flare-up, based upon your edema assessment. Sometimes, docs aren't as aggressive about resuming home regimens as they should be then our patients run into all kinds of complications. Being able to assess his baseline kidney function may have given you some insight as to what was going on as well.

Whew, this was supposed to be a quick reply! lol Anyway, these were just some thoughts I had, areas for you to focus your assessment on that may have helped you in managing this patient.

If you haven't done it already, may I recommend you consider joining the AACN? They have great resources for both ICU nurses and tele/step-down nurses. Their educational materials may help increase your knowledge and may give you an added self-confidence in dealing with patients like this. Good luck to you in your practice.

[Virgo_RN, BSN, RN]

pt was symptomatic with the periph edema and gunky lungs, low sats, Doe, etc. Seriously- what were they waiting for? For her to go into complete heart failure?Flash pulmonary edema? esp with her hx? This is one of those times, I "eat it", and call the doc back until we get somewhere productive- ie- resolution of symptoms- its not normal to have gunky lungs, pitting edema, doe, sustained bursts of hr in the 150's. The only time I have ever seen anyone tolerate that was a guy in his 30's , and it may have been svt due to hyperthyroid. This pt of yours sounded very frail.Yes maybe she was stable when you called the doc, but if that rate was to continue enough times, she wasnt going to stay stable, esp with that hx. Cant believe they didnt get a cards consult for cardizem gtt and transfer to cards floor.

That's because you don't put someone who is in NSR on a Cardizem gtt.

[martymoose, BSN, RN]

oh, I'm sorry- i read she was persistantly in afib in the 150s more than not. My mistake.

[Virgo_RN, BSN, RN]

It sounded more like paroxysmal AF, because the episodes of AF were self limiting, and the person was in NSR the rest of the time. Persistent would be if the pt. were in AF all the time.

An 81yo person with that kind of cardiac history probably has chronic CHF, and the stress of surgery would be a likely cause of an acute exacerbation.

The edema, DOE, and wet lungs could easily be caused by an acute exacerbation of chronic CHF, which is acting as a trigger for the AF (so, treat the CHF and you treat the AF). Another possible cause of the wet lungs and low O2 sats would be pneumonia (and infection could be a contributor to the AF as well). The pt. could easily have both things going on at once, which would put a huge stress on the post-op body, especially an 81yo with those comorbidities.

Again, the treatment for paroxysmal asymptomatic AF is to attempt to identify and treat the underlying cause(s), rather than throw antiarrhythmics at it.

Diuresis would be one of the first things to look at, which this patient received 40mg. of Lasix. Prophylactic ABX probably wouldn't be a bad idea either, for the possible pneumonia. Supportive care to get through the post op recovery phase is also important.

As far as anticoagulation, I suspect that his pt. is most likely on LMWH for DVT prophylaxis already.

But, we are not doctors, and we don't have the full picture on this patient. There is a lot of missing information, so it's all a stab in the dark, really.

I am curious as to what type of surgery they had, and why the decision to go ahead with the surgery was made? They sound like a poor surgical candidate.

Any updates on this patient?

[Virgo_RN, BSN, RN]

Can't edit, so I'll just add that signs and symptoms related to AF that I would expect to see would include acute changes in LOC, dizziness, hypotension, palpitations, diaphoresis, pallor, worsening SOB, etc. In the absence of these s/s, the patient is said to be "asymptomatic". The pt. in the OP was experiencing s/s more consistent with CHF.

[Sugarcoma, RN]

Wow, you guys have given me a lot of excellent advice and things to consider.

Emergency RN, I hope to develop as strong a backbone as you have.

JrWest, I almost spewed coke all over my keyboard after reading this "Sometimes we have to argue(oops , i mean, collaborate) with docs" I laughed so hard.

Virgo, you are a wealth of knowledge!

Some additional info: I need to be careful here because I do not want to identify myself or pt in this post. Pt. originally came in to another floor in my hosp with cholecystitis. Scheduled for SX but something happened that caused it to be delayed and pt. went septic and GB necrosed. Very very messy. Went to unit after er sx and had a very difficult recovery including resp failure resulting in intubation. Multiple new heart arrhythmias during recovery. Originally on lopressor but hemodynamically unstable so lopressor was decreased and an old school CCB was prescribed. When I originally got pt. I gave CCB ASAP (newly prescribed) and crossed fingers hoping that would cure the issue, but it did not. Sx resident who came with team basically said they had been dealing with this for a while and that this pt was very hard to treat. (never afib before though). Pt was on Heparin for DVT prophylaxis. As well as ABX. I kind of got the feeling that they did not want to touch this and to let cards deal with it in the a.m.

RE: home meds, a necessary home med had not been given since admission (synthroid) Lytes were normal ex CA which was in the high 7 range.

Im not back until Friday and hoping to find out what happened with this pt.

[Virgo_RN, BSN, RN]

Thank you for the new info. It really does sound like this patient is teetering on the brink.

There are only 2 cardioselective CCBs that I am aware of, Verapamil and Cardizem. These will not convert the pt. to NSR, but will slow conduction through the AV node, so that when this person is in AF, the ventricular rate will be controlled. However, the drug isn't just slowing conduction when the pt. is in AF, but it is doing so at all times. A high enough dose/the wrong drug/the wrong combination of drugs needed to slow the RVR could also cause the rate to be too slow when the pt. is in NSR, or worst case scenario, throw them into complete heart block. Now the patient needs a pacemaker but they are too frail to make it off the table, so they have a temp pacer and they're back in ICU/CCU and they're pacemaker dependent.

I would be very surprised to see any cardiologist attempt to chemically convert, since the pt. is not persistently in AF. Chemical conversion is simply not indicated.

RF ablation is invasive and has risks that may outweigh the benefits to this particular patient at this particular time. This patient may not make it out of the cath lab alive.

Sounds to me like the doctors have been doing all they can for this patient. I'm not sure what more anyone would expect the doc to do under the circumstances. I can't imagine a patient with this kind of cardiac history going through all of this without their cardiologist being aware.

I'm also wondering if maybe this patient was transferred out of the ICU a little too soon, or that perhaps they should have gone to your cardiac floor/PCU or an ICU step-down? Not to sound crass or insensitive, but it might be a good idea to revisit their code status.

[Virgo_RN, BSN, RN]

Virgo, you are a wealth of knowledge!

Not really. I used to work on a cardiac floor and we took patients like this all the time. Now I'm in the ED and I don't know crap.