Clots related to fast afib

Specialties CCU

Published

Hello! I wonder if someone might help here. I work in a med/surg ICU and we monitor telemetries in the hospital as there is no CCU. A post-op cholectomy, 84 years old, not on anticoagulants, with a history of HTN, was on telemetry immediately post-op. He went into fast afib, as he had done briefly and previously pre-op. When the cardiologist on-call was paged, he prescribed 50 metoprolol po. Of course the patient stayed in fast afib, 160-200, since po takes a while to work. After one hour being that fast, I paged the cardiologist and informed him of the rate, and that he was otherwise asymptomatic, with a drop in BP to 100/45, from 130/70. The cardiologist said it was fine. When I expressed my concern that the patient wasn't putting out much urine and was only getting Ringer's at 75/hr, and that I was worried about a clot, he said a patient needs to be going fast like that for about 48 hours to throw a clot. REALLY? I was shocked, but that came from the cardiologist. I documented what I said and left it to that. What do you all think? Is that correct??

Thank you!

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Specializes in ICU.

How far out from surgery? I don't think you'd want to anticoagulate someone just out of surgery and you'd let the surgeon run that show anyway. Maybe that's the reason for delay in addressing that from cardiology. The urine output thing needs more pt / case/ history info.

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I agree about not anticoagulating someone who is fresh, post-op. We're talking 6+ hours. However, I mentioned that because of the fast afib. The patient is under cardiology which is why the cardiologist was paged, and not the surgeon. My concern is the fast afib. 160-200 bpm for 90 minutes seems a bit much, no? In the ICU, we would have started an amio drip stat...not to mention a bit of fluid too. Bloods were done but I wasn't made aware of the results as the patient wasn't on my unit. I was just monitoring him on telemetry.

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Specializes in ICU.

I've never heard that about the clotting potential; I agree though that it would be up to surgery. I don't get why you would let someone sit at that high of a rate for so long though- why not give something IVP? A heart can only beat that fast for so long without something going wrong. Are you saying after 90 minutes he came out of it?

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After about 90 minutes, he went 130-180 and continued til the end of my shift, with me documenting like a madwoman. It was certainly stressful because of , as you stated, I was worried about him really going sour. I would have loved to see his labs, and maybe give him more fluid, if not a little amio.

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Specializes in ICU.

Surely the cardiologist saw this patient prior to surgery, to clear him for surgery, in view of his previous atrial fib and hypertension. I do not know about the "48 hours to form a clot" thing, but I do know this patient was at greater risk for a clot due to his advanced age, recent surgery, and history of hypertension. Personally, I would have given a courtesy call to the surgeon, esp. if you were concerned about low urine output.

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Specializes in ICU.

Oh, BTW, what is a cholectomy? Do you mean colectomy, or cholecystectomy?

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Specializes in ICU.

I was wondering that too, applewhiteRN:)

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Usually the rule of thumb for afib and a clot my cardiologists use is 24 hrs. If a patient knows when they go into afib and it's been less than 24 hrs, they will just receive a cardioversion. If unknown time or greater than 24 hrs, you do a tee and then a dccv. The more worrying thing is cardiac demand ischemia and potential for prerenal failure second to decreased CO.

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Specializes in Critical Care.

The general recommendation is to start anti-coagulation after 48-72 hours in A-fib, since the type of clot we're worried about won't "mature" until beyond that point. This is also why it's still safe to cardiovert someone who we know has only been in A-fib less than 48 hours. If the duration of A-fib is unknown, elective cardioversion is contraindicated with an echo (preferably TEE) to rule out a clot that could be thrown in SR.

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Specializes in CTICU.

I'd have to know the patient's history to determine the correct treatment - if they have heart failure, which wouldn't be surprising in an 80+yo, they may be fluid overloaded and giving more fluid will just distend the atria more and make the AF worse. I wouldn't worry about low CO or perfusion-related renal injury as long as your mean BP is fine, which it was with a SBP of 100.

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Specializes in Internal medicine/critical care/FP.

takes a while for a clot to form. they don't just pop up after 10 minutes of fibz

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