Clots related to fast afib

[maloneys]

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!

[dandk1997RN, MSN, RN]

...and in addition to everything above, it's likely that if you correct that rate, you will correct the BP.

[JenHRN]

I would also be concerned that rapid afib would mask the signs of a post-op bleed. How are you going to know if the pt is bleeding internally when they are already tachy and hypotensive :/ The cardiologists I work with would have definitely addressed it with something IV push or a drip.

[Twisted Nurse]

When the cardiologist on-call was paged, he prescribed 50 metoprolol po. Of course the patient stayed in fast afib, 160-200

HR in 160-200s? Sounds like he went into Atrial fib RVR.

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.

I agree with the cardiologist and the above poster. B/c he is fresh out of surgery, he shouldn't be on any anticoags d/t the high risk of bleeding. You have a right to worry, being in A. fib is not a good thing. Usually, if a pt goes into A. fib post op, a cardiac drug will normally be ordered. I work with post op CABGs so I see A. fib all the time in my patients. Usually if a pt goes into A. fib, we usually do an Amiodarone protocol.

But always remember your ABCs! For ex....Is the pt's sats ok? If not give them oxygen. You said he was asymptomatic. So being in A. fib wasn't affecting him too much. Some pts can be in V-tach and not even know it. Is his BPs really low? If his EF isn't low or if he doesn't have hx of CHF....a bolus wouldn't hurt. Not to mention the cardiologist gave you the order for Metoprolol. Basics are always the key! Hope this helps!

[emesibaja]

How low was your urine output? Were you doing hourly?

If he was getting LR we can say he was being hydrate so that rules out pt being dried.

On the initial call I would have asked for a drip or ivp plus would have order stat electrolyte just to make sure low Lytes were contributing to the problem.

Since he gave you metoprolol po , after hr or so I would have call him back and say hey I need iv stuff, doesn't sound like that cardiologist was very concerned.

Was the pt on rate control meds prior to surgery and maybe they didn't give him his meds the night before bc they made npo a and maybe that was why he went in to afib? Or af was new?