Moments of Terror

Pete495 · Apr 12, 2006

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 · Apr 12, 2006

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, CRNA · Apr 12, 2006

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

London88 · Apr 12, 2006

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 · Apr 13, 2006

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 piss yourself. Good job and great teaching point, thanks.

Pete495 · Apr 13, 2006

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 · Apr 13, 2006

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 · Apr 13, 2006

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 · Apr 13, 2006

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.

yoga crna · Apr 14, 2006

I had a moment of terror yesterday in my office practice. The power went off in our facility and a five square mile area. The emergency generator failed to last more than 15 minutes--it was checked by our biomed guy two weeks ago and lasted 3 hours. I have no idea what happened to it. The battery in the monitor lasted exactly 30 minutes and the alarms on the anesthesia machine were chirping and then only the oxygen worked. Thank God, the surgery was liposuction and we were almost finished. We opened the window shades, brought in flashlights, the surgeon suctioned by hand. I quickly put propofol and ketamine in a battery operated pump and gave a little versed to the patient. I am an old anesthetist who learned the craft without using monitors, so the manual blood pressure cuff, precordial stethoscope and watching the patient's color worked fine. For suction at the end of the case, I used an asepto syringe. Patient was fine, no recall, but I would rather not repeat the day.

Now the big problem. The power came back on, went out, then back on. I called the electric company and they said they could not guarantee that there would be power for at least four-five more hours. The next case was a breast augmentation. Would you have gone ahead with that case? The patient, who is an RN insisted we go ahead and that she would assume the risk and sign anything we wanted. It did not fit into her schedule to have the surgery another day. The surgeon was afraid of losing the case (and money) if we didn't do her.

We didn't do her, did her today and she was ultimately happy with the decision.

We are closed next week and the new generator will be delivered and set up before our next surgery,

That was my moment of terror that I don't plan on repeating any time soon. It was not as exciting as the cardiac events you guys are seeing, but it is no less scary.

Yoga

GCShore · Apr 14, 2006

I had a moment of terror yesterday in my office practice. The power went off in our facility and a five square mile area. The emergency generator failed to last more than 15 minutes--it was checked by our biomed guy two weeks ago and lasted 3 hours. I have no idea what happened to it. The battery in the monitor lasted exactly 30 minutes and the alarms on the anesthesia machine were chirping and then only the oxygen worked. Thank God, the surgery was liposuction and we were almost finished. We opened the window shades, brought in flashlights, the surgeon suctioned by hand. I quickly put propofol and ketamine in a battery operated pump and gave a little versed to the patient. I am an old anesthetist who learned the craft without using monitors, so the manual blood pressure cuff, precordial stethoscope and watching the patient's color worked fine. For suction at the end of the case, I used an asepto syringe. Patient was fine, no recall, but I would rather not repeat the day.
Now the big problem. The power came back on, went out, then back on. I called the electric company and they said they could not guarantee that there would be power for at least four-five more hours. The next case was a breast augmentation. Would you have gone ahead with that case? The patient, who is an RN insisted we go ahead and that she would assume the risk and sign anything we wanted. It did not fit into her schedule to have the surgery another day. The surgeon was afraid of losing the case (and money) if we didn't do her.
We didn't do her, did her today and she was ultimately happy with the decision.
We are closed next week and the new generator will be delivered and set up before our next surgery,
That was my moment of terror that I don't plan on repeating any time soon. It was not as exciting as the cardiac events you guys are seeing, but it is no less scary.
Yoga

Wow! I was doing clinical last week and lost power....fortunately, the generators did function and my patient was spontaneously breathing......I asked my CRNA if I got an A for the day since I didn't void or defacate during the event..... :lol2: