Post CV A-Fib Protocol?

[PMFB-RN, RN]

So every hospital with a heart program I have ever worked in has an a-fib protocol for post CV surgery patients. However where I currently work we do not. As the rapid response nurse I am frequently called to deal with a-fib on our step down and surgical med surge floors. Every time I must call the surgical resident on call and we go about treating it as if this is the first time this has ever happened. It results in long delays in patient care and inconsistency in treatment. I have proposed that we institute a Rapid Response a-fib protocol. I have a meeting on Tuesday morning with the head of CV surgery, one of the CV fellows and their nurse practitioner to propose the protocol. I have several protocols in mind, basically those that have worked well in other heart programs where I have worked but want to see if the CV team has something in mind. My selling points to the CV team are faster treatment for the patient, more consistent treatment, and the opportunity to get the treatment the CV team wants, not what some surgical resident they might not even know wants. My other selling point is that just about all open heart programs have such a protocol. This is true in my experience but I have only worked in 4 programs. My question to you all is does your hospital have a a-fib protocol for post CV surgery patients? I want to know if such protocol are as widespread as I think they are.

[Biffbradford]

The CVICU where I last worked did have an AFIB protocol.

[MunoRN, RN]

I've worked with two CV surgery programs and neither has had an A-fib protocol. We do have an amiodarone for A-fib protocol, but it has to be ordered, just being in A-fib doesn't activate the amiodarone protocol.

I'm curious what the protocol consists of for those that do use it. In my experience, treatment of A-fib in post CV surgery patients varies too widely to qualify for a protocol because treatment is based on a wide range of variables such as; specific type of surgery (CABG vs valve vs Maize), pre-op A-fib Hx, tolerance of A-fib (rate controlled, BP, CO), pulmonary/thyroid Hx (for amiodarone), QTc baseline and potential need for other QT prolonging drugs such as seroquel, haldol, xyprexa, etc. Plus, for the most part there is no treatment indicated for A-fib in most CV surgery patients other than correcting mag and potassium levels. If there is a one-size fits all treatment for a-fib in post CV surgery patients I'm sure my Docs would be interested.

[nursemaReN]

I used to work on CT stepdown for a year and a half or so. We had a post op A-fib protocol. it was Metop 5mg IV x3 then if it still didn't break, then amio bolus and gtt. then if THAT didn't work, we would bounce them to the unit for dccv.

Now, in our CCU (not post op patients,but still go into rapid A-fib) we use Dilt 15mg ivx1 then a dilt gtt. it's all different every where. I noticed usually though you could break the fib with 5mg metop.

[BelgianRN]

Did the protocol specify anything concerning LVEF or any type of contractility disorder to take into acount when pushing B-blockers?

[PMFB-RN, RN]

"did the protocol specify anything concerning lvef or any type of contractility disorder to take into acount when pushing b-blockers?

my last hospitals protocal did not have beta blockers in it's protocal for a-fib. one before that did and listed was "use with caution" my experience is that the rns are far more likley to take lvef into account when pushing drugs than the just-woke-up-never-met-this-patient surgical resident on call for the sicu.

[BelgianRN]

my experience is that the rns are far more likley to take lvef into account when pushing drugs than the just-woke-up-never-met-this-patient surgical resident on call for the sicu.

amen to that :)

[suanna]

For AF the standing orders are for lytes and gasses. As a rule if HR >100 we call the doc without waiting to treat lytes. If lytes are out of whack and pt stable we may give a try at treating them before other pharm. intervention. We have no standing "protocal" that is activated on a-fib onset, but we do have a page of orders that spell out med regiems to choose from for each patient: Amio PO, Amio IV, cardiazem, beta blockade. The choice of treatment depends on the docs preference but the conversation is pared down to: Nurse:

" Mrs Bla in rm 18 is in AFRVR SBP 90s." Doc: "do the amio IV and call if unstable per protocal. Alternately the order is - "Do the Cardizem," . It saves a lot of late night conversation about loading dose, maint, labs, ...