37th Annual Toronto Thoracic Surgery Refresher Course

Transcription

1 37th Annual Toronto Thoracic Surgery Refresher Course PREVENTION OF POST OPERATIVE ATRIAL FIBRILLATION Dr. Carmine Simone Director, Intensive Care Unit Head, Division of Critical Care Departments of Medicine and Surgery Thoracic Surgeon Department of Surgery

2 OVERVIEW Prevention strategies prior to surgery Prevention strategies after surgery Prevention strategies during surgery

3 QUESTIONS year old man in PAC preparing for lobectomy. In order to estimate patient s risk for post operative AF you would order all of these investigations except: a. 2D echo b. Blood work, including MG, Ca levels c. ECG d. Cardiac EP study

4 QUESTIONS year old post VATS lobectomy for lung cancer. To reduce risk of AF, post operative orders should include all of these items except: a. Magnesium b. Atorvastatin c. Ketorolac d. Digoxin

5 QUESTIONS year old male post pneumonectomy for lung cancer with history of DVT and PE. Now in PARR and patient is hemodynamically stable and on room air. Pre-op HR was 80. This patient s risk for developing AF is: a. 15% b. 20% c. 30% d. 50%

6 Atrial fibrillation Atrial fibrillation (AF) very common after major noncardiac surgery 12-30% after lobectomy 23-67% after pneumonectomy 13-46% after esophagectomy** Average time of onset is 2-3 days after surgery May result in hypotension and stroke if untreated Can triple step-down or ICU stay and can lengthen hospital stay by up to 9 days

7 Atrial fibrillation Risk factors Independent risk factors include: Lobectomy, bilobectomy, pneumonectomy Age > 70, male sex, previous history of arrhythmias Preoperative heart rate > 79 bpm LV diastolic dysfunction, valvular disease Multiple lung wedges, segmentectomy not independent risk factors To date no studies to show significant reduction in AF with VATS versus open thoracotomy Clinical studies suggest that other risk factors include: Atrial natriuretic peptide, BNP and N-terminal BNP History of PE etiology unknown but thought to be due to remodeling of atrium muscle

8 Atrial fibrillation Mechanisms Sympathetic nervous system activation Enhanced activity or reninangiotensin aldosterone system Post operative inflammatory response Decrease ability to regulate electrolyte transport into cardiac muscle Increased left or right heart pressures Increased TV regurgitation jet velocity

9 Prevention strategies - PAC History Previous arrhythmias DVT or PE Noncompliant with medications Resting EKG Resting heart rate >75 PACs, PVCs 2D echo Valvular disease Diastolic dysfunction Pulmonary hypertension Bloodwork Magnesium, calcium, ESR, WBC (ANP, BNP)

10 Prevention strategies - PAC Medications Noncompliant with cardiac medications Imovane Haldol Social Smoking doubles risk IV drug use Cocaine Ginseng containing herbal preparations Excessive green tea, tea or coffee/day

11 Strategies for prevention - Drugs Beta-blockers 2 studies have evaluated efficacy of beta-blockers for AF prophylaxis Metoprolol 100 mg po BID versus placebo Propranolol 10 mg po q 6 hours versus placebo x 5 days Safe to use in COPD patients BOTTOM LINE - Effective Biggest concern is hypotension and bradycardia post operatively If patients develop complication higher morbidity and mortality with beta blockers Calcium channel blockers Diltiazem versus digoxin Diltiazem versus placebo Verapamil versus placebo BOTTOM LINE - Effective Biggest concern is hypotension

12 Strategies for prevention - Drugs Amiodarone Very effective for treatment of AF unrelated to surgery Amiodarone versus verapamil terminated Amiodarone versus untreated Higher incidence of ARDS, pulmonary fibrosis which is dose related (Studies used 3x current treatment doses) BOTTOM LINE Use cautiously in pneumonectomy patients, but very effective for treatment Higher incidence of bradycardia, heart block requires monitoring Cardiology should be involved

13 Strategies for prevention - Drugs Magnesium Competitive calcium channel blocker Safe and effective in post operative cardiac patients Small study in post operative thoracotomy patients Statins Anti-inflammatory effect of cholesterol lowering agents Effective in lowering post operative AF in thoracic patients

14 Strategies for prevention - Drugs NSAIDs Potent anti inflammatory drugs shown to cause reduction in AF Digoxin Multiple studies Data regarding efficacy for prevention of AF after pulmonary resection are mixed Substantial potential for toxicity Data does not support use for either prevention or treatment

15 Strategies for prevention - Intraoperative Epidural analgesia Decreased sympathetic drive Reduction in AF correlated with effective block Hypotension a major concern VATS versus open No studies to suggest VATS AF rate less than open Fluid restriction No studies to suggest efficacy

16 Strategies for prevention Post-operative Fluid restriction In general surgical patients shown to increase rate of AF Albumin shown to decrease incidence of AF NSAIDs Ketorolac Statins Atorvastatin Beta-bockers used cautiously Oral magnesium Magnesium Rougier 15 cc BID x 3 days

17 Strategies for prevention Recommendations Pre-operative 2D echo to ensure no diastolic dysfunction, valvular disease Correct electrolyte abnormalities (Mg, Ca) Beta-blockers where indicated Intra-operative Epidural analgesia for thoracotomy patients Post-operative Magnesium Ketorolac Atrovastatin Low threshold to stop metoprolol i.e. leukocytosis, fever, changing CXR

18 SUMMARY AF very common complication No strong evidence to guide practice of prophylaxis Anti-inflammatory agents, correction of electrolytes, beta-blockers and reduction of sympathetic drive such as pain all potentially effective

19 QUESTIONS year old man in PAC preparing for lobectomy. In order to estimate patient s risk for post operative AF you would order all of these investigations except: a. 2D echo b. Bloodwork, including MG, Ca levels c. ECG d. Cardiac EP study

20 QUESTIONS year old post VATS lobectomy for lung cancer. To reduce risk of AF, post operative orders should include all of these items except: a. Magnesium b. Atorvastatin c. Ketorolac d. Digoxin

21 QUESTIONS year old male post pneumonectomy for lung cancer with history of DVT and PE. Now in PARR and patient is hemodynamically stable and on room air. Pre-op HR was 80. This patient s risk for developing AF is greater than: a. 15% b. 20% c. 30% d. 50%

22 37th Annual Toronto Thoracic Surgery Refresher Course THANK YOU Dr. Carmine Simone Director, Intensive Care Unit Head, Division of Critical Care Departments of Medicine and Surgery Thoracic Surgeon Department of Surgery