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MillsPeninsulaHospitalCardiovascularCo-managementMetric NewOnsetPostoperativeAtrialFibrillationPreventionProtocolfor CardiacSurgeryPatients Background: Newonsetpostoperativeatrialfibrillation(POAF)affectsapproximately11-40%ofpostcardiacsurgery patients.Itisthesinglemostcommonpostoperative“complication”observed.Numerousstudies havelinkedPOAFtoincreasedperioperativemortality,lengthofstay,hospitalreadmission,aswellas hospitalcost. Adiverseregimenofprophylacticstrategieshavebeentrialed,withvaryingdegreesofsuccess. Bothbetablockersandamiodaronehavebeenidentifiedtobeeffectiveandrelativelysafechoices,and havebeenshowntodecreasetheincidenceofPOAFbyupto50%.Additionally,theventricularratein thosepatientswhodoexperiencePOAFwerebettercontrolled. ThecurrentprotocolwillfocusontheprophylaxisandpreventionofnewonsetPOAF,andnotonthe treatmentofPOAF. Objective: ToimplementaneffectiveprotocoltodecreasetheincidenceofPOAFincardiacsurgerypatientsand positivelyimpactperioperativeoutcomes. Thisprotocolisnotmeanttobeaclinicaltrial,norisitmandatory.Thesurgical/medicalteamwill alwayshavethediscretiontoimplementand/orwithdrawfromtheprotocolbasedontheclinical situation. Method: Therearethreeenvironmentswherethereisanopportunitytoinitiatetheprotocol.Those environmentsarethepreoperative,intraoperative,andimmediatepostoperativephasesgenerally correspondingtooutpatient,operatingroom,andinpatientsettings. ThecausesofPOAFarelikelymulti-factorial.Avarietyofpatientfactorsaswellassurgicaltechnical factorshavebeenimplicated. FactorsImplicatedinPostoperativeAtrialArrhythmias Atrialtrauma/inflammation Atrialstretch Atrialischemia Epicardial/Pericardialinflammation Hypoxia Acidosis Electrolyteimbalances Sympatheticautonomousdischarge Circulatingcatecholamines TargetPopulationandInclusionCriteria: AllpatientsundergoingcardiacsurgeryatMillsPeninsulahospitalarepotentialcandidatesforthe protocol.Eachpatientmustbeapproachedindividuallyandverballyconsenttotheprotocol.A handoutwithgeneralinformationwillbemadeavailabletofacilitateenrollment. Patientswithpre-existingatrialfibrillation(paroxysmalorpersistent)orotheratrialtachycardiasare alsoeligibleforthisprotocol,howeverwillnotbeincludedintheoutcomesassessment.Athorough historyofpre-existingatrialfibrillationorotheratrialtachycardiasshouldbedocumented. WhilePOAFisobservedinpatientsundergoingalltypesofcardiacsurgerybothemergentandelective,a highriskcohortcanbeidentified. HighRiskPopulationforDevelopmentofPOAF Elderly(age>70) Valvularoperationsorcombinedvalve/CABG Multiplepre-existingcomorbidities:(HTN,renalfailure,CVA,CHF) Enlargedatrialchambers>6cm HighcalculatedSTSPROMscore Patientswiththesecharacteristicsshouldbeidentifiedashighriskandimplementingprophylactic measuresshouldbeconsidered. Exclusioncriteria Patientswithpre-existingatrialarrhythmiasarenotexcludedbutwillnotbeincludedintheoutcomes assessment. Patientsalreadyreceivingeitherorbothprotocolmedicationsshouldcontinuethemuntilthetimeof theoperation. 1. Exclusionguidelinesforstartingbetablockers a. Bradycardia<50, b. Pre-existing2ndor3rddegreeheartblock c. PoorlycontrolledCHF(NYHAclassIIIorIV)orsevereLVdysfunctionprohibiting usageofbetablocker d. Historyofasthma/obstructivelungdisease, e. Allergiestobetablockers 2. ExclusionguidelinesforstartingAmiodarone a. Bradycardia<50, b. Pre-existing2ndor3rddegreeheartblock, c. ProlongedQTc>480msecifQRS<120msecorQtc>530msecifQRS>120msec d. Untreated/unstablehypo/hyperthyroidism, e. Interstitiallungdisease/pulmonaryfibrosis, f. Allergiestoiodine/amiodarone g. Womenofchild-bearingage/pregnancy h. Livertransaminasestwicenormallimit PatientstakingotherAVnodalblockingagents,otherantihypertensivemedicationsareatriskfor developingheartblockorsymptomatichypotension.Aclinicaldecisionshouldbemadeaswhetheror nottostartthesepatientsontheprotocol. Althoughcoumadinwilltypicallybediscontinuedpriortosurgery,patientoncoumadinandamiodarone shouldhavetheircoumadindosedecreasedby50%. Pregnantorlactatingpatientsshouldnotreceiveamiodarone. AtrialFibrillationProphylaxisProtocol Themedical/surgicalteamwillidentifyapatientscheduledtoundergocardiacsurgeryandmakea clinicaldecisionastowhethertheprotocolshouldbeimplemented. Thepatientshouldbeinformedoftheprotocol,andconsentobtained. 1. Preoperativetesting a. Reviewofhistorytoidentifyallergiesorpre-existingarrhythmias b. PhysicalexaminationtoruleoutactiveCHF c. BaselineEKG d. Thyroidfunctionpanel e. Bedsidespirometry f. StandardbloodworkforsurgeryincludingcoagulationstudiesandLFTs TimingandDosage Anewprescriptionwillbegiventothepatientintheoutpatientsetting. Amiodarone 1. Preoperative:Maystartanytimepriortosurgery,howeverideally5dayspriorto operation. a. Dosage: i. Patientweight>70kg,400mgBID ii. Patientweight<70kg,200mgBID iii. IfunabletotakePOmedication,Amiodaronedrip(150mgIVbolusfollowed bydrip)canbeadministered,alternativelyAmiodaroneviaanNGT/OGTcan beconsidered 2. Intraoperative: a. Ifthepatientdidnothavetheopportunitytoreceiveaproperpreoperativedose, intraoperativeamiodarone150-300mgIVcanbegivenasabolusintheoperating room. b. Allpatientsontheprotocolshouldhavetemporaryventricularpacingwiresplaced orothermeansofreliablepacing. 3. Postoperative:ifstablehemodynamics(cardiacoutputandrhythm)medicationsshould continueuntilpostopday5 a. Dosage: i. Patientweight>70kg,continueAmiodarone400mgbiduntilPOD#5 ii. Patientweight<70kg,continueAmiodarone200mgbiduntilPOD#5 iii. IfunabletotakePOmedication,Amiodaronedrip(150mgIVbolusfollowed bydrip),alternativelyAmiodaroneviaanNGT/OGTcanbeconsidered 4. BeyondPOD#5andfollowingdischarge:ItisreasonabletocontinueAmiodaronebeyond theinitial5postoperativedaysatthesurgeon’sdiscretion 5. Ifcontinuedpost-discharge,Amiodaronetherapyshouldbestoppedonemonthpostsurgery. Betablockers 1. Preoperative:Maystartanytimepriortosurgery,howeverideally5dayspriorto operation a. Dosage: i. Ifalreadyonbetablocker,continuedoseuntiltimeofsurgery ii. Lopressor25mgbid(canreducedoseifborderlinebradycardicor hypotensive) iii. IfunabletotakePO,thenLopressor5mgIVq6hours 2. Intraoperative:norecommendations 3. Postoperative:ifthepatienthasstablehemodynamics(stablecardiacoutputandrhythm) a. Dosage: i. StartLopressor25mgPObid ii. IfunabletotakePO,thenLopressor5mgIVq6hours 4. BeyondPOD#5:ItisreasonabletocontinueLopressorbeyondtheinitial5postoperative daysatthesurgeon’sdiscretion.Alternatively,thepatient’soutpatientbetablockadecan besubstituted. 5. Ifthepatienthasacardiomyopathy,convertLopressortoToprol-XLorCoregpriorto discharge. 6. AvoidotherQTprolongingagentswhileonamiodarone. Outcomes: TheincidenceofnewonsetPOAFwillbetracked.ThedefinitionofPOAFwillbecongruentwithSTS guidelines. Potentialsideeffectsandcomplications Theshortdurationoftherapyfortheprotocol(10days)waschosentominimizepotentialsideeffects andcomplications. Intheliterature,useofamiodaronewasassociatedwithanincreasedincidenceofbradycardia, hypotension,andneedfortemporarypacing.Pulmonarytoxicityfromshorttermexposureto amiodaroneseemstobeextremelyrarebuthasbeenreported.Theincidenceofpermanentpacemaker implantationwasnotincreased. Theincidenceofintraoperativecomplicationsandmajoradverseoutcomesfollowingsurgerydonot appeartoincreasewiththisdosingregimen. Thereisnopublishedconsensusfromtheprofessionalsurgicalsocietiesinregardstoimplementingsuch aprotocol.(RecentguidelineswerepublishedbytheSTSforGeneralThoracicSurgery).Therefore, acceptanceandimplementationofthisandsimilarprotocolsisatbest,sporadicacrossthecountry. Withanyprophylactictreatment,avoidanceofmajoradverseoutcomesrelatedtotheregimenis imperative,asthiswoulddefeattheentirepurposeofthestrategy. Theclinicalteammustthereforeacceptthattherewillinevitablybeanincreaseincertainadverse events(bradycardia,hypotension,needfortemporarypacing),howeverthebenefitsthatwillultimately begainedbythepreventionofPOAFwilloutweighthesecomplications.Alongerhospitalstayis anticipatedundercertaincircumstancestoavoidpacemakerplacementintheeventofbradycardia thoughttoresultwiththeeliminationofAVNblockingagents. References: 1.PostoperativeAtrialFibrillationSignificantlyIncreasesMortality,HospitalReadmission,andHospital Costs.LaPar,DamienJ.etal.TheAnnalsofThoracicSurgery2014,Volume98,Issue2,527–533 2.RostagnoC,LaMeirM,GelsominoS,etal.Atrialfibrillationaftercardiacsurgery:incidence,risk factors,andeconomicburden.JCardiothoracVascAnesth2010;24:952–8. 3.SaxenaA,DinhDT,SmithJA,ShardeyGC,ReidCM,NewcombAE.Usefulnessofpostoperativeatrial fibrillationasanindependentpredictorforworseearlyandlateoutcomesafterisolatedcoronaryartery bypassgrafting(multicenterAustralianstudyof19,497patients).AmJCardiol2012;109:219–25. 4.MathewJP,FontesML,TudorIC,etal.Amulticenterriskindexforatrialfibrillationaftercardiac surgery.JAMA2004;291:1720–9. 5.ProphylacticAmiodaroneforPreventionofAtrialFibrillationAfterCardiacSurgery:AMetaAnalysisBagshaw,SeanM.etal.TheAnnalsofThoracicSurgery2006,Volume82,Issue5,1927–1937 6.PreoperativeAmiodaroneasProphylaxisagainstAtrialFibrillationafterHeartSurgeryDaoudEGetal., NEnglJMed1997;337:1785-1791