Post esophagectomy diaphragmatic hernia: a case report of ...
Post Esophagectomy ATRIAL FIBRILLATION PROPHYLAXIS
description
Transcript of Post Esophagectomy ATRIAL FIBRILLATION PROPHYLAXIS
Objectives Gain an appreciation and understanding
of incidence and impact of atrial fibrillation in post-esophagectomy patients
Review the evidence supporting selection of a prophylactic medication
Mrs. CW 48 yo female admitted to ICU 24 May ID ht: 165 cm wt: 61 kg BMI: 22.4 CC: post surgical – 3 hole esophagectomy HPI: Nausea and hemoptysis while
vacationing in Costa Rica – Hosp admit upper GI Bleed with massG&E upon return - squamous cell Ca by biopsy
PMH: hypertension, hypothyroid, alcohol abuse
Mrs. CW Allergies: none Intolerance: none Surgeries: none Social History
Non-smokerAdmits to past alcohol abuse
○ Currently 4-5 per week
Medications PTACondition Medication
Bronchitis ciprofloxacin 250 mg bid x 5 days (28/4)
Hypertension ramipril 5 mg daily
Esophageal Ca pantoprazole 40 mg dailymorphine syrup 20 mg TID
Hypothyroid levothyroxine 100mcg daily
Current MedicationsCondition Medication
Alcohol abuse thiamine 100 mg IV daily x3d (2nd today)folate 5 mg IV dailymultivitamin IV daily
Hypertension ramipril 5 mg daily
Post esophagectomy
pantoprazole 40 mg daily
Constipation Docusate 200 mg BIDBowel protocol
Current MedicationsCondition Medication
Hypothyroid levothyroxine 75 mcg daily
DVT Prophylaxis heparin 5000 U subcut daily
Hypokalemia prevention
potassium chloride 20 MEq/L IV x 3 days (2nd today)
Pain Hydromorphone/bupivacaine epidural PCACelecoxib 200 mg NJ BID x2dAcetaminophen 1000 mg NJ QID
Review of systems Vitals
MAP 87, HR 75 NSR, Resp 20, T 37.5, O2 Sat 96% RA
UnremarkablePsych, EENT, Resp, CVS, GI, GU, MSK,
Skin, Endocrine, Fluids, ID
Labs 24 May WBC 9.3 Hg 86 (110 preop) MCV 97
Plt 120 Na 140, K 4.6 Cl 108 BUN 5.4 Scr 66, eGFR 83 Alb 28 Ca 2.07 Mg 0.83 PO4 1.21 Bili 11 AST 53 ALT 28 ALP 34 GGT 28
DRPs Patient is at risk DVT secondary to sub-
therapeutic dose of anti-coagulation Patient is at risk of atrial fibrillation
secondary to lack of prophylactic therapy Patient is receiving potassium
supplementation with no clear indication Patient is at risk of hypothyroid due to
reduced dose of levothyroxine in hospital Patient is at risk of alcohol withdrawal
Primary Goals of Therapy Health Care Team
Post operative recovery/rehabilitationReduce morbidity associated with atrial
fibrillationMinimize medication adverse effects
PatientPain managementDischarge home
Guideline - A Fib Associated with General Thoracic SurgeryLobectomy Pneumonectomy Esophagectomy
Should continue β-blockers if taking prior to surgeryreduce dose by half if epidural (IB)
Diltiazem reasonable- not taking β-blockers pre-op (IIaB)
Amiodarone (IIaB) Amiodarone (IIaB)
Initiate β-blockers (IIbB)
Magnesium supplementation as augmentation (IIaB)
Ann Thorac Surg 92(3):1144–52
PICO Patient: post-esophagectomy
Intervention: anti-arrhythmics
Comparator: placebo
Outcome: prevention of atrial fibrillation
Literature Search Search terms
Esophagectomy, atrial fibrillation Databases
Medline, IPA, CDSR, ACP Journal Club Limits
Humans, English Results
1 review - 3 RCTs
A Fib Post Esophagectomy 13 - 46% occurrence post surgery Most common POD 2-3 Risk factors
Postop hypoxiaMaleAge > 65COPDHeart diseaseGastric conduit dilitation
Etiology Better understood with pulmonary
resectionInflammationIncreased heart pressureIncreased risk with larger resections
Unknown with esophagectomyHigher incidence with larger resections
Impact of AFib Hemodynamic instability Increased pulmonary complications Increased length of hospitalization by 5
days Increased mortality
Bayliff C, Massel D, Inculet R. Propranolol for the prevention of postoperative arrhythmias in general thoracic surgery. The Annals of thoracic surgery.[Internet]. 1999 [cited 2012 Jun 20];67:182–6.
MethodsD Double blind RCT in adultsP N=99 Major thoracic surgery – esophagectomy,
lobectomy, pneumonectomy, - no previous A FibI Propranolol 10 mp PO Q6H starting preop to POD 5C PlaceboO 1. Arrhythmias (AFib, A Flutter, SVT, VTach, VFib by
Holter2. Adverse events – hypotension, CHF,
bronchospasm3. Duration of hospital stay
T Surgery until discharge
Results Less treated arrhythmias with propranolol 6%
vs 20%ARR = 14% (CI 0.6%-27.2%) p=0.071 NS
Any arrhythmia higher in propranolol72% vs 62%
Adverse effectsHypotension 49% vs 26% p=0.003Bradycardia 25% vs 4% p=0.018NS difference - bronchospam, pulmonary edema, MI3 deaths – 2 in active one in placebo
Esophagectomy Subgroup
N=31 Chi2=1.94 p=0.1621 NS Included AFib, VTach, SVT
Arrhythmia No arrhythmia
Propranolol 0 17Placebo 3 11
Limitations small numbers - underpowered Population of interest subgroup Mixture of arrhythmias prevalent Vague definition of treated arrhythmia
Ritchie AJ, Tolan M, Whiteside M, McGuigan J a., Gibbons JRP. Prophylactic digitalization fails to control dysrhythmia in thoracic esophageal operations. The Annals of Thoracic Surgery [Internet]. 1993 Jan [cited 2012 Jun 19];55(1):86–8.
MethodsD Open RCT in adultsP N=80 elective thoracic esophageal operations,
benign and malignant, no previous AFibI Digoxin 0.5 mg BID - 1800 and 2200 1 day preop,
then 0.25 mg daily starting with premeds to POD 9 guided by levels target 1-2 mcg/L
C No digoxinO Arrhythmias by ECGT Surgery until discharge
Results
More arrythmia in malignant p=0.002 Less arrythmia in placebo p=0.29 NS 76% of arrhythmias within 6 hr post-op
Limitations Unblinded, small numbers No power calculation No detail of digoxin TTR Subgroups analysis not pre-defined Lacked description of procedure Lacked details of arrythmia observed
Tisdale JE, Wroblewski H a, Wall DS, Rieger KM, Hammoud ZT, Young JV, et al. A randomized, controlled study of amiodarone for prevention of atrial fibrillation after transthoracic esophagectomy. The Journal of thoracic and cardiovascular surgery [Internet]. 2010 Jul [cited 2012 Jun 19];140(1):45–51.
MethodsD Open RCT in adultsP N=80 trans-thoracic esophagectomy (open and min
invasive)no previous A Fib or A Flutter, majority for esophageal Ca
I Amiodarone infusion 43.75 mg/h at anesthesia to POD 4 (96 hrs)
C No amiodaroneO 1. Atrial fibrillation by continuous ECG
2. Duration of hospital stay3. Duration of ICU stay4. Adverse events – hypotension, bradycardia, respiratory
complications5. Cost of hospitalization
T Surgery until discharge
Results Less AFib with amiodarone15% vs 40%
ARR = 25% (CI 18.8%-43.8%) p=0.02 NNT 4 NS difference in length of stay
Hospital 11 vs 12 days p=0.31ICU 68 vs 77 hours p=0.097
Adverse effectsNS difference – hypotension, bradycardia, QTc>500
ms, ARDS, pneumonia, atelectasis2 deaths – placebo – MI, toxic megacolon
NS difference in cost of hospitalization
Limitations small numbers – unblinded Single centre Decision to treat subject to bias
Reflects clinically important AF Underpowered for secondary outcomes
Recommendation Instituting routine prophylaxis is not
recommendedamiodarone
○ Reduces AFib, but lacks measurable impact in morbidity/mortality and length of stay
○ Only trend to shorten stay in ICUDigoxin – no benefit
β-blockers – support continuation if taking prior to surgery
Questions
References1. Fernando HC, Jaklitsch MT, Walsh GL, Tisdale JE, Bridges CD, Mitchell JD, et
al. The Society of Thoracic Surgeons practice guideline on the prophylaxis and management of atrial fibrillation associated with general thoracic surgery: executive summary. The Annals of thoracic surgery [Internet]. 2011 Sep [cited 2012 Jun 19];92(3):1144–52.
2. Tisdale JE, Wroblewski H a, Kesler K a. Prophylaxis of atrial fibrillation after noncardiac thoracic surgery. Seminars in thoracic and cardiovascular surgery [Internet]. 2010 Jan [cited 2012 Jun 19];22(4):310–20.
3. Bayliff C, Massel D, Inculet R. Propranolol for the prevention of postoperative arrhythmias in general thoracic surgery. The Annals of thoracic surgery [Internet]. 1999 [cited 2012 Jun 20];67:182–6.
4. Ritchie AJ, Tolan M, Whiteside M, McGuigan J a., Gibbons JRP. Prophylactic digitalization fails to control dysrhythmia in thoracic esophageal operations. The Annals of Thoracic Surgery [Internet]. 1993 Jan [cited 2012 Jun 19];55(1):86–8.
5. Tisdale JE, Wroblewski H a, Wall DS, Rieger KM, Hammoud ZT, Young JV, et al. A randomized, controlled study of amiodarone for prevention of atrial fibrillation after transthoracic esophagectomy. The Journal of thoracic and cardiovascular surgery [Internet]. 2010 Jul [cited 2012 Jun 19];140(1):45–51.
3 hole esophagectomy