Critical Care Mailbag – Unstable Atrial Fibrillation

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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Robert M. H. -

What about a patient with chronic pul HTN and rapid AFib ? Do they need rapid rate control?
Does lowering heart rate in critically ill AFib with both chronic and acute pul HTN always have high risk of circulatory collapse?
Phenylephrine and epi would be bad in patient with chronic Pul HTN?
Great discussion

Anand S. -

From Weingart:
We are in the realm of pure opinion now, but I would play it as >150 they need to be slowed down.
I would be speaking with our cardiologists as to how
b/c anything you do will f*ck with these folks
phenyl is sh*tty
epi is great
would have all of these people on vasopressin if they are borderline hypotensive
so shock if super unstable
call for help if not


If it wasn't for this episode I'm not sure if I would have managed things as smoothly as I did this evening. I had never used the slow cardizem infusion and tonight I had a pt in the ICU with EF < 20% and all the usual comorbidities and high risk features discussed in the episode. After 9 minutes of the infusion, with a little buffer from low dose phenylephrine, his rate came down in controlled fashion and once he was at the desired rate he was started on the standard titration parameters starting at 2.5 mg/hr and the phenylephrine was able to be titrate down and nearly off. One thing I will mention is that our pharmacist had a hard time grasping what I was trying to do as the standard infusion rate is 2.5 mg/hr rather than per minute. Additionally, the max default rate for cardizem programed into the pumps is 30 mg/hr (not sure if that is standard everywhere) so the infusion had to be entered under an alternative agent in order to infuse at the desired 2 mg/min (2 ml/min). Nonetheless, this method worked perfectly without any further compromise in hemodynamics, not to mention the staff thought it was the craftiest management for unstable AF they had ever seen.
Thanks again.

chris r. -

Articles regarding medication dosage adjustments in obese patients state that diltiazem should be dosed based on Total Body Weight due to lipophilicity, Do you adjust your Diltizaem doses for obese patients? Do you give the same dose for a 70kg patient as you would give to a patient weight 150kg? 200kg?

Tiffany W. -

Just for clarification, the example of the hypoTN pt w/ 40/20 in A-fib, wouldn't you sync cardiovert vs defib assuming most are narrow complex A-fib?

Noel N. -

A question re: the 3 choices of rate control agents in the context of lone afib (at 14:55 in the podcast), shouldn't we avoid the esmolol if we are using phenylephrine vasopressor? Isn't there increased risk of coronary vasoconstriction from unopposed alpha activity?

Robert A. -

Can you give a citation for the MAGIC study that you cite for magnesium for chronic a-fib? I don't see that they used Magnesium in the MAGIC-AF study (Singh SM, d'Avila A, Kim YH, et al. The modified stepwise ablation guided by low-dose ibutilide in chronic atrial fibrillation trial (The MAGIC-AF Study). Eur Heart J. 2016;37(20):1614-1621. doi:10.1093/eurheartj/ehw003)

Anand S. -

I'll let Scott chime in but this article compares Mg to amiodarone in critically ill

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