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Post Esophagectomy ATRIAL FIBRILLATION PROPHYLAXIS

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.

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Post Esophagectomy ATRIAL FIBRILLATION PROPHYLAXIS

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  1. Post Esophagectomy ATRIAL FIBRILLATION PROPHYLAXIS

  2. 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

  3. 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 mass • G&E upon return - squamous cell Ca by biopsy • PMH: hypertension, hypothyroid, alcohol abuse

  4. Mrs. CW • Allergies: none • Intolerance: none • Surgeries: none • Social History • Non-smoker • Admits to past alcohol abuse • Currently 4-5 per week

  5. Medications PTA

  6. Current Medications

  7. Current Medications

  8. Review of systems • Vitals • MAP 87, HR 75 NSR, Resp 20, T 37.5, O2 Sat 96% RA • Unremarkable • Psych, EENT, Resp, CVS, GI, GU, MSK, Skin, Endocrine, Fluids, ID

  9. 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

  10. 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

  11. Primary Goals of Therapy • Health Care Team • Post operative recovery/rehabilitation • Reduce morbidity associated with atrial fibrillation • Minimize medication adverse effects • Patient • Pain management • Discharge home

  12. Guideline - A Fib Associated with General Thoracic Surgery Ann Thorac Surg 92(3):1144–52

  13. PICO • Patient: post-esophagectomy • Intervention: anti-arrhythmics • Comparator: placebo • Outcome: prevention of atrial fibrillation

  14. Literature Search • Search terms • Esophagectomy, atrial fibrillation • Databases • Medline, IPA, CDSR, ACP Journal Club • Limits • Humans, English • Results • 1 review - 3 RCTs

  15. A Fib Post Esophagectomy • 13 - 46% occurrence post surgery • Most common POD 2-3 • Risk factors • Postop hypoxia • Male • Age > 65 • COPD • Heart disease • Gastric conduit dilitation

  16. Etiology • Better understood with pulmonary resection • Inflammation • Increased heart pressure • Increased risk with larger resections • Unknown with esophagectomy • Higher incidence with larger resections

  17. Impact of AFib • Hemodynamic instability • Increased pulmonary complications • Increased length of hospitalization by 5 days • Increased mortality

  18. 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.

  19. Methods

  20. Results • Less treated arrhythmias with propranolol 6% vs 20% • ARR = 14% (CI 0.6%-27.2%) p=0.071 NS • Any arrhythmia higher in propranolol • 72% vs 62% • Adverse effects • Hypotension 49% vs 26% p=0.003 • Bradycardia 25% vs 4% p=0.018 • NS difference - bronchospam, pulmonary edema, MI • 3 deaths – 2 in active one in placebo

  21. Esophagectomy Subgroup • N=31 Chi2=1.94 p=0.1621 NS • Included AFib, VTach, SVT

  22. Limitations • small numbers - underpowered • Population of interest subgroup • Mixture of arrhythmias prevalent • Vague definition of treated arrhythmia

  23. 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.

  24. Methods

  25. Results • More arrythmia in malignant p=0.002 • Less arrythmia in placebo p=0.29 NS • 76% of arrhythmias within 6 hr post-op

  26. 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

  27. 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.

  28. Methods

  29. 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=0.31 • ICU 68 vs 77 hours p=0.097 • Adverse effects • NS difference – hypotension, bradycardia, QTc>500 ms, ARDS, pneumonia, atelectasis • 2 deaths – placebo – MI, toxic megacolon • NS difference in cost of hospitalization

  30. Limitations • small numbers – unblinded • Single centre • Decision to treat subject to bias • Reflects clinically important AF • Underpowered for secondary outcomes

  31. Recommendation • Instituting routine prophylaxis is not recommended • amiodarone • Reduces AFib, but lacks measurable impact in morbidity/mortality and length of stay • Only trend to shorten stay in ICU • Digoxin – no benefit • β-blockers – support continuation if taking prior to surgery

  32. Questions

  33. References • 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. • 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. • 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. • 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. • 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.

  34. 3 hole esophagectomy

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