The purpose of this quality improvement initiative is to lower the incidence of complications among patients undergoing a CABG or valve repair/replacement surgery in VCSQI member heart centers. We hope to demonstrate that by lowering the incidence of post-operative atrial fibrillation, hospital costs and resources used will be contained while clinical processes are improved. We hope to improve clinical quality through sharing information and collaborating in the analysis of outcomes data.
VCSQI’s objective has been to design and implement a pre-surgical medication protocol that is statistically successful in reducing the incidence of new post operative atrial fibrillation in cardiac surgery patients. A copy of the prophylaxis protocol is located in Section 1. A sample patient information sheet in Section 2 and information on the cost of Amiodarone in Section 3.
SECTION 1. VCSQI ATRIAL FIBRILLATION PROPHYLAXIS PROTOCOL
Atrial fibrillation is a common post operative complication seen in the cardiac surgical patient population. When this complication occurs it can be associated with delayed surgical recovery of patients, longer length of stay, and higher hospital costs.
Objective: To design and implement a pre surgical medication protocol that is statistically successful in reducing the incidence of new post operative atrial fibrillation in cardiac surgery patients.
Participants: Prospective protocol implementation and clinical record review of Cardiac surgery patients from the members of the Virginia Cardiac Surgery Quality Initiative (VCSQI). The VCSQI group plans to implement the protocol January 3rd, 2005 and use supplemental data collection for this CQI study in conjunction with the standard STS national database collection tool.
One VCSQI member has a Protocol in place as standard of practice for more than 2 years. This site will act as the control for this CQI Study initiative.
II. Protocol Medications The two primary medications in this protocol will be Amiodarone and Lopressor.
- Exclusion Criteria for Amiodarone includes Patients with:
- Interstitial Lung Disease or Pulmonary Fibrosis
- Bradycardia with pulse < 55 bpm
- Untreated or uncontrolled Thyroid Disease
- With known Chronic Atrial Fibrillation
- With Allergy to Iodine or Amiodarone
- Exclusion Criteria for Lopressor includes patients with:
- Bradycardia with pulse < 55 bpm
- Active Congestive Heart Failure
- Bronchospasm or Asthmatic Pulmonary disease
- Already receiving Beta Blocker Therapy
III. Prevention Medications
- Start 400 mg. p.o. TID if weight > 70 Kg. or 200 mg p.o. TID if weight < 70 Kg. five days to 24 hours prior to cardiac surgery unless the patient meets one of the medication exclusion criteria above.
- All other patients should receive 400mg if weight > 70 Kg. or 200 mg. if weight < 200 mg. by mouth with sip water only, on the morning of surgery on the day of surgery.
- Patients with NO PRE OP loading dose should receive Amiodarone 1200 mg. PO on the day of surgery OR alternative intravenous dose as follows:
- Amiodarone 150 mg IV after coming off CPB then Amiodarone 900 mg in 500 cc D5W to infuse at 1 mg/min over 6 hours then 0.5 mg/min until empty.
- Post operatively, all patients should receive 200 mg TID via NGT or by mouth until discharge or post operative day 10, which ever comes first.
- If heart rate < 55 bpm, FIRST Hold Beta Blocker for 8 -24 hours before holding Amiodarone medication.
- Stop Verapamil before starting Amiodarone.
- Beta Blockade
- Start Lopressor 25 mg Q 12 hours five days to 24 hours prior to cardiac surgery for all patients that have normal LV function. unless patient meets one of the medication exclusion criteria above.
- Post operatively, give Lopressor 5 mg IV or 25mg PO via NGT Q 6 hours while patient intubated Administer the day of surgery only after hemodynamic stability attained post operatively.
- Do not hold beta blocker unless native heart rate is less than 55 bpm.
- Continue atrial pacing during the periop period if needed.
- After extubation, Lopressor 25 mg by mouth BID.
- On the day of discharge, patients should be switched to their preoperative beta blocker or Lopressor 25 mg. BID.
IV. Treatment of Breakthrough Post Operative Atrial Fibrillation
- Follow institution-specific protocols for post operative atrial fibrillation.
- Hold PO Amiodarone when receiving Amiodarone via IV infusion.
- Discharge medications as outlined by institution specific protocol.
- If Atrial Fibrillation > 24 hours start Coumadin. Do not start Heparin infusion. For patients in and out of atrial fibrillation for > 48 hours, discuss with surgeon.
- Patients, who remain in atrial fibrillation for 24 hours, consider increasing dose of Amiodarone, adding an additional agent, or DC cardioversion. Discuss DC cardioversion vs. anticoagulation and home management of atrial fibrillation.
V. Post Discharge Management of Atrial Fibrillation
- Maintain medication management of atrial fibrillation.
- Maintain beta blocker. Discuss with surgeon appropriate combination therapy.
- Continue Coumadin with target level of 2-2.5 INR. Identify physician to manage Anticoagulation and PT/INR levels.
VI. Clinic Follow-up
If still in atrial fibrillation at clinic visit, refer patient to a cardiologist.
VII. Amiodarone and Lipid Lowering Medication
- The data on administering both Amiodarone and some lipid lowering medication was clarified with pharmacy PhD. The incidence and risk of side effects is low in the short term dosage the protocol covers. The medication interaction concern relates to the following: May aggravate liver problems and development of leg cramps.