Most available data on atrial fibrillation pertains to chronic outpatient management or atrial fibrillation following cardiac surgery. This data may not apply perfectly to most critically ill patients. Extrapolation of available data to the management of critically ill patient is challenging, with much left to clinical judgement.
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Josh is the creator of PulmCrit.org. He is an associate professor of Pulmonary and Critical Care Medicine at the University of Vermont.
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Hi Josh,
This is such a great addition, and very welcome.
My question relates to the utility of verapamil as the UK has no IV diltiazem.
I’ve only used it in the haemodynamically robust, well, ED-based patient. Have you used it in lieu of diltiazem in the critically ill?
I would be interested in other readers experience of this drug and its use in this population – I tend to pre-treat with calcium to ameliorate any haemodynamic perturbations from this medication.
This is such an intresting articles to read,
am really impressed
Lets say you think DC cardioversion is indicated. What voltage would you recommend (say their old vs young etc) and what do you usually pre-sedate them with if they’re awake? Thanks
Great article, but wanted to mention verapamil – my go to drug for tachycardia. I don’t have diltiazem maybe that’s better since diltiazem is less cardiac specific and is a vasodilator. That might explain hyptoension seen in studies. Verapamil is mostly cardiac specific and rarely decreases BP (you can try to prevent that by pretreating with some calcium). In my experience verapamil reduces heart rate faster and more potently than metoprolol. Often have given metoprolol 15mg i/v without any major effect, but verapamil usually works after 5mg (with flutter I often need 5-10mg to reduce AV conduction to 3:1). Would… Read more »
Question abour re-bolusing amio: when do you consider the initial amio bolus of 150mg followed by the 1mg/min infusion to have failed before re-bolusing? Is the time different when you’re targeting rate control vs rhythm control?
I just wanted to point out a discrepancy in the algorithm for esmolol that might need to be corrected?
I wanted to clarify on the dosing/timing of magnesium administration for atrial fibrillation with RVR. For the 2-4g of Mag, how fast are you pushing the dose? Is this given over 15, 30 mins, or an hour?
20 mins for me. 30 mins is what they used in the Bouida study