Raigmore Critical Care Guidelines Atrial Fibrillation in Critical

Raigmore Critical Care Guidelines Atrial Fibrillation in Critical Care Aim To provide guidance on initial management of atrial fibrillation in critical care Scope All adult patients in Critical Care with suspected atrial fibrillation Suspected Atrial Fibrillation (AF) in Critical Care Atrial fibrillation is probably the most common arrhythmia to occur in ICU patients. It is usually related to the global inflammatory response, and therefore should not be thought of as an isolated clinical phenomenon. As such, treatment is primarily supportive. It is not usual practice to anticoagulate patients with AF on ICU. Is the AF New? No Yes New AF • Ensure AF is not a response to hypovolaemia, and consider giving a 500 ml fluid bolus (crystalloid) • Check serum potassium, and replace intravenously if value is < 4. 5 mmol/l • Check serum magnesium, and replace intravenously if value is <1 mmol/l • Perform a CXR to ensure that a central line, if present, is not too long and irritating the myocardium. • If the patient is receiving dobutamine/adrenaline, consider reducing the dose or stopping it. Longstanding AF • Cardioversion to sinus rhythm is likely to be impossible, and therefore rate control is primary target. • If patient is hypotensive with fast AF, give 500 mls crystalloid and reassess. If remains hypotensive, not thought to be related to hypovolaemia, use digoxin 500 mcg iv as rate control. • If patient is normotensive with fast AF, aim to rate control with a beta blocker (Bisoprolol 2. 5 mg enterally, or metoprolol 5 -10 mg iv slow bolus) • If patient remains in AF, give amiodarone 300 mg iv over 1 hour, followed by 900 mg (in 5% dextrose) infused over 23 hours. Cardioversion Electrical cardioversion for AF should be reserved for a peri-arrest situation only. In this case, an initial shock (biphasic) of 120 -150 J, escalating as necessary, is appropriate Adapted from Royal Devon and Exeter– M Mac. Kinnon 22. 11. 2016