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Atriumfibrilleren na cardiothoracale operatie

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Ward management of patients developing AF

Beoordeeld: 26-11-2010

Uitgangsvraag

Ward management of patients developing AF.

Aanbeveling

1. All patients in AF should have a 12-lead electrocardiogram performed to confirm the diagnosis and differentiate AF from atrial flutter. ECG monitoring or recording (continuous or at intervals) should be performed to identify changes in ventricular rate and reversion to sinus rhythm.
2. All stable patients going into AF should undergo venesection within 6 h to establish their haemoglobin, white cell count, serum sodium, potassium, urea and creatinine levels. Any reversible abnormalities should be corrected and serum potassium should be tested daily and maintained above 4.5 mmol/l.
3. All patients going into AF should have their oxygenation assessed, and saturations should be maintained above 95%.
4. All patients going into AF should have their fluid balance status assessed. Hypovolaemia or fluid overload should be corrected.
5. All patients in post-operative AF should have daily serum electrolyte tests in order to minimise electrical excitability.


(Grade E recommendations based on expert consensus)

Onderbouwing

Competent ward management of patients who go into AF is as important for the optimal care of these patients as their pharmacological management. Prompt identification of reversible factors that may contribute to continued AF and also prompt identification of the complications of this condition and its treatment will reduce the morbidity and prolonged hospital stay associated with this condition. However, it is often difficult to quantify the benefits of competent ward management and even more difficult to present these strategies as a publication and the statements below represent the views of our expert panel as to what may constitute optimal care.

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Autorisatiedatum en geldigheid

Laatst beoordeeld  : 26-11-2010

Laatst geautoriseerd  : 26-11-2010

Geplande herbeoordeling  : 01-11-2015

Revisiedatum uiterlijk november 2015

Initiatief en autorisatie

Initiatief:
  • Nederlandse Vereniging voor Thoraxchirurgie
Geautoriseerd door:
  • Nederlandse Vereniging voor Thoraxchirurgie

Algemene gegevens

Deze richtlijn is mede gebaseerd op de EACTS-guidelines on the prevention and management of de novo atrial fibrillation after cardiac and thoracic surgery.

 

Notitie specifiek met betrekking op de Nederlandse situatie:
Lees ipv Warfarine: Coumarine-derivaten
Deze notitie vormt een integraal onderdeel van de Engelstalige tekst van de hierbij behorende richtlijn.

Doel en doelgroep

This guideline covers the prophylaxis and treatment of de novo AF in adults undergoing cardiac and thoracic surgery. It includes recommendations for intra-operative strategies to
minimise the incidence of AF, the pharmacological treatment of AF and recommendations for anticoagulation of these patients. In addition, monitoring and ward management
of these patients are also addressed. It excludes recommendations for the surgical management of patients coming to surgery with chronic AF, and recommendations for
patients in chronic AF not undergoing cardiothoracic surgery.

Samenstelling werkgroep

  • Joel Dunning (James Cook University Hospital, Middlesbrough, UK)
  • Tom Treasure (Guy’s Hospital, London, UK)
  • Michael Versteegh (Leiden University Medical Center, The Netherlands)
  • Samer A.M. Nashef (Papworth Hospital, Cambridge, UK)

on behalf of the EACTS Audit and Guidelines Committee

 

Acknowledgements

The EACTS Audit andGuidelineCommittee is grateful to thefollowing authors for assisting with the literature reviewprocess by publishing Best Evidence Topics for the ICVTS:

Muneer Amanullah, Ali Behranwala, Phil Botha, Mohammed Hanif, Noman Khasati, Graham Morritt, Darbhamulla Nagarajan, Mohammed Nouraei, Brian Nyawo, Savvas Omorphos, Anish Patel, Brian Prendergast, Shahzad Raja, Jagan Rao, Andrew Ronald, Anthony Rostron, Aliu Sanni, Vivek Shrivastava.

Methode ontwikkeling

Evidence based

Werkwijze

This guideline comprises several novel aspects in the methodology employed in the derivation of this document. Many guidelines are based on a single systematic review and
multiple clinical questions are then answered on the basis of the papers found from this one review. In contrast, we felt that it was important to perform a full literature review for
every single question addressed in order to maximise the robustness of the guideline. We used a structured systematic review protocol named ‘Best Evidence Topics’ to construct each review, where the search strategy, results of the search and a full appraisal of all papers are published in a structured format. The details of this protocol are described in the Interactive Cardiovascular and Thoracic Surgery (ICVTS) [5]. Guidelines often fall short of expectations due to a failure to consult those clinicians who are most likely to
use them. For this guideline, every literature review has already been published in full in the ICVTS. Every topic was published online and clinicians were able to post comments
on the topic over a 2-month period. These comments were then published together with the full paper in the ICVTS and are now available to all readers in full text online at www.icvts.org.

 

These guidelines assess individual studies according to recommendations developed and refined over time [5] and previously used in the specialty [6]. Briefly, level 1 papers are
randomised controlled trials, level 2 papers are cohort studies, level 3 papers are case-controlled studies or small cohort studies and level 4 studies are experimental papers.
The ‘b’ suffix implies that the study is an original article at this level and the ‘a’ suffix implies that the paper is a systematic review or meta-analysis of papers at that level (further details are available from the website of the Oxford Centre for Evidence based Medicine: http://www.cebm.net/levels_of_evidence.asp 2001).
Systematic literature review was up to the end of 2005. Once recommendations are made, they are graded according to the quality of papers used to come to our conclusion:

  • Grade A evidence: based on multiple level 1a or level 1b papers
  • Grade B evidence: based on multiple level 2a/2b papers or individual level 1a/1b papers
  • Grade C evidence: based on multiple level 3a/3b papers or individual level 2a/2b papers
  • Grade D evidence: based on individual level 3a/3b papers or level 4 papers
  • Grade E evidence: based on expert consensus in the absence of acceptable papers