A 48-year-old man is evaluated in the surgical intensive care unit for tachycardia and hypotension. He underwent a hemicolectomy due to a perforated colonic diverticulum yesterday. The patient has a history of hyperlipidemia but no known history of heart disease. His current medications include piperacillin/tazobactam, famotidine, and benzodiazepines and opioids for sedation.
The patient is intubated and the ventilator is in the assist control mode. His temperature is 39.4 C (103 F) , blood pressure is 86/55 mm Hg, and pulse is 142/min. Oxygen saturation is 99% on 40% FiO₂.
Examination shows flat neck veins and tachycardia with an irregular rhythm. Breath sounds are heard bilaterally without wheezes or rhonchi. The abdomen is soft but diffusely tender and the incision is clean. The stoma is pink without any fluid output in the bag. The patient's extremities are warm with 2+ pulses and no peripheral edema. His urine output is 10 mL/hr.
Laboratory results are as follows:

ECG shows atrial fibrillation with rapid ventricular response. There are no significant ST-segment or T wave changes.
Which of the following would be the most appropriate next step in management of this patient?

Question

A 48-year-old man is evaluated in the surgical intensive care unit for tachycardia and hypotension. He underwent a hemicolectomy due to a perforated colonic diverticulum yesterday. The patient has a history of hyperlipidemia but no known history of heart disease. His current medications include piperacillin/tazobactam, famotidine, and benzodiazepines and opioids for sedation.
The patient is intubated and the ventilator is in the assist control mode. His temperature is 39.4 C (103 F) , blood pressure is 86/55 mm Hg, and pulse is 142/min. Oxygen saturation is 99% on 40% FiO₂.
Examination shows flat neck veins and tachycardia with an irregular rhythm. Breath sounds are heard bilaterally without wheezes or rhonchi. The abdomen is soft but diffusely tender and the incision is clean. The stoma is pink without any fluid output in the bag. The patient's extremities are warm with 2+ pulses and no peripheral edema. His urine output is 10 mL/hr.
Laboratory results are as follows:

ECG shows atrial fibrillation with rapid ventricular response. There are no significant ST-segment or T wave changes.
Which of the following would be the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_96b8_22bd_853d_3fae61179b59_MD0002_00 Patients who present with new-onset atrial fibrillation (AF) (especially with rapid ventricular response) should always be evaluated for an underlying cause or trigger. This patient with AF has fever, hypotension, flat neck veins, warm (vasodilated) extremities, leukocytosis, and low urine output. His hypotension and AF are likely due to sepsis after recent diverticular perforation and hemicolectomy. A bolus of IV fluids would be the best initial strategy to increase blood pressure, decrease the heart rate, and improve organ perfusion. Treating sepsis may restore sinus rhythm; if this fails, a survey for the causes listed in the table should be considered in addition to rate control. (Choice A) Hemodynamically unstable arrhythmias (eg, associated with imminent cardiac arrest) are treated with electric cardioversion. However, this patient's AF, rather than being the primary hemodynamic disturbance, is due to underlying sepsis; and his low blood pressure still allows for IV fluid administration to treat the sepsis. Cardioversion without addressing the underlying cause is unlikely to improve blood pressure, and the AF will almost certainly return. (Choice B) IV digoxin is indicated for rate control in patients with heart failure, but it is not a potent atrioventricular-blocking drug and has a very narrow therapeutic window. However, this patient does not need acute rate control as hypotension is likely the cause of his tachycardia. (Choice C) IV metoprolol would not be indicated for rate control as the patient is hypotensive and tachycardic from sepsis. Tachycardia is a normal compensation for hypotension, even if the patient is in sinus rhythm. (Choice E) The patient has several signs of shock, including hypotension and low urine output. Norepinephrine is usually reserved for patients in whom initial IV fluid boluses fail to maintain organ perfusion. Educational objective: Patients with new-onset atrial fibrillation (especially with rapid ventricular response) should always be evaluated for an underlying cause or trigger (eg, sepsis, hypoxia, congestive heart failure, poorly controlled hypertension, hyperthyroidism, valvular heart disease). Treating the underlying cause may restore sinus rhythm and avert the need for cardioversion. __________ References: Incidence and prognostic impact of new-onset atrial fibrillation in patients with septic shock: a prospective observational study. (http://www.ncbi.nlm.nih.gov/pubmed/20537138)

A 48-Year-Old Man Is Evaluated in the Surgical Intensive Care