HEALTHCARE SIME DARBY NURSING AND HEALTH SCIENCES COLLEGE

SUBJECT NAME

: CRITICAL CARE NURSING OF CARDIOVASCULAR DISORDERS

SUBJECT NUMBER TUTOR'S NAME NAME

: CCCD 6112

: MS SUNITA : AIBENA LING NGIIK FENG (CCC/0028/11) DHANA JOTHI JUDY TAN LYE CHEN ROSHAKILA BTE WASLI (CCC/0029/11) (CCC/0030/11) (CCC/0039/11)

DUE DATE

: 08 FEBUARY 2012

CONTENT No. 1. 2. 3. 4. 5. 6. Subject Content Introduction Biodata Old note Current note Immediate treatment Diagnostic method Medication Amiodarone Flecanide Lasix Tazosin Dopamin Simvastatin Flumucil Symbicort Tubehalar Neb Duolin Controloc Cardipin Finastride Dyazide Celebrex Herbesser Fentanyl Propofol NaCl Voluven Prevention Prognosis Critique Conclusion References Page

7. 8. 9. 10. 11.

INTRODUCTION Atrial fibrillation describes an irregular and often rapid heart rhythm. The irregular rhythm, or arrhythmia, results from abnormal electrical impulses in the heart. The irregularity can be continuous, or it can come and go. In atrial fibrillation, multiple impulses travel through the atria at the same time.

Instead of a coordinated contraction, the atrial contractions are irregular, disorganized, chaotic, and very rapid. The atria may contract at a rate of 400-600 per minute.

These irregular impulses reach the AV node in rapid succession, but not all of them make it past the AV node. Therefore, the ventricles beat slower, often at rates of 110-180 beats per minute in an irregular rhythm.

The resulting rapid, irregular heartbeat causes an irregular pulse and sometimes a sensation of fluttering in the chest.

Atrial fibrillation can occur in several different patterns. Intermittent (paroxysmal): The heart develops atrial fibrillation and typically converts back again spontaneously to normal (sinus) rhythm. The episodes may last anywhere from seconds to days. Episodes of AF that terminate spontaneously within 7 days (most episodes last less than 24 hours) Persistent: Atrial fibrillation occurs in episodes, but the arrhythmia does not convert back to sinus rhythm spontaneously. Medical treatment is required to end the episode. Episodes of AF that last more than 7 days and may require either pharmacologic or electrical intervention to terminate Permanent: The heart is always in atrial fibrillation. Conversion back to sinus rhythm either is not possible or is deemed not appropriate for medical reasons. AF that has persisted for more than 1 year, either because cardioversion has failed or because cardioversion has not been attempted. Risk factors: Hemodynamic stress Atrial ischemia Inflammation Noncardiovascular respiratory causes 3

 Alcohol and drug use Endocrine disorders Neurologic disorders Genetic factors Advancing age Symptoms: A number of people have no symptoms. The most common symptom in people with intermittent atrial fibrillation is palpitations a sensation of rapid or irregular heartbeat. This may make some people very anxious. Many people also describe an irregular fluttering sensation in their chests. Some become light-headed or faint. Other symptoms include weakness, lack of energy or shortness of breath with effort, and chest pain. Treatment:

Control rate: The first treatment goal is to slow down the ventricular rate Restore and maintain normal rhythm: About half the people with newly diagnosed atrial fibrillation will convert to normal rhythm spontaneously in 24-48 hours . Prevent stroke: Stroke is a devastating complication of atrial fibrillation. It occurs when a piece of a blood clot formed in the heart breaks off and travels to the brain, where it blocks blood flow.

Defibrillation (cardioversion): This technique uses electrical current to "shock" the heart back to normal sinus rhythm. This is sometimes called DC cardioversion. Pacemaker : A pacemaker is an electronic device that prevents slow heartbeats, and may reduce the likelihood of atrial fibrillation in a small number of patients. The takes the place of the "natural pacemaker," the SA node, supplying electrical impulses to keep the heart beating in a normal rhythm when the SA node no longer

BIODATA Name Age/Sex Race Nationality : Mr. Onikandan Nair : 79 years old / Male : Indian : Malaysian : On 31/01/2011 lung fibrosis : On 06/06/2011 Hypertension, pulmonary fibrosis, respiratory arrest, rheumatoid arthritis, pneumonia, both eye cataract, done : On 13/07/2011 NSAID indural acute renal insufficiency : On 31/12/2011 Respiratory failure secondary to pulmonary fibrosis, chronic rheumatoid arthritis Past Surgical History : In 1990 Right total knee replacement : In 1995 Left total knee replacement : In 2000 Colonoscopy : In 2002 Arthroscopy right knee and open dislodg debridment Social History Allergies : Is smoker and drunker for many years. : Ponstan Induced acute renal insufficiency

Past Medical History

Past Family History : Unknown, no siblings

Confirm diagnosis : On 13/01/2012 Atrial fibrillation : On 14/01/2012 Cardiac arrest : On 16/01/2012 Acute pulmonary injury From the old note, 31/12/2011 The patient had admitted in High Dependency Unit (HDU) with the complaint of sweating ++, shortness of breath and atrial fibrillation that shown in the electrocardiogram (ECG). Chest x-ray (CXR) done. CXR 5

There is extensive dense reticulation of both lungs obscuring the heart borders. No obvious pleural effusion seen. No rib lesion seen. Extensive lung fibroids,however no significant reduction in the lung volume.

Impression

The SPO2 of the patient started to drop to 80% - 85% room air, oxygen was commenced on 15liter/min via high flow mask. Patient blood pressure also drop to 40/20mmHg and cardio-respiratory arrest. After active resuscitation done in the HDU, patient was transfer to Neonatal Intensive Care Unit (NICU). Patient was ventilated by BiPAP support. Continuous bladder drainage, nasogastric tube (NGT) and femoral line was inserted. Active fluid resuscitation was done. The patient blood pressure became normal but ECG still showing atrial fibrillation. 01/01/2012 Post intubation CXR done CXR There is extensive reticulation of both lungs The tip of ETT is 4cm above the carina. The heard and mediastinal borders are obscured by the opacities. No rib lesion seen.

02/01/2012 NGT feeding 500mls per day was started. Intravenous drip was off. The tracheal aspiration that done on 31/12/2011 result shows pseudomonas. 03/01/2012 Urine output 30-50mls/day noted and intravenous lasix 20mg given. Arterial blood gases (ABG) was done. (Refer to table 1) 04/01/2012 Renal II was done and Potassium show 2.1mmol/L. Mist KCL 15mls BD is ordered. ABG was done. (Refer table 1) 05/01/2012 Intake output chart show balance +700mls noted and intravenous lasix 20mg 6

given. ABG was done (Refer table 1) 06/01/2012 Patient was more alert. Patient was extubated and started on oxygen 4 liter/min via nasal prong. NGT was removed and allowed orally. ABG was done. (Refer table 1) 07/01/2012 CBD was off and patient was start on daily chest physio. 08/01/2012 No changes continue the same management. 09/01/2012 Patient complained of knee pain and Cap. Celebrex 200mg daily was ordered. 10/1/2012 11/1/2012 No changes in the management. Patient was referred to nephrologists due to low urine output and lower limbs swollen. Left knee x-ray done. Cryo cuff is ordered to applied to the left knee, BD XRAY LEFT KNEE Left total knee replacement insitu. Periprosthetic lucency noted at the tibial component. No perprosthetic lucencynoted at the femoral component. There is large left knee effusion. Periprosthetic lucency at the tibial component of the total knee replacement with large knee effusion.prosthetic loosening or infection has to be considered. 12/1/2012 The only changes were withholding the subcutaneous Arixtra 2.5mg. Various blood tests were done. (Refer table 2) From the current note, 13/01/2012 At 2230hrs Due to frequent atrial fibrillation, shortness of breath and blood pressure drop to 80/60 mmHg, patient is transfer to Coronary Care 7

Impression

Unit. At 2340hrs 14/01/2012 At 0010hrs Pre-cardioversion, intravenous Fentanyl 25mcg and intravenous Propofol 50mg are given. Bagging is started by using the resuscitation valve bag by anesthetist. At 0010hrs At 0015hrs At 0020hrs Synchronized cardioversion 100J is given but the ECG still showing atrial fibrillation Synchronized cardioversion 150J is given but the ECG still showing atrial fibrillation. Synchronized cardioversion 200J is given and the ECG show the atrial fibrillation reverted to sinus rhythm. Post-cardiaoversion, blood pressure: 60/40mmHg. SPO2:100% with O2 given. Intravenous Voluven 250mls is given. Recheck blood pressure: 90/60mmHg. Intravenous Amiadarone 150mg in 50cc is given over 2 hours and to stop when pulse rate return to less then 70bpm. Hand bagging is stopped and O2 is commenced on 4liter/min via face mask. Post procedure: to prop up patient and allowed orally after fully conscious. At 0045hrs Blood pressure is drop again to 70/40mmHg. Input and output chart shows positive balance, 1000-2000mls past 3 days. Renal profile is done. (Refer table 3) Intravenous Voluven is given but the blood pressure still in the low side. Intravenous infusion of Dopamine is started. At 0100hrs Patient vital signs is stable. Doctors plan for cardioversion due to chronic atrial fibrillation.

15/01/2012 Having difficulty in passing urine, CBD inserted. Urine output noted <35mls. Patient started on fluid restriction and intravenous infusion Lasix start in 1.5mg/hours. Renal profile is done. (Refer table 3) KIV for Heamodialysis

16/01/2012 Renal profile is done. (Refer table 3). Femoral catheter is inserted and heamodialysis is started, 2 liter of fluid is extracted. At2205hrs ECG show atrial fibrillation again, Heart rate: 128-145bpm. Intravenous infusion Amiadarone 150mg in 50cc NaCl is given over 30minutes. To start again if pulse rate >100bpm. Then to start intravenous infusion Amiadarone 600mg in 50cc NaCl to given over 24 hrs. To stop infusion if pulse rate <60bpm. 17/01/12 At 0450hrs ECG show atrial fibrillation is reverted to sinus rhythm. Intravenous infusion Amiadarone is stopped. Heamodialysis started and extracted 2liter of fluid.

Immediate Treatment Due to frequent atrial fibrillation and blood pressure drop to 80/60 mmHg. Doctors plan for cardioversion. Pre-cardioversion, intravenous Fentanyl 25mcg and intravenous Propofol 50mg are given. Bagging is started by using the resuscitation valve bag by anesthetist. Atrial fibrillation reverted to sinus rhythm after synchronized cardioversion is given for 3 times that is 100J, 150J and 200J. Post-cardiaoversion, blood pressure: 60/40mmhg. SPO2:100% with O2 given. Intravenous Voluven 250mls is given. Recheck blood pressure: 90/60mmHg. Intravenous Amiadarone 150mg in 50cc is given over 2 hours and to stop when pulse rate return to less then 70bpm. Hand bagging is stopped and O2 is commenced on 4liter/min via face mask. Post procedure: to prop up patient and allowed orally after fully conscious. ECG show atrial fibrillation again on the following day, Heart rate: 128-145bpm. Intravenous infusion Amiadarone 150mg in 50cc NaCl is given over 30minutes. To start again if pulse rate >100bpm. Then to start intravenous infusion Amiadarone 600mg in 50cc NaCl to given over 24 hrs. To stop infusion if pulse rate <60bpm.

10

DIAGNOSTIC METHOD CHEST X-RAY Date 31/12/2011 Result There is extensive dense reticulation of both lung obscuring the heart borders. No obvious pleural effusion seen. No rib lesion seen. Extensive lung fibroids,however no significant reduction in the lung volume. 01/01/2012 Post intubation Chest x-ray There is extensive reticulation of both lungs The tip of ETT is 4cm above the carin The heard and mediastinal borders are obscured by the opacities. No rib lesion seen. Impression

ECG is done on 31/12/11, 13/1/12 and 16/1/12 show atrial fibrillation. XRAY LEFT KNEE Left total knee replacement insitu. Periprosthetic lucency noted at the tibial component. No perprosthetic lucencynoted at the femoral component. There is large left knee effusion. Impression Periprosthetic lucency at the tibial component of the total knee replacement with large knee effusion. Prosthetic loosening or infection has to be considered. Table 1 Arterial Blood Gases Results DATE 03/01/2012 04/01/2012 11

TIME PH CO2 PCO2 PO2 BICARB BASE EXCESS DATE TIME PH CO2 PCO2 PO2 BICARB BASE EXCESS

1615 7.31 89 83 33.8 13.9 94.4

1832 7.35 94 79 39.1 17.2 96.4

2052 7.34 88 84 354 17.5 95.4

2104 7.42 93 67 39.4 17.1 97.7

0753 7.47 141 59 40.1 17.3 97.2

1130 7.39 129 73 39.2 17.3 98.7

1243 7.41 83 73 41.4 17.4 95.6

2251 7.42 74 57 33.8 11.3 94.5

05/01/2012 1000 7.45 76 56 36.2 13.5 95.3 1345 7.47 56 54 36.9 14.1 89.7 1600 7.39 73 68 36.5 14.6 93.5 1900 7.40 76 58 32.9 10.1 94.6

06/01/2012 0730 7.35 90 64 31.8 8.8 96.1 1046 7.35 129 75 35.6 14.2 98.6

Table 2 HAEMATOLOGY Full Blood Picture Hemoglobin Total RBC Reticulocytes PackCellVolume MCHC MCV MCH Platlets ESR TotalWBC Different Count Neutrophils Lymphocytes Monocytes Eosinophils Basophils Immuno CReactiveProtein 30mg/L <5 12 93% 4% 2% 1% 0% 40-74 20-45 2-15 1-6 0-1 10.9g/dL 3.9X 10^6/uL 0.8% 35% 31g/dL 89fL 28pg 252X 10^3/uL 38mm/H 9.5X 10^3/uL 13.0-18.0 4.2-6.0 0.2-2.0 37-54 30-37 80-99 26-33 150-400 0-12 4.0-11.0

Table 3 Renal Profile DATE Urea nitrogen Sodium Pottasium Chloride Creatinine MEDICATION 1) IV Amiadarone 600mg over 24 hours (Antiarrhythmics) Indication Severe rhythm disorders where other therapies cannot be used including tachyarrhythmias associated with Wolff-Parkinson-White syndrome, atrial flutter and fibrillation and all types of paroxysmal tachyarrhythmias. Action class III anti-arrhythmic with weak class I, II (b blocker) and class IV actions prolongs effective refractory period of myocardial cells, AV node and anomalous pathways depresses automaticity of SA and AVN may also be a non-competitive blocker of a and b receptors haemodynamic effects: coronary vasodilator (direct effect on smooth muscle, Ca channel blockade, and a blockade), peripheral vasodilator, negative inotrope Contraindication SA or AV blocks, sinus bradycardia, severe bradycardia. Shock. History of thyroid dysfunction. Iodine sensitivity. Lactation. IV: Also severe respiratory failure, circulatory collapse, severe arterial hypotension. If bolus iv, also hypotension, congestive heart failure, cardiomyopathy. Contraindications do not apply in cardiopulmonary resuscitation of shock resistant ventricular fibrillation Side effect Bradycardia, hypothyroidism, hyperthyroidism, corneal microdeposits, GI upset, raised serum transaminases, acute liver disorders, extrapyramidal tremor, nightmares, sleep 13 16/01/2012 21.2 126 5.1 88 465 15/01/2012 16.6 132 4.0 92 345 14/01/2012 10.4 135 4.7 99 196

disorders, photosensitivity, skin pigmentation, pulmonary toxicity (presenting as dyspnoea and/or non-productive cough) 2) Tab Flecanide 50mg BD(Antiarrhythmics) Indication AV nodal reciprocating tachycardia. Wolff-Parkinson-White syndrome. Paroxysmal atrial fibrillation in patients with disabling symptoms. Symptomatic sustained ventricular tachycardia. Premature ventricular contractions and/or non-sustained ventricular tachycardia not responding to other therapy. Action depresses phase 0 and slows conduction throughout the heart delays repolarization in (canine) vnetricular muscle with significant prolongation of intracardiac monophasic action potential causes concentration related increase in PR, QRS and intra-atrial conduction intervals and prolongs effective ventricular refractory period sinus node function may also be affected particularly in patients with intrinsic sinus node disease. Contraindication Cardiac failure, history of MI with asymptomatic ventricular arrhythmias, long standing atrial fibrillation where no attempt to convert to sinus rhythm, haemodynamically significant valvular heart disease, 2nd or 3rd degree AV block, sinus node disease in absence of pacemaker, structural organic heart disease, abnormal left ventricular function. Side effect Photosensitivity, nausea, vomiting, dizziness, visual disturbances, elevated liver enzymes, jaundice. Allergic skin reactions, increased antinuclear antibodies. Decreased blood counts. Peripheral neuropathy paraesthesia, ataxia. Rarely corneal deposits, pneumonitis, urticaria, hallucinations, depression, confusion, amnesia, dyskinesia, convulsions. 3) IV Lasix 80mg TDS( Loop diuretics) Indication Oedema.

14

Action Lasix (fruesemide) is a powerful diuretic. It interferes with salt (sodium, chloride) and water absorption in the kidney, and increases the amount of water lost from the body in the urine. The onset of action is less than one hour after oral dosing, and less than five minutes after intravenous administration. Frusemide has a half life of 100 minutes.

Contraindication Precomatose states associated with liver cirrhosis, anuria, electrolyte deficiency, hypovolaemia, dehydration, renal failure caused by nephrotoxic or hepatotoxic agents, severe hypokalaemia or hyponatraemia. Lactation. Side effect Fluid and electrolyte imbalance. GI upset, hypotension, rash, hyperuricaemia, hyperglycaemia. 4) IV Tazosin 4.5g TDS(Penicillins) Indication Lower respiratory tract, intra-abdominal, skin and skin structure infections, complicated and uncomplicated UTI, bacterial septicaemia. With an aminoglycoside for bacterial infections in neutropenic patients. Appendicitis complicated by rupture with peritonitis and/or abscess in children aged 212 years. Action Piperacillin is a broad spectrum, semisynthetic penicillin with bactericidal activity (cell wall synthesis inhibitor) against many Gram positive, Gram negative and anaerobic bacteria. Tazobactam is a potent beta lactamase inhibitor, and extends the antibacterial spectrum of piperacillin to include many beta lactamase producing bacteria usually resistant to it.Both components of Tazocin are well absorbed after intramuscular administration.Peak plasma concentrations following intravenous infusion are achieved within minutes of completing the infusion, and within 40-50 minutes after intramuscular injection.Plasma elimination half lives range from 0.7-1.2 following single or multiple doses, and is not affected by dose or duration of infusion. Piperacillin and tazobactam are both widely distributed in tissues and body fluids (including intestinal mucosa, gallbladder, lung and bile).Both Tazocin 15

compounds are primarily renally excreted. Half lives increase with decreasing creatinine clearance, and dose adjustments are recommended when creatinine clearance is < 40 mL/min. (Half lives also increase in patients with hepatic impairment, however dosage adjustments are not required in these patients) Contraindication Hypersensitivity to penicillins, cephalosporins or other beta-lactams Side effect Skin reactions, GI upset, allergy, superinfection, hypokalaemia. Rarely leucopenia, interstitial nephritis, renal failure, haemolytic anaemia, hepatitis, cholestatic jaundice, pseudomembranous colitis (discontinue immediately). 5) IV Dopamin 200mg by titration Indication Acute heart failure. Action Dopamine stimulates dopaminergic receptors at lower doses producing renal and mesenteric vasodilation while at higher doses stimulate both dopaminergic and adrenergic receptors producing cardiac stimulation and renal vasodilation. It increases heart rate and force of contraction. At low infusion rates vasodilatation occurs in the renal, mesenteric, coronary and cerebral beds. At higher rates vasoconstriction in skeletal muscles and a rise in BP. Contraindication Pheochromocytoma, uncorrected tachyarrhythmias, ventricular fibrillation. Hypersensitivity. Side effect Nausea, vomiting, tachycardia, ectopic beats, palpitation, anginal pain, hypotension, vasoconstriction, bradycardia, hypertension, dyspnoea, headache, widened QRS complexes, azotaemia. 6) Tab Simvastatin 20mg ON(Statins) Indication 16

As an adjunct to diet in primary hypercholesterolaemia or mixed dyslipidaemia when response to diet and other non-pharmacological measures is inadequate. As an adjunct to diet in homozygous familial hypercholesterolaemia. To reduce risk of cardiovascular mortality and morbidity in patients with atherosclerotic disease or diabetes. Action Simvastatin is a prodrug metabolised in the liver to form the active -hydroxyacid derivative. This inhibits the conversion of HMG-CoA to mevalonic acid by blocking HMGCoA reductase, an early and rate-limiting step in cholesterol biosynthesis. It reduces total cholesterol, LDL-cholesterol and triglycerides and increases HDL-cholesterol levels. Contraindication Active liver disease. Pregnancy, lactation Side effect Reports of myopathy, rhabdomyolysis, interstitial lung disease. 7) Flumacil 600mg BD(Acetylcysteine) Indication Capsule/Granule/Dry Syrup: : As a mucolytic therapy in acute, chronic bronchial and pulmonary disease associated with thick mucous secretions eg, acute bronchitis, chronic bronchitis and acute exacerbation, pulmonary emphysema, mucoviscidosis and bronchiectasis. Action Exerts mucolytic action through its free sulfhydryl group which opens up t h e d i s u l f i d e b o n d s i n t h e m u c o p r o t e i n s t h u s l o w e r i n g m u c o u s v i s c o s i t y . T h e e x a c t mechanism of action in acetaminophen toxicity is unknown. It is thought to act by providingsubstrate for conjugation with the toxic metabolite Ampule: Treatment of respiratory infection characterized by thick and viscous hypersecretions. Contraindication Granule: Pregnancy and lactation.

17

Pediatric Sachet: Since Fluimucil Pediatric contains saccharose; therefore, it should not be used in the case of hereditary fructose intolerance, glucose-galactose malabsorption syndrome and sucrose-isomaltase deficiency. Side effect Capsule/Granule/Dry Syrup: The rare possible adverse reactions related to the use of Fluimucil are pyrosis, nausea, vomiting and diarrhea. Stomatitis, dizziness and tinnitus has been reported in such limited cases. Occasionally, allergic reactions eg, itching, urticaria, cutaneous eruption (exanthema, rash), bronchospasm, tachycardia and reduced blood pressure occur following NAC administration. Occasionally, mild gastrointestinal disturbances. Ampule: Use of Fluimucil by systemic route may occasionally be followed by hypersensitivity reactions eg, urticaria and rarely, bronchospasm. During administration by aerosol, nasopharyngeal and gastrointestinal irritation eg, rhinorrhea, stomatitis, nausea and vomiting may also be experienced. 8) Symbicort Tubehaler 2 puff BD(Beta2 agonists, long-acting/corticosteroids) Indication Regular treatment of asthma where long acting 2-agonist and inhaled corticosteroid is appropriate. Symptomatic treatment of severe COPD with a history of repeated exacerbations despite regular therapy with long acting bronchodilators. Action
-

Budesonide is an inhaled corticosteroid that directly reduces airway swelling and inflammation. Eformoterol, a long acting beta2agonist, acts by dilating and opening the airways up to make breathing easier. Regular use of Symbicort can reduce the number and severity of asthma attacks.

Side effect Hoarseness, candidiasis of mouth and throat. Tremor, palpitations, headache, muscle cramps, agitation, sleep disturbance. Rarely, skin reactions, paradoxical bronchospasm, hypersensitivity, angioedema.

18

9) Neb Duolin 1vial QID Indication Management of reversible bronchospasm associated w/ obstructive airway diseases in patients who require more than a single bronchodilator. Action Duolin Inhaler contains two bronchodlators that are used for treating asthma and chronic obstructive pulmonary disease (COPD). Levosalbutamol is a selective short-acting beta2agonist that acts on all the airways of the lungs from the trachea (windpipe) to the terminal bronchioles (small airways) and works as bronchodilator by relaxing the smooth muscle in the airway walls to widen the airways. Ipratropium is an anticholinergic that acts on specific receptors (muscarinic receptors) in the bronchioles of the lung and inhibits the interaction of acetylcholine (a neurotransmitter or chemical messenger of the nervous system) with muscarinic receptors, which prevents spasm of the airway wall caused by acetylcholine. The synergistic action (interacting to enhance the action of each other) of the two drugs working together by different mechanisms, reduces bronchospasm (contraction of the airways) to a greater extent than would be provided by each drug alone and increases air flow into the lungs, relieving symptoms of COPD such as tightness of the chest, wheezing and shortness of breath Contraindication Hypertrophic obstructive cardiomyopathy, tachyarrhythmia. Hypersensitivity to atropine, soya lecithin. Side effect Fine tremor of skeletal muscles, nervousness, tachycardia, dizziness, palpitations, headache, hypokalemia, dry mouth, dysphonia, allergic reactions. 10) Tab Controlac 40mg OM(Pantoprazole) Indication
-

In combination with 2 appropriate antibiotics (see Dosage & Administration) for the eradication of Helicobacter pylori in patients with peptic ulcers with the objective of reducing the recurrence of duodenal and gastric ulcers caused by this microorganism.

Duodenal ulcer; gastric ulcer; moderate and severe forms of reflux esophagitis. 19

Symptomatic improvement (eg, heartburn, acid regurgitation, pain on swallowing) and healing of mild refluxesophagitis. Long-term management and prevention of relapse in reflux esophagitis. Prevention of gastroduodenal ulcers induced by nonselective nonsteroidal antiinflammatory drugs (NSAIDs) in patients at risk with a need for continuous NSAIDs treatment.

Zollinger-Ellison syndrome and other pathological hypersecretory conditions.

Action According to the Mayo Clinic, pantoprazole decreases the amount of acid produced by the stomach. It provides relief not only for heartburn and acid reflux, but for Zollinger-Ellison syndrome. Zollinger-Ellison is a disorder that causes the stomach to produce too much acid. Contraindication -

In cases of known hypersensitivity to any component of Controloc or of the combination partners. Controloc must not be used in combination treatment for eradication of Helicobacter pylori in patients with moderate to severe hepatic or renal dysfunction since currently no data are available on the efficacy and safety of Controloc in combination treatment of these patients.

Side effect Treatment with Controloc can occasionally lead to headache or diarrhea. There were rare reports of nausea, upper abdominal pain, flatulence, skin rash, pruritus or dizziness. Edema, fever, thrombophlebitis (Controloc IV only), the onset of depression and disturbances in vision (blurred vision) were reported in individual cases. Inform the physician or pharmacist about any side effect the patient may observe which has not been listed previously. 11) Tab Cardipin 100mg daily Indication

20

Conditions where modification of platelet behaviour is considered beneficial, including transient ischaemic attacks, secondary prevention of myocardial infarction, and for prophylaxis against stroke, vascular occlusion anddeep vein thrombosis. Action It has anti-inflammatory, analgesic and antipyretic effect, and inhibits platelet aggregation. The mechanism of action is associated with inhibition of COX activity - the main enzyme metabolism of arachidonic acid which is a precursor of prostaglandins which play a major role in the pathogenesis of inflammation, pain and fever. Reduction of prostaglandins (mainly E1) in the thermoregulation center leads to a decrease in body temperature due to expansion of blood vessels of the skin and increase perspiration. Analgesic effect is due to both central and peripheral effects. Reduces aggregation, platelet adhesion and thrombus formation through suppression of synthesis of thromboxane A2 in platelets. Reduces mortality and risk of myocardial infarction in unstable stenocardia. It is effective in primary prevention of cardio-vascular system and secondary prevention of myocardial infarction. At a daily dose of 6 g or more inhibits the synthesis of prothrombin in the liver and increases the prothrombin time. Increases fibrinolytic activity of plasma and reduces the concentration of vitamin K-dependent coagulation factors (II, VII, IX, X). Increases the rate of hemorrhagic complications in carrying out surgical procedures, increases the risk of bleeding during therapy with anticoagulants. It stimulates the excretion of uric acid (violating its reabsorption in the renal tubules) but in high doses. The blockade of COX-1 in the mucosa of the stomach leads to inhibition of gastroprotective prostaglandins, which may lead to ulceration of the mucous membrane and subsequent bleeding. Contraindication -

Patients suffering from active peptic ulceration or haemophilia or known to be allergic to aspirin. Use in pregnancy: There is clinical and epidemiological evidence of the safety of aspirin in pregnancy, but it may prolong labour and contribute to maternal and neonatal bleeding and is best avoided in the last trimester of pregnancy.

Use in children: Not recommended. Use in the elderly: Elderly patients do not tolerate aspirin as well as younger patients. They may experience tinnitus, nausea, anorexia and gastrointestinal irritation though this would be less likely at the doses recommended for antiplatelet action. 21

Side effect Unwanted effects are those of soluble aspirin. It may precipitate bronchospasm, and induce attacks of asthma in susceptible subjects; may also induce gastrointestinal haemorrhage 12) Tab Finastride 5mg daily Indication BPH. To reduce incidence of acute urinary retention and need for surgery. May be used alone or in combination with doxazosin. Action The mechanism of action of Finasteride is based on its preferential inhibition of Type II 5areductase through the formation of a stable complex with the enzyme. Inhibition of Type II 5a-reductase blocks the peripheral conversion of testosterone to DHT, resulting in significant decreases in serum and tissue DHT concentrations, minimal to moderate increase in serum testosterone concentrations, and substantial increases in prostatic testosterone concetrations. As DHT appears to be the principal androgen responsible for stimulation of prostatic growth, a decrease in DHT concentrations will result in a decrease in prostatic volume (approximately 20-30% after 6-24 months of continued therapy). In men with androgenic alopecia, the mechanism of action has not been fully determined, but finasteride has shown to decrease scalp DHT concentration to the levels found in hairy scalp, reduce serum DHT, increase hair regrowth, and slow hair loss. Contraindication Children, exposure of pregnant women to finasteride either via direct contact with crushed tab or through semen of male sexual partners who are taking finasteride; pregnancy, lactation. Side effect Impotence, ejaculation disorder, decreased volume of ejaculate, decreased libido, testicular pain, breast tenderness and enlargement, hypersensitivity, urticaria. 13) Tab Dyazide 1 STAT(Diuretic combinations) Indication 22

Mild to moderate hypertension. Oedema. Action

-

Dyazide is an oral diuretic, antihypertensive agent. Its hydrochlorothiazide component blocks reabsorption of sodium (and attendant chloride anions). Its triamterene component acts by a different mechanism - it interferes with the exchange of sodium ions for potassium and hydrogen ions.

Diuretic activity following a single dose is evident within the first hour, reaches a peak at 2 to 3 hours, and tapers off during subsequent 7 to 9 hours. Because of the potassium-conserving effect of its triamterene component, Dyazide reduces the risk of hypokalaemia when seen with other diuretics. Therefore, it is of particular value in patients who might otherwise suffer from hypokalaemia and resultant side effects.

The need for potassium supplements is virtually eliminated with the use of Dyazide. Hypochloraemic alkalosis, sometimes a problem with thiazides alone, has not been reported with Dyazide

Contraindication Hyperkalaemia. Severe or progressive renal failure, increasing hepatic dysfunction, hypercalcaemia, diabetic ketoacidosis, Addison's disease. Side effect Nausea, vomiting, diarrhoea, cramps, weakness, dizziness, headache, dry mouth, rash, decrease in blood pressure, hyperglycaemia, hypercalcaemia. Rarely, blood dyscrasias, SLE, photosensitivity, reversible renal failure. 14) Cap Celebrex 200mg daily(NSAIDs) Indication Osteoarthritis, rheumatoid arthritis, ankylosing spondylitis. Action The mechanism of action of celecoxib is believed to be due to inhibition of prostaglandin synthesis. Unlike most NSAIDs, which inhibit both types of cyclooxygenases (COX-1 and COX-2), celecoxib is a selective noncompetitive inhibitor of cyclooxygenase-2 (COX-2) enzyme. It binds with its polar sulfonamide side chain to a hydrophilic side pocket region 23

close to the active COX-2 binding site. Both COX-1 and COX-2 catalyze the conversion of arachidonic acid to prostaglandin (PG) H2, the precursor of PGs and thromboxane. Contraindication History of hypersensitivity to sulfonamides, aspirin/anti-inflammatory induced allergies, active peptic ulceration or GI bleeding, inflammatory bowel disease, severe renal (CrCl <30ml/min) or severe hepatic impairment, moderate to severe CHF, ischaemic heart disease, peripheral artery disease, cerebrovascular disease. Pregnancy; contraception must be used. Lactation. Side effect Myocardial infarction, hypertension, fluid retention, GI upset, dizziness, hypertonia, insomnia, sinusitis, upper respiratory tract infection, dyspnoea, urinary tract infection, rash, pruritus. Reports of serious skin and hypersensitivity reactions (discontinue). 15) Tab Herbesser 30mg BD Indication HTN. May be used alone or in combination w/ other antihypertensives. Angina pectoris, variant angina. Action The therapeutic benefits achieved with Herbesser 90 SR eg, improvement of myocardial ischemia and hypotensive effect, are believed to be related to its ability to dilate vessels by inhibiting the influx of calcium ion into smooth muscle cells of the coronary and peripheral vessels, etc. Action on Blood Pressure: Lowers the elevated blood pressure gradually although hardly affects the normal blood pressure (rat, human). Suppresses the elevation of blood pressure induced by exercise load (human). Lowers blood pressure without decreasing cerebral and renal blood flow (dog, human). Suppresses myocardial and vascular hypertrophy together with lowering blood pressure (rat). Effects on Myocardial Ischemia: Increases coronary blood flow into myocardial ischemic region by dilating the collateral channels and large coronary artery (dog). Suppresses coronary artery spasms (monkey, human). Decreases myocardial oxygen consumption without decreasing cardiac output by decreasing afterload and heart rate due to peripheral vasodilating effect (dog). Retains cardiac function and myocardial energy metabolism and 24

reduces the infarct size by inhibiting extra calcium ion influx during myocardial ischemia (rat). Contraindication SA block, 2nd- or 3rd-degree AV block; pregnancy. Side effect Dizziness, fatigue, headache; facial flushing; skin rash; GI disturbances, constipation; bradycardia, AV block; increased SGOT & SGPT. 16) IV fentanyl citrate Indication Fentanyl citrate injection is indicated: for analgesic action of short duration during the anesthetic periods, premedication, induction and maintenance, and in the immediate postoperative period (recovery room) as the need arises.
-

for use as a narcotic analgesic supplement in general or regional anesthesia. for administration with a neuroleptic such as droperidol injection as an anesthetic premedication, for the induction of anesthesia, and as an adjunct in the maintenance of general and regional anesthesia.

for use as an anesthetic agent with oxygen in selected high risk patients, such as those undergoing open heart surgery or certain complicated neurological or orthopedic procedures.

Action Fentanyl is a potent opioid analgesic that increases pain threshold, alters pain reception and inhibits ascending pain pathways by binding to stereospecific receptors within the CNS. Onset Duration amounts enter the breast milk. Protein-binding: 80% Metabolism : Hepatic via N-dealkylation and hydroxylation. Excretion : Urine (as metabolites and unchanged drug); 4 hrs (elimination half-life). 25 : Rapid. : Short.

Distribution : Rapidly into tissues; appears in the CSF, crosses the placenta and small

Contraindication Hypersensitivity Side effect Nausea, vomiting; bradycardia, oedema, CNS depression, confusion, dizziness,drowsiness, headache, sedation, transient hypotension, peripheral vasodilation; increased intracranial pressure. High IV dose may cause chest wall rigidity. Transdermal: Rash, erythema and itching. Potentially Fatal: Respiratory depression, trunk rigidity, laryngospasm, bronchoconstriction.

17) IV Propfol Indication Propofol is an IV anesthetic agent that can be used for both induction and/or maintenance of anesthesia as part of a balanced anesthetic technique for inpatient and outpatient surgery in adults and in children 3 years. Propofol should only be administered to intubated, mechanically ventilated adult patients in the intensive care unit (ICU) to provide continuous sedation and control of stress responses. In this setting, propofol injection should be administered only by persons skilled in the management of critically ill patients and trained in cardiovascular resuscitation and airway management. Action Propofol is a short-acting anaesthetic given for induction and maintenance of general anaesthesia. Onset: 30 sec. Duration: 3-10 min. Distribution: Extensively redistributed from brain to other tissues; crosses the placenta and enters breast milk. Protein-binding: 95% Metabolism: Extensively hepatic; converted to water-soluble sulfate and glucuronide conjugates. Excretion: Urine (as metabolites); faeces. Elimination half-life:40 min (initial); 4-7 hr (terminal). 26

Contraindication Electroconvulsive therapy, obstetrics. Sedation in children 16 yr. Pregnancy, lactation. Side effeect Involuntary muscle movements; nausea, vomiting, headache, fever; pain, burning or stinging at inj site. Potentially Fatal: Apnoea, bradycardia, hypotension, convulsions; anaphylaxis. 18) Normal saline (NaCl) Indication Sodium Chloride Injection, USP is indicated as a source of water and electrolytes. 0.9% Sodium Chloride (sodium chloride (sodium chloride injection) injection) Injection, USP is also indicated for use as a priming solution in hemodialysisprocedures. Action -

Normal Saline is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment. It contains no antimicrobial agents. The pH is 5.0 (4.5 to 7.0). It contains 9 g/L Sodium Chloride with an osmolarity of 308 mOsmol/L. It contains 154 mEq/L Sodium and Chloride

Contraindication None known. Side effect Reactions which may occur because of the solution or the technique of administration include febrile response, infection at the site of injection, venousthrombosis or phlebitis extending from the site of injection, extravasation, andhypervolemia. If an adverse reaction does occur, discontinue the infusion, evaluate the patient, institute appropriate therapeutic countermeasures and save the remainder of the fluid for examination if deemed necessary

27

19) IV Voluven Indication Voluven (6% hydroxyethyl starch 130/0.4 in 0.9% sodium chloride injection) is indicated for the treatment and prophylaxis of hypovolemia Action Voluven is administered by intravenous infusion only. The daily dose and rate of infusion depend on the patients blood loss, on the maintenance or restoration of hemodynamics, and on the hemodilution (dilution effect). The product can be given repetitively over several days. The initial 10 to 20 mL should be infused slowly, and the patient should remain under close observation in case of possible anaphylactoid reactions. Contraindication The use of Voluven is contraindicated in the following conditions: known hypersensitivity to hydroxyethyl starch fluid overload (hyperhydration) and especially in cases of pulmonary edema and congestive heart failure renal failure with oliguria or anuria not related to hypovolemia patients receiving dialysis treatment severe hypernatremia or severe hyperchloremia intracranial bleeding

Side effect Anaphylactoid reactions (mild influenza-like symptoms, bradycardia, tachycardia, bronchospasm, non-cardiac pulmonary edema) have been reported with solutions containing hydroxyethyl starch. If a hypersensitivity reaction occurs, administration of the drug should be discontinued immediately and the appropriate treatment and supportive measures should be undertaken until symptoms have resolved

PROCEDURE Synchronized cardioversion ACLS guideline in preparing the patient are intravenous access, airway management equipment, sedative drugs, and a cardioverter/defibrillator monitoring device.

28

The patient should be adequately sedated with a short-acting agent such as midazolam or propofol. In addition, an opioid analgesic, such as fentanyl, is commonly used. Reversal agents, such as flumazenil and naloxone, should be available. The defibrillator should be placed in the synchronized mode, which permits a search for a large R or S wave. The delivered energy is selected. Most monophasic and biphasic models can deliver up to 360 Joules. Manual button depression by the operator causes the defibrillator to discharge an electric current that lasts less than 4 milliseconds and avoids the vulnerable period of cardiac repolarization when VF can be induced. The operator should be aware of this brief delay as the cardioverter searches for a large positive or negative deflection. If deflections are too small for the defibrillator to synchronize, the physician can change the leads or place them closer to the patient's chest or heart. If the patient develops VF, always turn off synchronization to avoid delay in energy delivery. Two options exist for placement of paddles on the chest wall. First is the anterolateral position in which a single paddle is placed on the left fourth or fifth intercostal space on the midaxillary line; the other paddle is placed just to the right of the sternal edge on the second or third intercostal space. The second option is the anteroposterior position. A single paddle is placed to the right of the sternum, as above, and the other paddle is placed between the tip of the left scapula and the spine. Since the skin can conduct away a significant portion of the current, conductive gel or pre-gelled pads are commonly used to ensure good contact. Under ideal circumstances, only 10-30% of the total current reaches the heart. The paddles should be placed firmly against the chest wall to avoid arcing and skin burns. Although there is a risk of receiving a shock if touching the patient or the stretcher, bed, or other equipment in which the patient is in contact, there has been recent evidence that continued contact with the patient is safe during biphasic defibrillation. Pacemakers and ICDs should be at least 10 cm from direct contact with paddles and should eventually be interrogated for any malfunction after cardioversion. The anteroposterior approach is preferred in patients with implantable devices to avoid shunting current to the implantable device and damaging the system. Energy requirements for atrial fibrillation are 100-200 J initially and 360 J for subsequent shocks. A study showed good response to higher energy shocks of 720 J for the treatment of refractory atrial fibrillation. Biphasic shocks require a typical energy level of 75 J for correction of atrial fibrillation. Cardioversion of atrial fibrillation secondary to hyperthyroidism is 90% successful. Only 25% of patients with atrial fibrillation caused by severe mitral regurgitation are successfully treated, and half revert in the first 6 months. 29

Atrial flutter and PSVT require less energy: 50 J initially, then 100 J if needed. Cardioversion of VT involves shocks of 50-100 J initially, then 200 J if unsuccessful. PREVENTION To reduce or eliminate caffeinated and alcoholic beverages from your diet, because they can sometimes trigger an episode of atrial fibrillation. It's also important to be careful when taking over-the-counter (OTC) medications. Some, such as cold medicines containing pseudoephedrine, contain stimulants that can trigger atrial fibrillation. Also, some OTC medications can have dangerous interactions with anti-arrhythmic medications. Preventing blood clots. An anticoagulant drug called warfarin (Coumadin) is given. Reducing heart rate. There are three classes of heart-function drugs that can be used alone, or in combination to reduce the heart rate. They are digitalis drugs, beta blockers drugs and calcium channel blocker drugs. You may be able to prevent atrial fibrillation (AF) by leading a healthy lifestyle and taking steps to lower your risk for heart disease. These steps include:

Not smoking Following a heart healthy diet that is low in saturated fat, trans fat, and cholesterol and that includes a variety of grains, fruits, and vegetables daily Getting regular physical activity Maintaining a healthy weight

30

PROGNOSIS AF is associated with a 1.5- to 1.9-fold higher risk of death, which is in part due to the strong association between AF and thromboembolic events, according to data from the Framingham heart study. Medical therapies aimed at rhythm control offered no survival advantage over rate control and anticoagulation, according to the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial. The study addressed whether rate control and anticoagulation are sufficient goals for asymptomatic, elderly patients. Atrial fibrillation (AF) is associated with increased morbidity and mortality, in part due to the risk of thromboembolic disease, particularly stroke, in AF and in part due to its associated risk factors. Studies have shown that individuals in sinus rhythm live longer than individuals with AF. Disruption of normal atrial electromechanical function in AF leads to blood stasis. This, in turn, can lead to development of thrombus, most commonly in the left atrial appendage. Dislodgement or fragmentation of a clot can then lead to embolic phenomena, including stroke. Development of AF predicts heart failure and is associated with a worse New York Heart Association Heart Failure classification. AF may also worsen heart failure in individuals who are dependent on the atrial component of the cardiac output. Those with hypertensive heart disease and those with valvular heart disease are particularly at high risk for developing heart failure when AF occurs. In addition, AF may cause tachycardia-mediated cardiomyopathy if adequate rate control is not established. The risk of stroke from AF that lasts longer than 24 hours is a major concern and is usually addressed by prescribing a blood thinner (Coumadin or dabigatran). Prognostic score systems, such as CHAD2, appear to underestimate risk of embolic stroke in patients older than 75 years; thus, some studies recommend treating all patients older than 75 years, unless a compelling contraindication is noted. The CHADS2 score predicts ischemic stroke not only for patients with a history of atrial fibrillation but also for patients without atrial fibrillation who have a history of coronary heart disease. In the latter group, net benefit of prophylactic anticoagulation has yet to be established. Atrial fibrillation in association with acute myocardial infarction AF is a common finding in patients presenting with an acute myocardial infarction. A metaanalysis pooled data from 43 studies and more than 278,800 patients. The study found that AF in the setting of acute myocardial infarction was associated with 40% increase in 31

mortality compared to patients in sinus rhythm with acute myocardial infarction. The causes of death were unclear, but may be related to triple anticoagulation therapy with aspirin, clopidogrel, and warfarin, or may be related to hemodynamic consequences associated with the loss of atrial contraction. Whether AF is a complication of myocardial infarction or a marker for myocardial infarction severity is unclear.

32

Critique Name: Judy Tan Lye Chen Matrix No.: CCC/0030/11 Critique Of Patient Management Since transferred to Coronary Care Unit in 13/01/2012, patient is having frequent and chronic atrial fibrillation (A Fib), shortness of breath and blood pressure (BP) drop to 80/60 mmHg. For this patient, doctor plan for synchronized cardioversion. Pre-cardioversion sedations are given and continue with synchronized cardioversion is performed for 3 times (first time is 100J, second time is 150J and the third time is 200J) until the electrocardiogram (ECG) show sinus rhythm. The health care teams detect the signs and symptoms rapidly and diagnosed accurately. The procedure is performed immediately by followed the America Heart Association (AHA) Advanced Cardiovascular Life Support (ACLS) year 2011 guideline. From the AHA ACLS guideline in year 2011, rhythms for unstable tachycardia include the A Fib rhythm. AHA defined tachycardia as a heart rate of more then 100 beats per minutes in adult but it may depend on your age and physical condition. The management of A Fib rhythm in this patient is followed the ACLS adult tachycardia (with pulse) algorithms. In AHA, it stated that if patient is having tachycardia with pulse and the symptoms is persist with hypotension, acutely altered mental status, ischemic chest discomfort, acute heart failure or signs of shock, immediate synchronized cardioversion is needed. Before synchronized cardioversion, sedation is considered if the patient is conscious. Do not delay cardioversion if the patient is extremely unstable. If the ECG rhythm show regular narrow complex, consider adenosine. Synchronized cardioversion uses a sensor to deliver a shock that is synchronized with a peak of the QRS complex (e.g. the highest point of the R wave). In this case, synchronized cardioversion is performed for 3 times by using 100J at the first time, 150J for the second 33

times and 200J for the third times. But in AHA ACLS guideline in year 2011, the recommended initial biphasic energy dose for cardioversion of atrial fibrillation is 120J. The initial monophasic dose for cardioversion of atrial fibrillation is 200J. If the initial cardioversion shock fails, providers should increase the dose in a stepwise fasion.

Critique On Pharmacology Used On Patient 1) IV Amiodarone In the nursing progress, it stated that doctor order intravenous (IV) Amiadarone 150mg in 50cc over 2 hours after synchronized cardioversion and to stop when pulse rate return to less then 70bpm on 14 Jan. ECG show A Fib again on 16 Jan at 2205hrs, Heart rate: 128145bpm. IV infusion Amiadarone 150mg in 50cc NaCl is given over 30minutes. Then start IV infusion Amiadarone 600mg in 50cc NaCl over 24 hrs. To stop infusion if pulse rate <60bpm. There is some different in managing this patient with A Fib rhythm with the infusion of IV Amiodarone. The dosage is different compared to the pharmacology management that stated in AHA ACLS guideline in year 2011. In the guideline given, the maximum cumulative dose of IV Amiodarone is 2.2g over 24 hours. In AHA, it written that the rapid infusion: 150mg IV over first 10 minutes (15mg per minute). May repeat rapid infusion (150mg IV) every 10 minutes as needed. Slow infusion: 360mg IV over 6 hours (1mg per minute). Maintenance infusion: 540mg IV over 18 hours (0.5mg per minute). 2) IV Voluven In the nursing progress, it stated that doctor order IV Voluven 250mls when the patients blood pressure is 60/40mmHg. The recheck blood pressure is 90/60mmHg. I agreed , IV Voluven able to increase blood pressure. Voluven expands the volume of blood plasma the liquid portion of the blood and thus draws fluid into small blood vessels know as capillaries. (Pharmaceutical News, 2007) 34

Critique Ben

Critique Jothi

35

Critique NAME : ROSHAKILA BTE WASLI

MATRIX NUMBER : CCC/0039/11 Patient management in atrial fibrillation to reduce heart rate. From this case study, three classes of heart-function drugs that can be used alone, or in combination to reduce the heart rate. They are digitalis drugs, beta blockers drugs and calcium channel blocker drugs. In the AFFIRM trial The therapeutic target in this group was heart-rate control. Drugs that were acceptable in the protocol for this purpose were betablockers, calcium-channel blockers (verapamil and diltiazem), digoxin, and combinations of these drugs. Heart-rate control during atrial fibrillation was assessed both at rest and during activity, which usually consisted of a six-minute walk. (Lipkin DP, Scriven AJ, Crake T, Poole-Wilson PA) According to Page RL, Connolly SJ, Crijns HJ, van Eickels M, Gaudin C, TorpPedersen C, Hohnloser SH, In the acute setting, intravenous drugs are favored for rate control, with conversion to oral agents for long-term maintenance. The onset of action of intravenous digitalis is much slower than intravenous -blockers or calcium blockers, and digitalis is therefore not widely used for acute rate control. It should also be noted that some drugs intended primarily for rhythm control, including amiodarone and dronedarone (via multiple mechanisms) and sotalol (via its -blocking properties) can also reduce the ventricular rate during AF. Interventional procedure Cardioversion of atrial fibrillation From this case study, Cardioversion and pretreatment with drugs for this patient can treat the atrial fibrillation to sinus rhythm. According to Dalzell G, Anderson J, Adgey AAJ,a provisional validation of this hypothesis comes from the documentation of a significant association between cardioversion success with low energy shocks, and pretreatment with drugs such as digoxin and amiodarone, which share the ability to improve left ventricular performance even in the presence of sinus rhythm. Another study say that control of the ventricular response in chronic atrial fibrillation has traditionally been attempted with digoxin, although this drug is ineffective during exercise or when cathecholamine levels are high, or in attempting cardioversion to sinus rhythm (Falk RH, Leavitt JI) 36

The drug-related aspects of atrial fibrillation and electrical cardioversion, the respective roles of digoxin, amiodarone, and warfarin,a significant feature being the relationship between left ventricular dysfunction and the indications for pretreatment with these drugs. (Lip GYH) A provisional validation of this hypothesis comes from the documentation of a significant association between cardioversion success with low energy shocks, and pretreatment with drugs such as digoxin and amiodarone,(Dalzell G, Anderson J, Adgey AAJ) obtain to sinus rhythm. According to Dalzell et al, an association between electrical (direct current) cardioversion success and prior treatment with digoxin was found only on univariate analysis, with the duration of atrial fibrillation being the only independent predictor of cardioversion success in multivariate analysis. Pretreatment with amiodarone, by contrast, is well-known to be effective in achieving cardioversion and sustaining sinus rhythm.(Gosselink AT, Crijns HJ, Van Gelder IC,Hillige H, Wiesfeld AC, Lie KI) References 1)Page RL, Connolly SJ, Crijns HJ, van Eickels M, Gaudin C, Torp-Pedersen C, Hohnloser SH. Rhythm- and Rate-Controlling Effects of Dronedarone in Patients With Atrial Fibrillation (from the ATHENA Trial). Am J Cardiol. 2011;107:10191022. 2)Lipkin DP, Scriven AJ, Crake T, Poole-Wilson PA. Six minute walking test for assessing exercise capacity in chronic heart failure. Br Med J (Clin Res Ed) 1986;292:653-5. 3)Lip GYH. Cardioversion of atrial fibrillation. Postgrad Med J 1995; 71: 457-65. 4)Dalzell G, Anderson J, Adgey AAJ. Factors determining success and energy requirements for cardioversion of atrial fibrillation. Q J Med 1991; 78: 85-95. 5)Gosselink AT, Crijns HJ, Van Gelder IC, Hillige H, Wiesfeld AC, Lie KI. Low-dose amiodarone for maintenance of sinus rhythm after cardioversion of atrial fibrillation or flutter. JAMA 1992; 267: 3289-93. 6)Falk RH, Leavitt JI. Digoxin for atrial fibrillation: a drug whose time has gone? Ann Intern Med 1991; 114: 573-5.

37

CONCLUSION Nursing care of the atrial fibrillation patient can present many challenges for the critical care nurse. Atrial fibrillation is the most common arrhythmia found in clinical practice. Treatments for the underlying cause and to prevent future episodes of atrial fibrillation must be done to treat the AF. Patients with heart failure or atrial fibrillation have a significantly higher risk of non cardiac postoperative mortality than patients with coronary artery disease; thus, patients and physicians should consider this risk, even if a minor procedure is planned.

38

REFERENCES

America Heart Association. (2011). Advanced Cardiovascular Life Support. United States of America: Elizabeth Pharmaceutical News. (2007, December 28). The U.S. Food and Drug Administration has approved Voluven, an intravenous solution that prevents and treats a dangerous loss of blood volume, a condition that sometimes occurs during and after surgery. Retrieved from http://www.news-medical.net Mayo Foundation (1998-2012) Medical Education and Research (MFMER) Retrieved from http://www.mayoclinic.com/health/atrial-fibrillation/DS00291/DSECTION=prevention WebMD LLC (1994-2012) eMedicine's patient education articles Atrial Fibrillation Retrieved
from http://emedicine.medscape.com/article/151066-overview#aw2aab6b2b5aa

News-Medical.Net (February 7, 2012) Atrial Fibrillation Prevention Retrieved from http://www.news-medical.net/health/Atrial-Fibrillation-Prevention.aspx

The HealthCentralNetwork, Inc (2001-2012) health encyclopedia-disease and conditions Retrieved from http://www.healthscout.com/ency/68/132/main.html#DiagnosisofAtrialFibrillation

39