atrial fibrillation ( af ) is a common arrhythmia with an estimated clinical prevalence of approximately 1% in the general population and as high as 9% in individuals by the age of 80 years
myocardial dysfunction observed in sepsis could contribute to arrhythmias and inflammation per se could induce or provoke af .
we describe the management of an acute af in an elderly patient scheduled for emergency laparotomy .
a 77 year - old lady ( weight : 50 kg ) of american society of anaesthesiologists ( asa ) iii was scheduled for emergency laparotomy and closure of hollow viscous perforation .
she had an uneventful general anaesthesia for laparoscopic appendicectomy 2 days ago . however , she had abdominal pain and fever postoperatively in the ward for last 24 hours . on examination
, she was febrile ; her pulse was 110/min , regular ; blood pressure was 106/72 mmhg and respiratory rate was 20/min .
blood investigations done 6 hours prior to surgery revealed haemoglobin of 11.9 g / dl , total counts of 14,000/mm with 13% band forms , serum sodium 140 meq / l , potassium 3.6 meq / l , platelets 220,000/mm and creatinine of 1.4 mg% .
electrocardiogram ( ecg ) showed sinus tachycardia with heart rate ( hr ) of 106/min . in the operating room , baseline monitors ( pulsoximetry / non - invasive blood pressure / ecg ) were established .
ecg showed hr of 156/min in af , which was not present earlier and confirmed with 12-lead ecg .
, intravenous metoprolol was administered to control ventricular rate in aliquots of 1 mg to a total of 5 mg .
as the patient 's blood pressure was stable , patient 's trachea was intubated with rapid sequence induction using midazolam 1 mg , fentanyl 250 mcg , propofol 60 mg and succinylcholine 60 mg .
central line was inserted in right internal jugular vein ( ijv ) under aseptic precautions .
anaesthesia was maintained with air , oxygen , sevoflurane , fentanyl , hydromorphone and rocuronium .
as the hr was refractory to beta blockers , intravenous amiodarone 150 mg was administered .
hr reduced to 8090/min with an improvement in blood pressure ( 126/86 mmhg ) and rhythm reverted back to sinus within 1520 min of administration .
arterial blood gas and serum electrolytes showed uncompensated metabolic acidosis ( bicarbonate = 16 meq / l ) and respiratory alkalosis ( pco2 = 26 mmhg ) with serum potassium of 3 meq / l . 20
mmol / l was administered along with 1 g of iv magnesium sulphate ( serum magnesium 1.2mg / dl ) and calcium chloride ( serum calcium 6 mg / dl ) in the icu .
serum c - reactive protein ( crp ) and procalcitonin was found to be elevated .
the patient 's trachea was extubated after 12 hours with controlled ventricular rate and sinus rhythm . on consultation with cardiologist , tab .
she was advised regular follow - up and discharged home on low - dose aspirin therapy .
fibrosis and loss of muscle mass of the left atrium play a major role in the development of af . genetic defects like lamin
. systemic disease , e.g. , inflammatory processes , sarcoidosis , autoimmune disorders , has also been linked to the development of af .
it was initially suspected by the observation that inflammatory states , such as myocarditis , pericarditis , and cardiac surgeries , are frequently associated with af .
there is a greater association between elevated crp and presence of af , which is supported by the findings from a large population - based cohort study of 5806 elderly individuals followed for a mean of 6.9 years .
every 1 mg / dl increase in serum crp was associated with a seven fold increased risk of recurrent af and a 12-fold increased risk of permanent af compared with controls .
advanced age , blunt thoracic trauma , shock ( notably septic shock ) , use of pulmonary artery catheter , and previous treatment with calcium channel blockers are the independent risk factors of af in intensive care patients .
our patient had af probably due to advanced age , underlying sepsis and electrolyte imbalances .
there are multiple therapeutic strategies for the management of af , which may confuse individual practitioners .
direct current cardioversion ( dcc ) , pharmacotherapy with antiarrhythmic drugs , and anticoagulation are the mainstay treatment modalities in acute af .
antiarrhythmic drugs with class i ( flecainide , propafenone ) and iii ( amiodarone ) agents are used when adopting a rhythm - controlling strategy , whereas class ii ( beta blockers ) and iv ( diltiazem , verapamil ) agents are reserved for rate - controlling measures , although class iii agents share rate - controlling properties .
as the blood pressure was stable in this patient , pharmacological conversion to sinus rhythm was attempted initially with beta blocker and then with intravenous amiodarone .
calcium channel blockers were not used in our patient as fatal complete heart block has been described with their use along with beta blockers .
amiodarone was considered for af of acute onset and to avoid secondary complications of af like ischaemia , systolic dysfunction and embolism .
airway was secured immediately in our patient to avoid hypoxia , hypercarbia , acidosis , which could further precipitate af , and to facilitate dcc if needed . in patients with ventricular rates more than 150 , ongoing chest pain , or with evidence of critical perfusion : systolic bp less than 90 mmhg , heart failure , or reduced consciousness , the need to restore haemodynamic stability by the restoration of sinus rhythm is of prime importance , and guideline consensus advocates dcc as the first - line therapy to achieve this , with pharmacologic strategies being used either secondarily or in conjunction with dcc .
the patient was discharged on low - dose aspirin therapy for 6 months to prevent thromboembolic complications following af .
acute af in an elderly patient coming for emergency surgery with underlying sepsis and electrolyte imbalance needs immediate hr control and conversion to sinus rhythm .
intraoperative vigilant monitoring , intravenous use of amiodarone , correction of electrolytes and underlying pathology played a vital role in the successful management of this patient .
 atrial fibrillation ( af ) is a common arrhythmia with an estimated clinical prevalence of approximately 1% in the general population and as high as 9% in individuals by the age of 80 years . 
 the aetiology is multifactorial . 
 systemic disease , e.g. , inflammatory processes , sarcoidosis , autoimmune disorders , has also been linked to the development of af . 
 myocardial dysfunction observed in sepsis could contribute to arrhythmias and inflammation per se could induce or provoke af . 
 we describe the successful management of an acute af in an elderly patient scheduled for emergency laparotomy and closure of hollow viscous perforation . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION