Clarke, Heidi

Gopalani, Radhan

Kline, Jonatha

Quadri, Faaria

Sankar, Kamarena

English

Scholarly Commons@Baptist Health South Florida

Baptist Health South Florida Scholarly Commons @ Baptist Health South Florida All Publications 12-5-2018 Ongoing evaluation of the impact of a post-operative atrial fibrillation prevention protocol for patients undergoing cardiothoracic surgery Kamarena Sankar Baptist Hospital of Miami, kamarenas@baptisthealth.net Jonatha Kline Baptist Health South Florida, JonathanDK@baptisthealth.net Heidi Clarke Baptist Hospital of Miami, heidic@baptisthealth.net Radhan Gopalani Baptist Hospital of Miami, radhang@baptisthealth.net Faaria Quadri Baptist Hospital of Miami, FaariaQ@baptisthealth.net Follow this and additional works at: https://scholarlycommons.baptisthealth.net/se-all-publications  Part of the Cardiology Commons, Cardiovascular Diseases Commons, Pathological Conditions, Signs and Symptoms Commons, Pharmacy and Pharmaceutical Sciences Commons, and the Surgery Commons Citation Sankar, Kamarena; Kline, Jonatha; Clarke, Heidi; Gopalani, Radhan; and Quadri, Faaria, "Ongoing evaluation of the impact of a post-operative atrial fibrillation prevention protocol for patients undergoing cardiothoracic surgery" (2018). All Publications. 3100. https://scholarlycommons.baptisthealth.net/se-all-publications/3100 This Conference Poster -- Open Access is brought to you for free and open access by Scholarly Commons @ Baptist Health South Florida. It has been accepted for inclusion in All Publications by an authorized administrator of Scholarly Commons @ Baptist Health South Florida. For more information, please contact Carrief@baptisthealth.net. • Atrial Fibrillation is a common post-operative complication that may occur in up to 40% of patients following cardiothoracic surgery (CTS)• Caused by pre-existing degenerative changes to myocardium and perioperative conditions that alter electrophysiological parameters• Per P&T approved protocol, all patients undergoing CTS will be initiated prophylactic medications post-operatively unless contraindicated. After extubation, patients will be switched to oral equivalents• Amiodarone 150 mg IV bolus followed by amiodarone infusion 1 mg/minute x6 hours then decrease rate to 0.5 mg/min x 18 hours• Metoprolol 5 mg IV every 6 hours, Hold for SBP < 100 or HR < 60 or if currently paced via epicardial wires• Ketorolac 30 mg IV every 6 hours x 48 hours while intubated reduce dose to 15 mg IV every 6 hours for CrCl 25-50 mL/min. Do not give ketorolac if patient is actively bleeding or CrCl < 25 mL/min• In April 2018, an interim analysis was done on 50 patients pre protocol implementation, and 100 patients post protocol implementation• This interim analysis helped guide nurses by helping to establish current hold parameters for protocol medications• Compare the incidence of POAF CTS patients prior to and after implementation of a protocol that standardizes the prophylactic management of Post-Operative Atrial Fibrillation (POAF) in all post-operative patients• Study Design: Single center, IRB exempt, retrospective chart review pre and post protocol implementation• Data Collection Period:• Pre Implementation: June 1st, 2017 to August 31st, 2017• Interim Evaluation: October 1st, 2017 to February 29th,  2018• Ad Hoc: March 1st, 2018 to October 21st 2018• Inclusion criteria• Age ≥ 18 years• Received Coronary Artery Bypass Graft and/or valvular surgery during pre and post protocol implementation periods listed above• Exclusion criteria• Active atrial fibrillation/flutter or either arrhythmia at time of surgery• Primary Endpoint• Incidence of POAF in CTS, patients prior to and after protocol implementation• Secondary Endpoint• Intensive Care Unit (ICU) and hospital Length of Stay (LOS)• Safety of protocol medications• P&T approved protocol complianceBACKGROUNDOBJECTIVESMETHODSRESULTSCONCLUSIONSDISCLOSURESREFERENCES• Incidence of POAF following CTS has reduced from 36% pre protocol to 22% post protocol with a relative risk reduction of 39%• Prescribing of amiodarone and NSAIDs through this protocol has continued to improve post protocol implementation• The number of protocol medications received is indirectly proportional to incidence of POAF development• History of Atrial Fibrillation poses a major risk for POAF development after CTS• The study contributors have nothing to disclose regarding any financial or nonfinancial relationships with the products described, reviewed, or evaluated in this presentation.1. Hashemzadeh K, Dehdilani M, Dehdilani M. Postoperative Atrial Fibrillation following Open Cardiac Surgery: Predisposing Factors and Complications. J Cardiovasc Thorac Res. 2013; 5(3):101-72. Dunning J, Treasure T, Versteegh M, Nashef SA; EACTS Audit and Guidelines Committee. Guidelines on the prevention and management of de novo atrial fibrillation after cardiac and thoracic surgery. Eur J Cardiothorac Surg. 2006 Dec;30(6):852-723. Fuster, V, Ryden LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Kay GN, Le Huezey JY, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann LS, Smith SC Jr, Priori SG, Estes NA 3rd, Ezekowitz, MD, Jackman WM, January CT, Lowe JE, Page RL, Slotwiner DJ, Stevenson WG, Tracy CM, Jacobs AK, Anderson JL, Albert N, Buller CE, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochmanm JS, Kushner FG, Ohman EM, Stevenson WG, Tarkington LG, Yancy CW; American College of Cardiology Foundation/American Heart Association Task Force. 2011 ACCF/AHA/HRS focused updates incorportated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2011 Mar 15;123(10):e269-4. January, CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE< Cleveland JC Jr, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG Tchou PJ, Tracy CM, Yancy CW; ACC/AHA Task Force Members. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014 Dec 2;130(23):2071Percent of Patients with Post Op Atrial FibrillationOUTCOMEUtilization of Prophylactic AgentsOngoing evaluation of the impact of a post-operative atrial fibrillation prevention protocol for patients undergoing cardiothoracic surgeryKamarena Sankar, PharmD; Jonathan Kline, PharmD, BCCCP; Heidi Clarke, PharmD, BCCCP; Radhan Gopalani, PharmD, BCPS; Faaria Quadri, PharmD, BCPS; Baptist Hospital of Miami, Department of Pharmacy; Miami, FL36%25%16%Pre Interim Ad Hoc74087884447286640102030405060708090100BB (%) Amiodarone (%) NSAID (%)Pre Interim Ad HocNo POAF (n=117) POAF (n=33)History of atrial fibrillation, n (%) 9 (8) 15 (45)Mitral valvular disease, n (%) 9 (8) 6 (18)Time on cardiopulmonary bypass (min) 98 139Hypotension requiring vasopressors, n (%) 51 (44) 21 (64)Pre Interim Ad HocICU LOS (days) 3 3.3 3.3Hospital LOS (days) 8 8.9 8.8LIMITATIONS• Small sample size• Two different investigators at different stages of the data collectionLength of StayPre(n=50)Interim(n=100)Ad Hoc(n=50)Age (years) 63 63 64Gender - male, n (%) 35 (70) 70 (70) 32 (64)CABG 32 (64) 60 (60) 36 (72)x1 3 (6) 11 (11) 6 (12)x2 13 (26) 21 (21) 21 (44)x3 15 (30) 21 (21) 13 (26)x4 1 (2) 7 (7) 1 (2)Valvular 12 (24) 30 (30) 9 (18)Aortic 6 (12) 21 (21) 5 (10)Mitral 6 (12) 10 (10) 4 (8)Combined 6 (12) 10 (10) 5 (10)Emergent 24 (48) 49 (49) 29 (58)Baseline CharacteristicsOUTCOMESRisk Factor Comparison (n=150)No POAF (n=117) POAF (n=33)Number of agents receivedAll three agents received, n (%) 52 (44) 8 (24)Two agents received, n (%) 44 (38) 9 (27)One agent received, n (%) 19 (16) 12 (36)No agent received, n (%) 2 (2) 4 (12)Protocol Compliance (n=150)Metoprolol Amiodarone NSAIDReceived Therapy 114 127 76ADR Requiring Dose Reduction or Discontinuation 18 31 12Safety Evaluation (n=150)Overall post protocol incidence of POAF = 22%

Ongoing evaluation of the impact of a post-operative atrial fibrillation prevention protocol for patients undergoing cardiothoracic surgery

Baptist Health South Florida Scholarly Commons @ Baptist Health South Florida All Publications 8-26-2019 Ongoing Evaluation of the Impact of a Post-operative Atrial Fibrillation Prevention Protocol for Patients Undergoing Cardiothoracic Surgery Kamarena Sankar Baptist Hospital of Miami, kamarenas@baptisthealth.net Jonatha Kline Baptist Health South Florida, JonathanDK@baptisthealth.net Heidi Clarke Baptist Hospital of Miami, heidic@baptisthealth.net Radhan Gopalani Baptist Hospital of Miami, radhang@baptisthealth.net Faaria Quadri Baptist Hospital of Miami, FaariaQ@baptisthealth.net Follow this and additional works at: https://scholarlycommons.baptisthealth.net/se-all-publications Citation Sankar, Kamarena; Kline, Jonatha; Clarke, Heidi; Gopalani, Radhan; and Quadri, Faaria, "Ongoing Evaluation of the Impact of a Post-operative Atrial Fibrillation Prevention Protocol for Patients Undergoing Cardiothoracic Surgery" (2019). All Publications. 3349. https://scholarlycommons.baptisthealth.net/se-all-publications/3349 This Conference Poster -- Open Access is brought to you for free and open access by Scholarly Commons @ Baptist Health South Florida. It has been accepted for inclusion in All Publications by an authorized administrator of Scholarly Commons @ Baptist Health South Florida. For more information, please contact Carrief@baptisthealth.net. • Atrial Fibrillation is a common post-operative complication that may occur in up to 40% of patients following cardiothoracic surgery (CTS)• Caused by pre-existing degenerative changes to myocardium and perioperative conditions that alter electrophysiological parameters• Per P&T approved protocol, all patients undergoing CTS will be initiated prophylactic medications post-operatively unless contraindicated. After extubation, patients will be switched to oral equivalents• Amiodarone 150 mg IV bolus followed by amiodarone infusion 1 mg/minute x6 hours then decrease rate to 0.5 mg/min x 18 hours• Metoprolol 5 mg IV every 6 hours, Hold for SBP < 100 or HR < 60 or if currently paced via epicardial wires• Ketorolac 30 mg IV every 6 hours x 48 hours while intubated reduce dose to 15 mg IV every 6 hours for CrCl 25-50 mL/min. Do not give ketorolac if patient is actively bleeding or CrCl < 25 mL/min• In April 2018, an interim analysis was done on 50 patients pre protocol implementation, and 100 patients post protocol implementation• This interim analysis helped guide nurses by helping to establish current hold parameters for protocol medications• Compare the incidence of POAF CTS patients prior to and after implementation of a protocol that standardizes the prophylactic management of Post-Operative Atrial Fibrillation (POAF) in all post-operative patients• Study Design: Single center, IRB exempt, retrospective chart review pre and post protocol implementation• Data Collection Period:• Pre Implementation: June 1st, 2017 to August 31st, 2017• Interim Evaluation: October 1st, 2017 to February 29th,  2018• Ad Hoc: March 1st, 2018 to October 21st 2018• Inclusion criteria• Age ≥ 18 years• Received Coronary Artery Bypass Graft and/or valvular surgery during pre and post protocol implementation periods listed above• Exclusion criteria• Active atrial fibrillation/flutter or either arrhythmia at time of surgery• Primary Endpoint• Incidence of POAF in CTS, patients prior to and after protocol implementation• Secondary Endpoint• Intensive Care Unit (ICU) and hospital Length of Stay (LOS)• Safety of protocol medications• P&T approved protocol complianceBACKGROUNDOBJECTIVESMETHODSRESULTSCONCLUSIONSDISCLOSURESREFERENCES• Incidence of POAF following CTS has reduced from 36% pre protocol to 22% post protocol with a relative risk reduction of 39%• Prescribing of amiodarone and NSAIDs through this protocol has continued to improve post protocol implementation• The number of protocol medications received is indirectly proportional to incidence of POAF development• History of Atrial Fibrillation poses a major risk for POAF development after CTS• The study contributors have nothing to disclose regarding any financial or nonfinancial relationships with the products described, reviewed, or evaluated in this presentation.1. Hashemzadeh K, Dehdilani M, Dehdilani M. Postoperative Atrial Fibrillation following Open Cardiac Surgery: Predisposing Factors and Complications. J Cardiovasc Thorac Res. 2013; 5(3):101-72. Dunning J, Treasure T, Versteegh M, Nashef SA; EACTS Audit and Guidelines Committee. Guidelines on the prevention and management of de novo atrial fibrillation after cardiac and thoracic surgery. Eur J Cardiothorac Surg. 2006 Dec;30(6):852-723. Fuster, V, Ryden LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Kay GN, Le Huezey JY, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann LS, Smith SC Jr, Priori SG, Estes NA 3rd, Ezekowitz, MD, Jackman WM, January CT, Lowe JE, Page RL, Slotwiner DJ, Stevenson WG, Tracy CM, Jacobs AK, Anderson JL, Albert N, Buller CE, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochmanm JS, Kushner FG, Ohman EM, Stevenson WG, Tarkington LG, Yancy CW; American College of Cardiology Foundation/American Heart Association Task Force. 2011 ACCF/AHA/HRS focused updates incorportated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2011 Mar 15;123(10):e269-4. January, CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE< Cleveland JC Jr, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG Tchou PJ, Tracy CM, Yancy CW; ACC/AHA Task Force Members. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014 Dec 2;130(23):2071Percent of Patients with Post Op Atrial FibrillationOUTCOMEUtilization of Prophylactic AgentsOngoing evaluation of the impact of a post-operative atrial fibrillation prevention protocol for patients undergoing cardiothoracic surgeryKamarena Sankar, PharmD; Jonathan Kline, PharmD, BCCCP; Heidi Clarke, PharmD, BCCCP; Radhan Gopalani, PharmD, BCPS; Faaria Quadri, PharmD, BCPS; Baptist Hospital of Miami, Department of Pharmacy; Miami, FL36%25%16%Pre Interim Ad Hoc74087884447286640102030405060708090100BB (%) Amiodarone (%) NSAID (%)Pre Interim Ad HocNo POAF (n=117) POAF (n=33)History of atrial fibrillation, n (%) 9 (8) 15 (45)Mitral valvular disease, n (%) 9 (8) 6 (18)Time on cardiopulmonary bypass (min) 98 139Hypotension requiring vasopressors, n (%) 51 (44) 21 (64)Pre Interim Ad HocICU LOS (days) 3 3.3 3.3Hospital LOS (days) 8 8.9 8.8LIMITATIONS• Small sample size• Two different investigators at different stages of the data collectionLength of StayPre(n=50)Interim(n=100)Ad Hoc(n=50)Age (years) 63 63 64Gender - male, n (%) 35 (70) 70 (70) 32 (64)CABG 32 (64) 60 (60) 36 (72)x1 3 (6) 11 (11) 6 (12)x2 13 (26) 21 (21) 21 (44)x3 15 (30) 21 (21) 13 (26)x4 1 (2) 7 (7) 1 (2)Valvular 12 (24) 30 (30) 9 (18)Aortic 6 (12) 21 (21) 5 (10)Mitral 6 (12) 10 (10) 4 (8)Combined 6 (12) 10 (10) 5 (10)Emergent 24 (48) 49 (49) 29 (58)Baseline CharacteristicsOUTCOMESRisk Factor Comparison (n=150)No POAF (n=117) POAF (n=33)Number of agents receivedAll three agents received, n (%) 52 (44) 8 (24)Two agents received, n (%) 44 (38) 9 (27)One agent received, n (%) 19 (16) 12 (36)No agent received, n (%) 2 (2) 4 (12)Protocol Compliance (n=150)Metoprolol Amiodarone NSAIDReceived Therapy 114 127 76ADR Requiring Dose Reduction or Discontinuation 18 31 12Safety Evaluation (n=150)Overall post protocol incidence of POAF = 22%

Ongoing Evaluation of the Impact of a Post-operative Atrial Fibrillation Prevention Protocol for Patients Undergoing Cardiothoracic Surgery

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Ongoing Evaluation of the Impact of a Post-operative Atrial Fibrillation Prevention Protocol for Patients Undergoing Cardiothoracic Surgery

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