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Failure of Standard ACLS Protocol in Refractory Ventricular Fibrillation Post Cardiac Bypass Surgery
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A3524 - Failure of Standard ACLS Protocol in Refractory Ventricular Fibrillation Post Cardiac Bypass Surgery
Author Block: U. Tariq1, R. Khan1, T. W. Jones2, W. Nasser3; 1Critical Care, Orlando Regional Medical Center, Orlando, FL, United States, 2Orlando Health, Orladno, FL, United States, 3Critical Care, Medicine/Pulmonary, Orlando, FL, United States.
Case Report: Post CABG arrhythmias represent a major cause of morbidity in patients. Incidence of supraventricular tachyarrhythmia is frequently encountered however sustained ventricular arrhythmias are quite uncommon after cardiac surgery with incidence of 0.41-1.4%. Epinephrine use can be lethal when used as an adjunct to resuscitation of cardiac arrest. Description: 64 year old Male patient with a past medical history of hypertension, coronary vessel disease (right coronary artery stent) and HIV (CD4 count of 359) was admitted to our institution for chest pain evaluation. Cardiac angiography was performed, which was significant for left ventricular ejection fraction of 60%, left main artery stenosis of 70% , left anterior descending artery stenosis of 70%, circumflex artery stenosis of 70% and a patent stent in right coronary artery. Patient underwent successful and uneventful 3-vessel CABG. 24 hours after his CABG he was noted to have decreased blood pressure and sudden decline in his mental status and immediately later was found to be in fine ventricular fibrillation (VFIB). Standard ACLS protocol was initiated. He was in refractory VFIB despite receiving amiodarone and attempted multiple cardioversions Ultimately the ACLS was stopped after thirty minutes due to unsuccessful outcome. Discussion: Refractory VFIB is rare after CABG. Epinephrine can predispose patients to VFIB by causing electoral storm, catecholamine surge and increasing myocardial oxygen demand due to beta adrenergic effects. Beta blockage (BB) is often overlooked during ACLS. It can block the deleterious effects of beta stimulation from exogenous epinephrine given during ACLS and also the endogenous catecholamine surge by the nervous system. We did not utilize BB during the ACLS procedure due the fact the guidelines suggest to use epinephrine pulseless VFIB. To date no randomized controlled human trial has evaluated early epinephrine administration in VFIB arrest and more research needs to be conducted to revise the current ACLS guidelines. We suggest the use of beta blockage and limit the use of epinephrine in refractory VFIB.
Author Block: U. Tariq1, R. Khan1, T. W. Jones2, W. Nasser3; 1Critical Care, Orlando Regional Medical Center, Orlando, FL, United States, 2Orlando Health, Orladno, FL, United States, 3Critical Care, Medicine/Pulmonary, Orlando, FL, United States.
Case Report: Post CABG arrhythmias represent a major cause of morbidity in patients. Incidence of supraventricular tachyarrhythmia is frequently encountered however sustained ventricular arrhythmias are quite uncommon after cardiac surgery with incidence of 0.41-1.4%. Epinephrine use can be lethal when used as an adjunct to resuscitation of cardiac arrest. Description: 64 year old Male patient with a past medical history of hypertension, coronary vessel disease (right coronary artery stent) and HIV (CD4 count of 359) was admitted to our institution for chest pain evaluation. Cardiac angiography was performed, which was significant for left ventricular ejection fraction of 60%, left main artery stenosis of 70% , left anterior descending artery stenosis of 70%, circumflex artery stenosis of 70% and a patent stent in right coronary artery. Patient underwent successful and uneventful 3-vessel CABG. 24 hours after his CABG he was noted to have decreased blood pressure and sudden decline in his mental status and immediately later was found to be in fine ventricular fibrillation (VFIB). Standard ACLS protocol was initiated. He was in refractory VFIB despite receiving amiodarone and attempted multiple cardioversions Ultimately the ACLS was stopped after thirty minutes due to unsuccessful outcome. Discussion: Refractory VFIB is rare after CABG. Epinephrine can predispose patients to VFIB by causing electoral storm, catecholamine surge and increasing myocardial oxygen demand due to beta adrenergic effects. Beta blockage (BB) is often overlooked during ACLS. It can block the deleterious effects of beta stimulation from exogenous epinephrine given during ACLS and also the endogenous catecholamine surge by the nervous system. We did not utilize BB during the ACLS procedure due the fact the guidelines suggest to use epinephrine pulseless VFIB. To date no randomized controlled human trial has evaluated early epinephrine administration in VFIB arrest and more research needs to be conducted to revise the current ACLS guidelines. We suggest the use of beta blockage and limit the use of epinephrine in refractory VFIB.
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