Title: Esmolol for Refractory Ventricular Fibrillation (VF) or Pulseless Ventricular Tachycardia (VT)<br/>Author: Ashley Martinelli<br/><a href='mailto:1912'>[Click to email author]</a><hr/><div style="color: rgb(33, 33, 33); font-family: wf_segoe-ui_normal, "Segoe UI", "Segoe WP", Tahoma, Arial, sans-serif, serif, EmojiFont; font-size: 15px; margin: 0px;">
<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">Patients with cardiac arrest due to VF/VT have a higher likelihood of survival compared to those with unshockable rhythms. Unfortunately some will still not survive even with following the AHA/ACLS algorithms leading to “refractory VF/VT.” The survival rate of refractory VF/VT is 3-15%, with poor neurologic outcomes. </span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">Esmolol has been proposed as a treatment for the electrical storm of VF/VT to counteract the deleterious effect of beta receptor stimulation by epinephrine.</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">A recent meta-analysis of 3 trials of beta-blockade vs control patients for refractory VF/VT found:</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;"> </span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">Beta-blockade</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">N=22</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">Control</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">N= 44</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">OR/CI</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">Temporary ROSC, n (%)</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">19 (86.4)</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">14 (31.8)</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">OR 14.46, 95% CI 3.63-57.57</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">Sustained ROSC, n (%)</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">13 (59.1)</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">10 (22.7)</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">OR 5.76, 95% CI 1.79-18.52</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">Survival with neurological function, n (%)</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">6 (27.3)</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">4 (9.1)</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">OR 4.42; 95% CI 1.05-18.56</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;"><b> </b></span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;"><b>Takeaway:</b> Esmolol needs to be studied further in prospective trials, but may be reasonable to attempt in refractory VF/VT.</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;"><b> </b></span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;"><b>Esmolol products:</b></span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;"><font style="font-family: Wingdings, serif, EmojiFont;">§</font><font style="font-family: Wingdings, serif, EmojiFont;"> </font><b>Esmolol vial: 10 mg/mL (10mL)</b></span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;"><font style="font-family: "Courier New", serif, EmojiFont;">o</font><font style="font-family: "Courier New", serif, EmojiFont;"> </font>Vial strength listed in mg, not mcg</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;"><font style="font-family: "Courier New", serif, EmojiFont;">o</font><font style="font-family: "Courier New", serif, EmojiFont;"> </font>Can cause complications with calculations, especially in high risk code scenario</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;"><font style="font-family: Wingdings, serif, EmojiFont;">§</font><font style="font-family: Wingdings, serif, EmojiFont;"> </font>Conversion of mg <font style="font-family: Wingdings, serif, EmojiFont;">à</font> mcg weight </span></font><font style="font-size: 14.6667px; font-family: Wingdings, serif, EmojiFont;">à</font><span style="font-family: Calibri, sans-serif, serif, EmojiFont; font-size: 14.6667px;"> </span><span style="font-size: 11pt; font-family: Calibri, sans-serif, serif, EmojiFont; text-indent: -18pt;">based calculation 500mcg/kg</span></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;"><font style="font-family: Wingdings, serif, EmojiFont;">§</font><font style="font-family: Wingdings, serif, EmojiFont;"> </font><u>Do not ask anyone to do this calculation during a code!</u></span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;"><font style="font-family: Wingdings, serif, EmojiFont;">§</font><font style="font-family: Wingdings, serif, EmojiFont;"> </font><b>Esmolol pre-made infusion: 2500 mg/250mL</b></span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;"><font style="font-family: "Courier New", serif, EmojiFont;">o</font><font style="font-family: "Courier New", serif, EmojiFont;"> </font>Pump is set up to deliver weight based doses in mcg/kg</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;"><font style="font-family: "Courier New", serif, EmojiFont;">o</font><font style="font-family: "Courier New", serif, EmojiFont;"> </font>No mental math required!</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;"> </span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;"><b>How to do it at UMMC to limit mistakes in calculation:</b></span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">1. Obtain an esmolol pre-made infusion bag</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">2. Program the pump for <u>50 mcg/kg/min continuous infusion</u> (this is a required step in pump programming)</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">3. Program the pump to give a <u>500 mcg/kg bolus x 1</u></span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">4. Permit the background infusion to run</span></font></div>
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<font size="2" style="font-family: Calibri, sans-serif, serif, EmojiFont;"><span style="font-size: 11pt;">5. Can give an additional bolus of 500 mcg/kg x 1 and increase rate to 100 mcg/kg/min depending on clinical response</span></font></div>
<fieldset><legend>References</legend>
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<span style="font-size: 11pt; font-family: Calibri, sans-serif, serif, EmojiFont;">Gottlieb M, Dyer S, Peska GD. Beta-blockade for the treatment of cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia: a systematic review and meta-analysis. Resuscitation 2020;146: 118-125.</span></div>
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