UMEM Educational Pearls

Category: Pharmacology & Therapeutics

Title: Esmolol for Refractory Ventricular Fibrillation (VF) or Pulseless Ventricular Tachycardia (VT)

Keywords: esmolol, cardiac arrest, ventricular tachycardia, ventricular fibrillation (PubMed Search)

Posted: 9/5/2020 by Ashley Martinelli (Updated: 4/16/2024)
Click here to contact Ashley Martinelli

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.

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.

A recent meta-analysis of 3 trials of beta-blockade vs control patients for refractory VF/VT found:

	Beta-blockade N=22	Control N= 44	OR/CI
Temporary ROSC, n (%)	19 (86.4)	14 (31.8)	OR 14.46, 95% CI 3.63-57.57
Sustained ROSC, n (%)	13 (59.1)	10 (22.7)	OR 5.76, 95% CI 1.79-18.52
Survival with neurological function, n (%)	6 (27.3)	4 (9.1)	OR 4.42; 95% CI 1.05-18.56

Takeaway: Esmolol needs to be studied further in prospective trials, but may be reasonable to attempt in refractory VF/VT.

Esmolol products:

§ Esmolol vial: 10 mg/mL (10mL)

o Vial strength listed in mg, not mcg

o Can cause complications with calculations, especially in high risk code scenario

§ Conversion of mg à mcg weight à based calculation 500mcg/kg

§ Do not ask anyone to do this calculation during a code!

§ Esmolol pre-made infusion: 2500 mg/250mL

o Pump is set up to deliver weight based doses in mcg/kg

o No mental math required!

How to do it at UMMC to limit mistakes in calculation:

1. Obtain an esmolol pre-made infusion bag

2. Program the pump for 50 mcg/kg/min continuous infusion (this is a required step in pump programming)

3. Program the pump to give a 500 mcg/kg bolus x 1

4. Permit the background infusion to run

5. Can give an additional bolus of 500 mcg/kg x 1 and increase rate to 100 mcg/kg/min depending on clinical response

References

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.