Driver

Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with refractory ventricular fibrillation

Driver. Resuscitation 2014;(85),1337-1341. http://dx.doi.org/10.1016/j.resuscitation.2014.06.032

Clinical Question

  • In patients with refractory ventricular fibrillation does the use of esmolol improve mortality?

Design

  • Retrospective observational analysis
  • Non-randomised
  • Non-blinded

Setting

  • Single centre, tertiary Emergency Department, USA
  • January 2011 – January 2014

Population

  • Inclusion:
    • ED diagnosis coded as: cardiac arrest, ventricular fibrillation or pulseless VT
    • initial rhythm: VF or VT
    • had received at least 3 defibrillation attempts, 300mg amiodarone and 3mg adrenaline and remained in cardiac arrest
  • Exclusion: received esmolol before cardiac arrest or after return of spontaneous circulation
  • 25 patients included

Intervention

  • Esmolol
    • loading dose 500mcg/kg
    • followed by infusion: 0-100mcg/kg/min

Control

  • Patients that did not receive esmolol

Outcome

  • Primary outcome: not defined
    • survival with good neurological outcome
      • 50% in esmolol group vs. 11% in control group, P=0.07
    • no significant difference in rates of ROSC or survival to discharge

Authors’ Conclusions

  • Prospective studies of beta-blockade in cardiac arrest are warranted. In patients with refractory VF beta-blockade should be considered

Strengths

  • Clear inclusion/exclusion criteria
  • Standardised dosing of esmolol
  • Reported use of therapeutic hypothermia and emergent cardiac catheterisation
  • Reported patient-orientated outcomes

Weaknesses

  • Retrospective
  • Small sample size
  • Non-randomised, non-blinded. Unclear why some patients treated with esmolol and others were not. Unclear why different rates of therapeutic hypothermia and emergent cardiac catheterisation between the two groups

The Bottom Line

  • The use of esmolol for refractory VF was associated with a dramatic, but non significant, improvement in mortality. This association may be due to a causal effect of esmolol. However, the small sample size or confounding variables such as the use of therapeutic hypothermia and emergent cardiac catheterisation may also account for the differences found. Further studies are required. In the mean time, if I have a patient with refractory VF, with no other treatment options available such as cardiac catheterisation I will use esmolol prior to stopping resuscitation.
  • Survival with good neurological outcome can be achieved with prolonged CPR (56-68 minutes)

External Links

Metadata

Summary author: @davidslessor
Summary date: 17 Dec 2014
Peer-review editor: @DuncanChambler

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