Dexmedetomidine for Alcohol Withdrawal Syndrome.

OBJECTIVE: To review available evidence evaluating dexmedetomidine in alcohol withdrawal syndrome (AWS) while identifying gaps in evidence for its use in this setting. DATA SOURCES: A MEDLINE search (1966-August 2015) to identify English-language articles evaluating the efficacy and safety of dexmedetomidine in alcohol withdrawal. Key words included alcohol, withdrawal, delirium tremens, and dexmedetomidine. Additional references were identified from a review of literature citations. STUDY SELECTION AND DATA EXTRACTION: All English-language observational studies, retrospective reviews, and clinical trials were included. Case reports and case series describing the use of dexmedetomidine in 10 or fewer patients were excluded. DATA SYNTHESIS: One randomized, controlled trial, 1 prospective observational study, and 6 retrospective reviews were identified. The only randomized, controlled trial identified showed that the addition of dexmedetomidine decreases benzodiazepine requirements more than placebo in the first 24 hours after initiation compared with the 24 hours prior to initiation (-56.8 mg vs -8 mg; P = 0.037). Overall, dexmedetomidine appears to lower benzodiazepine requirements in patients with AWS and decreases the sympathomimetic response seen in these patients. There was no convincing evidence that dexmedetomidine improves clinical endpoints in patients with AWS, such as need for mechanical ventilation or intensive care unit or hospital length of stay. CONCLUSIONS: Dexmedetomidine reduces hypertension and tachycardia in AWS and also reduces benzodiazepine requirements; however, the impact of these findings on important clinical endpoints is yet to be determined. Dexmedetomidine may be useful as adjunctive therapy; however, it cannot be recommended as a single agent in the management of AWS.

Bilateral passive leg raising attenuates and delays tourniquet deflation-induced hypotension and tachycardia under spinal anaesthesia: a randomised controlled trial.

BACKGROUND: The pneumatic tourniquet is frequently used in total knee arthroplasty. Tourniquet deflation may result in hypotension and tachycardia caused by the rapid shift of blood volume back to the ischaemic limb and a decrease in cardiac preload. Passive leg raising (PLR) represents a 'self-volume challenge' that can result in an increase in preload. Such a PLR-induced increase in preload was hypothesised to attenuate the decrease in preload resulting from tourniquet deflation. OBJECTIVE: To evaluate the effect of PLR on hypotension and tachycardia following tourniquet deflation. DESIGN: A randomised controlled trial. SETTING: Single medical centre. PATIENTS: Seventy patients who underwent unilateral total knee arthroplasty were randomised into two groups: tourniquet deflation with PLR (n = 35) or without PLR (control group, n = 35). INTERVENTION(S): Patients in both groups were administered a single dose of plain bupivacaine for spinal anaesthesia. The pneumatic tourniquet was inflated on the thigh and the surgery was performed. The study composed of four steps: for the PLR group, step 1 - inflation of the tourniquet while the patient was supine; step 2 - the patient's legs were raised to a 45° angle; step 3 - the tourniquet was deflated while the patient's legs were still raised; and step 4 - the legs were returned to the supine position. In the control group, the same perioperative procedure was used, but PLR was not conducted. MAIN OUTCOME MEASURES: The patients' blood pressure and heart rate were measured before, during and after tourniquet deflation. RESULTS: After tourniquet deflation, the magnitude of the changes in blood pressure and heart rate was less in the PLR group than that in the control group. In addition, the blood pressure nadir also occurred later in the PLR group than in the controls. CONCLUSION: Bilateral PLR is a simple, reversible manoeuvre that mimics rapid fluid loading. Bilateral PLR attenuates the severity of, and delays the time to, hypotension and tachycardia following deflation of a lower limb tourniquet. TRIAL REGISTRATION: ClinicalTrials.gov number NCT01592669.

Small bolus of esmolol effectively prevents sodium nitroprusside-induced reflex tachycardia without adversely affecting blood pressure.

PURPOSE: Hypotensive anesthesia with sodium nitroprusside (SNP) often is associated with reflex tachycardia. The purpose of this study was to investigate whether a small bolus of esmolol could counteract SNP-induced reflex tachycardia and sympathetic activation without affecting blood pressure. MATERIALS AND METHODS: Using a time-series study design, 27 healthy young patients scheduled for mandibular osteotomy were enrolled in this study. General anesthesia was maintained with 2% sevoflurane and 67% nitrous oxide in oxygen. SNP was administered to decrease the mean arterial pressure to 55 to 65 mm Hg. When heart rate (HR) increased reflexively to higher than 95 beats/min from SNP-induced hypotension, esmolol 0.5 mg/kg was given. Blood pressure and HR were measured, and the low-frequency component (0.04 to 0.15 Hz) of systolic blood pressure variability and high-frequency component (0.15 to 0.4 Hz) of HR variability were calculated to evaluate the autonomic condition. Data were analyzed using 1-way analysis of variance after multiple comparisons or t test. P < .05 was considered statistically significant. RESULTS: Of the 27 patients analyzed, 19 patients (70%) required esmolol. In these patients, SNP caused an increase in the low-frequency component of systolic blood pressure variability and a decrease in the high-frequency component of HR variability, leading to tachycardia (HR range, 95.9 ± 7.3 to 106.7 ± 7.4 beats/min; P < .001). Esmolol suppressed the effects of SNP on the low-frequency component of systolic blood pressure variability and high-frequency component of HR variability, resulting in an immediate decrease in HR to 86.9 ± 6.2 beats/min (P < .001), whereas mean arterial pressure remained unchanged. CONCLUSIONS: A small bolus of esmolol can suppress reflex tachycardia without significantly changing mean arterial pressure. Thus, esmolol restores the autonomic imbalance induced by SNP during hypotensive anesthesia.

[Comparative study between landiolol and amiodarone for therapeutic efficacy after open heart surgery].

Tachyarrhythmia, especially atrial fibrillation, remains as a common complication after open heart surgery and sometimes leads to fatal condition. Many reports showed that landiolol (ultra short-acting beta one blocker) and amiodarone were effective against postoperative atrial fibrillation (POAF). However, there were few comparative studies between these 2 drugs as prophylactic agents, and no report mentioned the therapeutic efficacy. Our study suggests that landiolol be the 1st choice for rate control of tachyarrhythmia because of easy dose adjustment and mild side effects. Amiodarone may be useful for the patients whose left ventricular function is poor.

[Risk management in brachial plexus block].

Peripheral nerve block has many advantages in surgical anesthesia with or without general anesthesia; postoperative analgesia, faster postoperative rehabilitation, and chronic pain management. However, serious adverse complications after peripheral nerve block can happen. Therefore, anesthetists should obtain full informed consent for possible complications, and require scrupulous attention to this procedure. This review focuses on complications of brachial plexus block because it is the most popular peripheral nerve block.

[Life-threatening cardiac arrhythmias]. / Akut lebensbedrohliche Herzrhythmusstörungen.

Cardiac arrhythmias are a common phenomenon and can be a challenge for the treating physicians in the acute situation. The article presents the different bradycardic and tachycardic cardiac arrhythmias and their treatment with practical advices for diagnosis.

Treatment of a recurrent atrial tachycardia by isolation of the right inferior pulmonary vein using a multi-electrode duty cycled ablation catheter.

We report on a 29-year-old man who underwent an ablation procedure for a focal atrial tachycardia. Three-dimensional mapping located the site of origin to the ostium of the right inferior pulmonary vein. By using a novel multi-electrode duty cycled ablation catheter, pulmonary vein isolation and elimination of tachycardia was achieved.

[Landiolol hydrochloride is useful for anesthetic management of cesarean section in a patient with Basedow disease].

We report successful anesthetic management of elective cesarean section in a 30-year-old patient with Basedow disease using landiolol hydrochloride, a short-acting beta-1 adrenergic blocker of which greatest advantages are its short duration of action, rapid clearance and high beta-1 selectivity. The patient received landiolol for the prevention of aggravated tachycardia and tachyarrhythmia during cesarean section. She received landiolol continuous infusion at a rate of 5 microg x kg x min(-1) to 8 microg x kg x min(-1) until the uneventful delivery of the infant with good Apgar score, under combined spinal epidural anesthesia (CESA). We could maintain maternal hemodynamics stable leading to good post-cesarean uterus contraction. No severe adverse effects were observed in the infant. In conculusion, landiolol is useful for maintaining the hemodynamics stable in a pregnant woman with Basedow disease and keeping the infant safe from any adverse effect by infusion of landiolol.

[64-year old patient with tachycardia and signs of heart failure]. / 64-jähriger Patient mit Herzrasen und Zeichen einer Herzinsuffizienz.

We report on a 64-year old patient with known Morbus Osler and high cardiac output failure due to distinct arterio-venous malformations of the liver. Since the patient suffered from severe right heart insufficiency despite optimized medical therapy, we decided to conduct an interventional occlusion of the hepatic shunts in three single sessions. The transient elevation of transaminases was reversible. After interventional therapy cardiac output decreased from 20 l/min to 15 l/min (25%) leading to a reduction of diuretic dosage and a sustained stabilization of the clinical condition.

[Sotalol prevents atrio-ventricular tachycardia but not atrial fibrillation with rapid ventricular response in a patient wiht WPW syndrome]. / Sotalol lagodzi objawy czestoskurczu przedsionkowo-komorowego, ale nie zapobiega migotaniu przedsionków.

We present a case of 23-year-old male with the Marfan syndrome multiple accessory pathways and atrio-ventricular reentry ant tachycardia (AVRT) as well as atrial fibrillation (AF). Sotalol was partially effective for AVRT, however, it did not prevent AF, RF ablation cured all arrythmias. This case shows that sotalol can attenuate AVRT recurrences, however, it does not prevent rapid conduction via accessory pathways during AF.

Clinically oriented device programming in bradycardia patients: part 1 (sinus node disease). Proposals from AIAC (Italian Association of Arrhythmology and Cardiac Pacing).

: Modern pacemakers have an increasing number of programable parameters and specific algorithms designed to optimize pacing therapy in relation to the individual characteristics of patients. When choosing the most appropriate pacemaker type and programing, the following variables must be taken into account: the type of bradyarrhythmia at the time of pacemaker implantation; the cardiac chamber requiring pacing, and the percentage of pacing actually needed to correct the rhythm disorder; the possible association of multiple rhythm disturbances and conduction diseases; the evolution of conduction disorders during follow-up. The goals of device programing are to preserve or restore the heart rate response to metabolic and hemodynamic demands; to maintain physiological conduction; to maximize device longevity; to detect, prevent, and treat atrial arrhythmia. In patients with sinus node disease, the optimal pacing mode is DDDR. Based on all the available evidence, in this setting, we consider appropriate the activation of the following algorithms: rate responsive function in patients with chronotropic incompetence; algorithms to maximize intrinsic atrioventricular conduction in the absence of atrioventricular blocks; mode-switch algorithms; algorithms for autoadaptive management of the atrial pacing output; algorithms for the prevention and treatment of atrial tachyarrhythmias in the subgroup of patients with atrial tachyarrhythmias/atrial fibrillation. The purpose of this two-part consensus document is to provide specific suggestions (based on an extensive literature review) on appropriate pacemaker setting in relation to patients' clinical features.

Cognitive aids: 'a must' for procedures performed by multidisciplinary sedation teams outside the operation room?

The human brain might not perform optimally during stressful situations. Cognitive aids can help in such situations to carry out all necessary treatment steps in a correct order. We present the case of a severe anaphylactic reaction during a percutaneous radiological intervention to drain an echinococcosis cyst on the radiology suite outside the operation room (OR), in which cognitive aids were successfully used to optimise patient care by a multidisciplinary team. Cognitive aids do not replace experience and skills of the individual caregivers, but can be invaluable tools for multidisciplinary teams dealing with crisis situations outside the OR.

Potential roles of the wearable cardioverter-defibrillator in acute phase care of patients at high risk of sudden cardiac death: A single-center Japanese experience.

BACKGROUND: The wearable cardioverter-defibrillator (WCD) has been expected to play a role as an effective bridge therapy to implantable cardioverter-defibrillator (ICD) implantation in patients at high risk of ventricular tachyarrhythmias (VA). Although WCD has been available since April 2014 in Japan, its usefulness remains unclear. METHODS AND RESULTS: During the early period after hospitalization, patients at high risk of VA after excluding some elderly patients were prescribed WCD. The consecutive 50 patients with WCD use (median age 56 years, 38 for secondary prevention) were studied. We analyzed clinical efficacy and safety of WCD, and examined its potential roles. Of the 50 patients, 38 used WCD only during hospitalization. During WCD use [median 16 (IQR 8-33) days], all patients wore WCD for 98% of a day regardless of in or out-of-hospital use. Sustained VA was detected in 4 patients (8%; for primary prevention in 1) with 7 episodes, and 6 of 7 episodes required shock therapy. Of the 6 shock therapies, 4 were for sustained ventricular tachycardia with the median rate of 236beats/min (IQR 203-250), and the other 2 for ventricular fibrillation. Subsequently, only 27 patients (54%) of all underwent ICD implantation following the WCD use, because of reduced risk of VA after optimal pharmacological therapy or improvement in the left ventricular function. CONCLUSIONS: The WCD use for the acute phase care of patients at high risk of VA can be safe and effective, and may be useful for evaluating indication of ICD implantation.

Antitachycardia devices: realities and promises.

Nonpharmacologic therapy for ventricular arrhythmias has gained growing attention with the development of the implantable cardioverter-defibrillator. In addition, the reports of adverse effects of drug therapy from several studies, including the Cardiac Arrhythmia Suppression Trial (CAST), have supported the need for these devices. The development of new implantable cardioverter-defibrillators that have the capability of antitachycardia pacing, bradycardia pacing, cardioversion and defibrillation has enhanced their clinical utility. The currently available implantable cardioverter-defibrillators have been shown to significantly improve survival after sudden cardiac arrest in patients with life-threatening ventricular arrhythmias. Newer devices with expanded capabilities may reduce mortality even further. In this report the features of currently available antitachycardia devices and implantable cardioverter-defibrillators are reviewed and the features and current implant data on newer antitachycardia devices are discussed.

Electrical management of arrhythmias with emphasis on the tachycardias.

Information from stimulation studies in human beings with tachycardia has resulted in the application of cardiac pacing in the treatment of such patients. Short-term pacing is especially useful in patients with atrial flutter. Long-term pacing with use of chronically implanted units can be applied to patients with different types of supraventricular and ventricular tachycardia. In these patients careful electrophysiologic studies are required before the pacing device is implanted. New developments enabling automatic and more individually designed modes of pacing are urgently needed.

Evaluation of antiarrhythmic therapy using Holter monitoring.

Premature ventricular complexes and nonsustained ventricular tachycardia mark a person with structural cardiac disease as a high--risk candidate for sudden cardiac death. Such ventricular arrhythmias are considered potentially lethal and should be distinguished from both those that are benign and those that cause hemodynamic consequences (i.e., lethal or malignant arrhythmias). Noninvasive Holter monitoring is the principal technique for detecting and evaluating the presence of potentially lethal ventricular arrhythmias. These arrhythmias undergo a high degree of spontaneous variability. Thus, to define a therapeutic drug effect, a reduction in the frequency of premature ventricular complexes of at least 75% and a reduction in the frequency of nonsustained ventricular tachycardia by at least 90% are required to eliminate the likelihood of spontaneous variability as the cause of this change in the frequency of arrhythmia. To define proarrhythmia, a different algorithm must be applied. When using antiarrhythmic drugs, a quantitative ventricular arrhythmia baseline for both frequency and type of arrhythmia must be established so that after therapeutic intervention repeat Holter monitoring can determine whether efficacy, inefficacy or proarrhythmia had occurred. Holter monitoring clearly reveals differential antiarrhythmic response rates among classes of antiarrhythmic drugs in patients with benign or potentially lethal arrhythmias. However, preliminary data have not clearly defined the relation between antiarrhythmic pharmacotherapy and a reduction in sudden cardiac death. The results of large-scale clinical trials that have only recently been undertaken must be assessed to determine whether sudden cardiac death can be prevented by adequately suppressing potentially lethal ventricular arrhythmias.

Differentiation and mechanisms of prevention and termination of verapamil-sensitive sustained ventricular tachycardia.

The purpose of this study was to differentiate by means of electrophysiologic study, a drug's ability to terminate or to prevent ventricular tachycardia (VT). Differences between the 2 effects were examined in patients with VT and the underlying mechanisms were studied in verapamil-responsive idiopathic sustained VT. The clinical significance of the distinction for chronic oral drug therapy is discussed. Thirty-five cases of inducible sustained VT were studied. A drug was considered "preventive" if it prevented VT induction and repetitive ventricular response, and "terminating" if it stopped induced VT within 15 complexes or could stop VT after its intravenous administration. Prevention and termination occurred together in 13 of 19 cases (68%) with disopyramide, in 10 of 19 cases (53%) with procainamide, in 8 of 12 cases (67%) with lidocaine, in 11 of 15 cases (73%) with mexiletine, and in 10 of 16 cases (63%) with verapamil. In the 16 in which verapamil terminated VT, VT rate immediately before termination slowed markedly from 167 +/- 33 to 134 +/- 28 beats/min. In the 6 cases without preventative effects, minimal and maximal premature intervals for VT induction increased significantly, from 291 +/- 70 to 335 +/- 85 ms and 323 +/- 68 to 423 +/- 109 ms, respectively, after verapamil administration. In 2 cases in which verapamil had a terminating effect, 5 mg of verapamil restored sinus rhythm but 10 mg caused premature beats resembling VT complexes. In another 2, 5 mg of verapamil lengthened the minimal premature interval; 10 mg increased both minimal and maximal premature intervals and lengthened the VT cycle.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of coronary revascularization to prevent tachycardia recurrences in survivors of ventricular fibrillation.

Long-term follow-up of 29 consecutive survivors of ventricular fibrillation who underwent revascularization demonstrated that recurrent arrhythmics events were common. Because revascularization alone does not prevent arrhythmia recurrence, treatment with an implantable defibrillator should be considered in these patients.