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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.