Mg Of Amiodarone Research Articles

Clinical features and outcomes of patients with refractory out-of-hospital cardiac arrest and an initial shockable rhythm

Abstract Background Clinical features of patients presenting with refractory out-of-hospital cardiac arrest (OHCA) and initial shockable rhythms of ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) remain poorly described. Purpose This study evaluated clinical characteristics, angiographic findings, and short-term outcomes among patients with refractory OHCA (defined as incessant VF/pVT after ≥3 direct-current shocks) compared to those without refractory OHCA. Methods Of 761 consecutive patients hospitalized for OHCA between 2014–2018 at two large tertiary health services in Victoria, Australia, 204 (27%) had an initial shockable rhythm and were stratified by the presence (n=74, 36%) or absence (n=130, 64%) of refractory OHCA. Primary outcome was in-hospital mortality. Multivariable logistic regression was performed to evaluate independent predictors of in-hospital mortality. Results The majority of patients were male (77%) and the median age was 62 years [IQR 52–72]. Refractory OHCA patients had longer cardiopulmonary resuscitation (23 vs 15 minutes), more frequently required ≥450 mg of amiodarone (34% vs 3.8%), had cardiogenic shock (80% vs 55%) necessitating higher adrenaline dose (4.0 vs 1.0 mg) and higher rates of mechanical ventilation (92% vs 74%) (all p<0.01). A total of 167 patients (82%) underwent coronary angiography, and refractory OHCA patients were less likely to be selected (74% vs 86%, p=0.035). No difference in door-to-needle times between those with and without refractory OHCA was noted (103 vs 99 minutes, p=0.586). Significant coronary artery disease (≥1 major vessel with >70% stenosis) was present in >70% of patients. Refractory OHCA group frequently had acute coronary occlusion (64% vs 47%), especially of the left circumflex artery (20% vs 6.4%) and graft vessel (7.3% vs 0.9%), and often had complex coronary lesions (type B2 or C) (57% vs 39%) compared to those without refractory OHCA (all p<0.05). Patients with both refractory OHCA and ST-elevation on electrocardiogram had the highest prevalence of acute coronary occlusion (85%, 22/26). Refractory OHCA group had higher rates of in-hospital mortality (45% vs 30%) and new requirement for dialysis (18% vs 6.3%) (all p<0.05). After adjustment, refractory OHCA heightened the risk of in-hospital mortality by over two-fold (OR 2.28, 95% CI 1.06–4.89, p=0.034) (Figure 1). Among those with refractory OHCA, higher cumulative prehospital adrenaline dose (OR 1.38, 95% CI 1.01–1.89 per 1 mg increase), and increased number of direct-current shocks (1.13, 1.00–1.27 per 1 additional shock) were independent predictors of in-hospital mortality, whereas undergoing coronary revascularization (0.28, 0.09–0.94) diminished this risk (all p<0.05) (Figure 2). Conclusion Refractory VF/pVT OHCA was associated with more intensive resuscitation, higher rates of acute coronary occlusion and poorer in-hospital outcomes, underscoring the need for future studies in this extreme-risk subgroup.Figure 1Figure 2

Amiodarone-Induced Myxedema Coma in Elderly Patients: A Systematic Review of Case Reports.

This systematic review aimed to explore whether elderly patients administered amiodarone were susceptible to developing myxedema coma. Utilizing the Cochrane guidelines, a comprehensive review of databases such as Medline (PubMed), Science Direct, CINAHL Cochrane, and Google Scholar was undertaken to examine case reports on amiodarone-induced myxedema coma. Following stringent criteria for inclusion, 12 pertinent case reports were identified. These findings suggested a high probability of myxedema coma development in patients who had been administered amiodarone. Specifically, patients who received an oral dosage of 100-200 mg of amiodarone were reported to have developed bradycardia and hypothermia alongside elevated thyroid-stimulating hormone (TSH) levels. Upon diagnosis, the majority of patients were treated with a regimen of levothyroxine and hydrocortisone medication. Despite the myriad potential causes of myxedema coma complicating the diagnosis, it was found that through a combination of clinical symptoms and serum TSH measurements, a confirmed diagnosis could be reached. Furthermore, it was observed that amiodarone-induced myxedema coma responded favorably to treatment with levothyroxine and glucocorticoids.

Esmolol, vector change, and dose-capped epinephrine for prehospital ventricular fibrillation or pulseless ventricular tachycardia

BackgroundRefractory ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT) cardiac arrest describes a subset of patients who do not respond to standard Advanced Cardiac Life Support (ACLS) interventions and are associated with poor outcomes. Esmolol administration and vector change defibrillation have shown promise in improving outcomes in these patients, however evidence is limited. ObjectivesThis study compares clinical outcomes between patients with prehospital refractory VF/pVT who received an Emergency Medical Service (EMS) bundle, comprised of esmolol administration, vector change defibrillation, and dose-capped epinephrine at 3 mg, to patients who received standard ACLS interventions. MethodsThis multicenter, retrospective, cohort study evaluated medical records between October 18, 2017 and March 15, 2022. Patients were enrolled if they experienced a prehospital cardiac arrest with the rhythm VF or pVT, had received at least three standard defibrillations, at least 3 mg of epinephrine, and 300 mg of amiodarone. Patients who received the EMS bundle after its implementation were compared to patients who received standard ACLS interventions prior to its implementation. The primary outcome was sustained return of spontaneous circulation (ROSC), defined as ROSC lasting 20 min without recurrence of cardiac arrest. Secondary outcomes included the incidence of any ROSC, survival to hospital arrival, survival at hospital discharge, and neurologically intact survival at hospital discharge. ResultsEighty-three patients were included in the study. Thirty-six were included in the pre-EMS bundle group and 47 patients were included in the post-EMS bundle group. Patients in the pre-EMS bundle group achieved significantly higher rates of sustained ROSC (58.3% vs 17%, p < 0.001), any ROSC (66.7% vs 19.1%, p < 0.001), and survival to hospital arrival (55.6% vs 17%, p < 0.001). The rates of survival to hospital discharge (16.7% vs 6.4%, p = 0.17) and neurologically intact survival at hospital discharge (5.9% vs 4.3%, p = 1.00) were not significantly different between groups. ConclusionsPatients who received the EMS bundle achieved sustained ROSC significantly less often and were less likely to have pulses at hospital arrival. The incidence of neurologically intact survival was low and similar between groups.

AMIODARONE-INDUCED PNEUMOTOXICITY AT LOWER DOSES THAN EXPECTED

TYPE: Late Breaking Abstract TOPIC: Lung Pathology PURPOSE: To determine if doses of amiodarone lower than 400 mg per day can result in increased risk of lung injury, such as pneumonitis or pulmonary fibrosis. METHODS: We used TriNetX, a federated, global research network that provides access to anonymized medical record information from more than 75 million patients in 55 large healthcare organizations. We created four patient cohorts consisting of patients on 100, 200, and 400 mg of amiodarone per day, as well as a control group not taking amiodarone. Patients with a history of lung disease were excluded. The 4 cohorts were evaluated for the endpoints of pneumonitis (ICD-10 code J84), and for the subset of pulmonary fibrosis (ICD-10 code J84.10). RESULTS: We found that at a low dose of 100 mg of amiodarone, risk of pneumonitis increased almost 4-fold (2.163% vs 0.554%), and the risk of pulmonary fibrosis was 2.2-fold increased (0.801% vs 0.355%). Doses of 100 vs 200 mg had comparable pneumonitis but at 200 mg the fibrosis risk increased significantly. See Fig. 1. Figure 1. Rates of pneumonitis and fibrosis at different amiodarone doses CONCLUSIONS: Amiodarone-associated pneumonitis and pulmonary fibrosis occur in a dose-dependent fashion, but doses of 100 and 200 mg had similar overall risk. All three amiodarone cohorts had significant risk elevation compared to the control group. CLINICAL IMPLICATIONS: The use of amiodarone at any dose can be associated with significant pulmonary toxicity compared to patients that are not taking it. Practitioners should be aware of these risks and properly inform and monitor patients who receive amiodarone treatment. DISCLOSURE: Nothing to declare. KEYWORD: Amiodarone pulmonary toxicity

Stellate Ganglion Block to Treat RVF: Case Report

Background Refractory Ventricular Fibrillation (RVF) is denoted as “ventricular fibrillation that is resistant to at least three defibrillation attempts, 300 mg of amiodarone, and does not exhibit Return of Spontaneous Circulation (ROSC) after &gt; 10 min of Cardiopulmonary Resuscitation (CPR)” Objective The case report describes the successful treatment of RVF with a Stellate Ganglion Block (SGB). Case Report The patient presented in the emergency department in severe respiratory distress leading to intubation. Shortly after being intubated, the patient was found to be in ventricular fibrillation. After CPR, ACLS protocol, and serial defibrillation the patient was in RVF. A beta blocker, metoprolol, was given and the patient received double sequential defibrillation three times but was still in ventricular fibrillation. A stellate ganglion block was then performed by a landmark approach, and after the next double sequential defibrillation, ROSC was obtained. The patient was alert and following commands for 6 hours and was extubated 5 days later. 8 days later, the patient subsequently passed away due to complications of hemodialysis. Conclusion SGB should be considered when treating RVF in the emergency department setting, after the failure of standard treatment methods. Why should an ED physician be aware of this? RVF treatment modalities in the emergency department differ from standard ACLS treatment, and ED physicians should be aware of this.

2226The randomised study of epicardial application of hydrogel with amiodarone for prevention of postoperative atrial fibrillation in patients after coronary artery bypass grafting

Abstract The purpose of our study was to evaluate safety and efficacy of local epicardial application of amiodarone - releasing hydrogel in the prevention of postoperative atrial fibrillation (AF) in patients undergoing coronary artery bypass grafting (CABG). Material and methods We present an open prospective randomised study, in which 60 patients (47 male), mean age of 62±8,5 were included. Baseline clinical, laboratory and instrumental characteristics were similar in all patients. Patients didn't have any arrhythmic complains or previously registered AF. All patients underwent elective CABG and were randomised into two groups: Group #1 (n=30) - had the amiodarone-releasing hydrogel application before chest closure, and Group #2 (n=30) regular CABG surgery, no local application. We used 60 mg of amiodarone in hydrogel. This dose was experimentally determined during previously performed animal study. Heart rhythm control was monitored continuously during first 5 postoperative days and occasionally (mornings and evenings) the remaining days before the discharge. The local ethics committee approved this study design. Results The incidence of postoperative AF occurrence was significantly lower in Group #1: AF was registered in 3.3% cases versus 37% of patients from Group #2 (p&lt;0.001). There was slight increase of PQ interval duration in Group #1 - 0.14 sec (0.12; 0.16), which however was significantly higher then in Group #2 - 0.12 (0.12; 0.14), (p&lt;0.01). QRS and QT intervals were similar in both groups without significant difference. There were no complications associated with the application procedure neither during postoperative period, such as AV block, infection or life-threatening situations. According to 5 days ECG monitoring, the average heart rate in the Group #1 was 59 (52; 60) beats per min versus 69 beats per min (65; 75) in Group #2 (p&lt;0.001). Temporary atrial or atrio-ventricular pacing used for correction of the heart rate if required in both groups. By the time of discharge none of the patients required permanent cardiac pacing. The length of stay in Group #1 was significantly shorter: 6 (6; 7) days versus 8 (8; 9) days (p&lt;0,001). Among all studied parameters, amiodarone-releasing hydrogel application and older age were statistically significant in postoperative AF occurrence (p&lt;0.01). According to the Cox regression model amiodarone-releasing hydrogel application decreases the incidence of postoperative AF by 18,9 folds. The older age instead increases the incidence of postoperative AF by 1,2 folds. Conclusions The local epicardial amiodarone (60 mg) application in hydrogel before chest closure is a safe procedure. This approach showed it's effectiveness in AF prevention in patient undergoing elective CABG.

P1900Amiodarone treatment duration and reasons for permanent drug discontinuation in patients with atrial fibrillation

Abstract Background and purpose Amiodarone is commonly use in patients with atrial fibrillation (AF), but the organ toxicity side effects limit its long-term use. We investigated the rates of and reasons for permanent amiodarone discontinuation among patients with AF in contemporary clinical practice. Methods A single-centre, ongoing, registry-based observational longitudinal study included consecutive AF patients prescribed with amiodarone in our hospital from January 2015 to December 2017. All patients underwent a loading protocol of 400–600 mg of amiodarone daily for 1–2 weeks, followed by 200–400mg daily for 4–8 weeks and 200mg daily or 1000mg weekly thereafter. Results Of 657 AF patients taking amiodarone (Mean age 62.2±11.0, female n=215 (32.6%), hypertension n=504 (76.7%), diabetes mellitus n=107 (16.3%), coronary arterial disease n=139 (19.8%), History of Myocardial infarction 86 (13.1%), Stroke/TIA 60 (9.1%), chronic kidney disease 157 (23.9%)), the drug was permanently discontinued in total of 248 patients (37.7%). The reasons for amiodarone discontinuation are shown in Figure. On multivariable Cox-regression analysis, physician's decision (HR 5.6; 95% CI 3.9–7.9, p&lt;0.001) and amiodarone side effects (HR 3.9; 95% CI 2.9–5.1, p&lt;0.001) were significantly associated with permanent amiodarone discontinuation. The overall time to discontinuation was 23.2±24.1 months. Compared with others, time to discontinuation was shorter in patients post AF ablation (17.3±21.3 vs 24.5±24.5, p=0.05), longer in those with AF progression (29.2±31.0 vs 20.9±20.3, p=0.014) and similar in patients with amiodarone side effects (23.7±17.7 vs 23.0±26.8, p=0.813). Pulmonary toxicity and proarrhythmia were not observed among study patients (Figure). Chart 1 Conclusion Our study showed that permanent discontinuation of amiodarone in contemporary clinical practice was due to the drug side effects in 12% of amiodarone-treated AF patients, occurring after a mean 2-year treatment course. The most prevalent side effect was thyroid dysfunction, whereas the prevalence of proarrhythmic effect was low. Notably, physician's fear of complications (which may not always be justified), also was an independent driver of permanent amiodarone discontinuation. More data are needed to inform optimal amiodarone use in AF patients in daily practice.

Evaluation of Amiodarone Use for New-Onset Atrial Fibrillation in Critically Ill Patients With Septic Shock.

Objective: To describe the use of amiodarone in critically ill, septic shock patients experiencing new-onset atrial fibrillation (NOAF) during the acute resuscitative phase of septic shock. Methods: Single-center, retrospective review of adult medical or surgical intensive care unit (ICU) patients with septic shock and NOAF. All patients received amiodarone for NOAF during the acute resuscitative phase of septic shock. The cohort was analyzed via descriptive statistics. Associations between amiodarone exposure and clinical outcomes were analyzed via a Cox proportional-hazards model. An a priori defined sensitivity analysis of hospital survivors was also employed. Main Results: A total of 239 patients were included in the analysis. Patients had a median baseline Charlson Comorbidity Index of 4 (interquartile range [IQR]: 2-6) and were acutely ill with a median Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 18 (IQR: 13-22) and an incidence of mechanical ventilation of 85%. In-hospital mortality was 56% with median ICU and hospital length of stay (LOS) of 9 and 15 days, respectively. Included patients received a median of 2760 (IQR: 1110-6415) mg of intravenous (IV) amiodarone during their ICU stay. Receipt of more than or equal to 2700 mg of amiodarone was identified as an independent factor associated with longer ICU LOS (hazard ratio [HR]: 1.30; 95% confidence interval [CI], 1.10-2.28). In a sensitivity analysis of hospital survivors (n = 105), receipt of more than or equal to 2700 mg of amiodarone remained independently associated with longer ICU LOS (HR: 1.64; 95% CI, 1.05-2.58). Conclusions: Exposure to more than or equal to 2700 mg of amiodarone in the setting of NOAF and septic shock is positively correlated with longer ICU LOS. Identifying opportunities to limit amiodarone exposure and address/resolve potential precipitating causes of NOAF in this clinical scenario may reduce the morbidity associated with septic shock.

One year experience with fast track algorithm in patients with refractory out-of-hospital cardiac arrest

BackgroundOverall prognosis in patients with out-of-hospital cardiac arrest (OHCA) remains poor, especially when return of spontaneous circulation (ROSC) cannot be achieved at the scene. It is unclear if rapid transport to the hospital with ongoing cardiopulmonary resuscitation (CPR) improves outcome in patients with refractory OHCA (rOHCA). The aim of this study was to evaluate the effect of a novel fast track algorithm (FTA) in patients with rOHCA. MethodsThis prospective single-center study analysed outcome in rOHCA patients treated with FTA. Historical patients before FTA-implementation served as controls. rOHCA was defined as: persistent shockable rhythm after three shocks and 300mg of amiodarone or persistent non-shockable rhythm and continuous CPR for 10min without ROSC after exclusion of treatable arrest causes. Results110 consecutive patients with rOHCA (mean age 56±14 years) were included. 40 patients (36%) were treated with FTA, 70 patients (64%) served as historical controls. Pre-hospital time was significantly shorter after FTA implementation (69±18 vs. 79±24min, p=0.02). Favourable neurological outcome (defined as cerebral performance categories Score 1 or 2) was significantly more frequent in FTA patients (27.5% vs. 11.4%, p=0.038). FTA-implementation showed a trend towards improved mortality (70.0% vs. 82.9%, p=0.151). Extracorporeal Life Support was similar between the two groups. ConclusionOur study suggests that a rapid transport algorithm with ongoing CPR is feasible, improves neurological outcome and may improve survival in carefully selected patients with rOHCA.

The Case Files

The Case Files

The effects of tibial intraosseous versus intravenous amiodarone administration in a hypovolemic cardiac arrest procine model.

This study compared the effects of amiodarone via tibial intraosseous (TIO) and intravenous (IV) routes on return of spontaneous circulation (ROSC), time to ROSC, maximum drug concentration (Cmax), time to maximum concentration (Tmax), and mean concentrations over time in a hypovolemic cardiac arrest model. Prospective, between subjects, randomized experimental design. TriService Research Facility. Yorkshire-cross swine (n = 28). Swine were anesthetized and placed into cardiac arrest. After 2 minutes, cardiopulmonary resuscitation (CPR) was initiated. After an additional 2 minute, 300 mg of amiodarone were administered via the TIO or the IV route. Blood samples were collected over 5 minutes. The plasma concentrations were analyzed using high-performance liquid chromatography tandem mass spectrometry. ROSC, time to ROSC, Cmax, Tmax, and mean concentrations over time. A multivariate analysis of variance indicated that there were no significant differences in the TIO and IV groups in ROSC (p = 0.515), time to ROSC (p = 0.300), Cmax (p = 0.291), or Tmax (p = 0.475). The mean Cmax of the TIO group was 56,292 ± 11,504 ng/mL compared to 74,258 ± 11,504 ng/mL for the IV group. The Tmax for TIO and IV groups were 120 ± 25 and 94 ± 25, respectively. A repeated measures analysis of variance indicated that there were no significant differences between the groups relative to concentrations over time (p > 0.05). The TIO provides rapid and reliable access to administer lifesaving medications during cardiac arrest.

A rare case of narrow QRS complex tachycardia.

The first ECG shows a regular narrow QRS complex tachycardia of approximately 160 beats/min. Clear P waves can be distinguished closely behind each QRS complex. These same P waves appear to be negatively deflected in the inferior leads, which could fit an atrioventricular (nodal) reentrant tachycardia (AVNRT) with retrograde P waves. In the next ECG, the R-P time appears to increase with every beat (arrows in Fig. 1), until a QRS complex (the fifth) is no longer followed by a P wave (triangle in Fig. 1). This is retrograde Wenckebach behaviour, in which the retrograde P wave appears to be an innocent bystander. Fig. 1 Retrograde Wenckebach behavior But it is not until the third ECG that we notice there is no longer any association between the QRS complexes and P waves. In this ECG, the morphology of the P wave has also changed, indicating a normal sinus rhythm (arrows in Fig. 2) with AV dissociation. In the rhythm strip at the bottom, we also notice a different QRS complex every third beat for the first 20 beats. This different QRS complex appears to be more narrow (approximately 80–90 ms) and is each time preceded by a sinus P wave, suggesting these might be fusion or capture beats (triangles in Fig. 2). Fig. 2 AV dissociation with fusion or capture beats These two findings combined lead to the conclusion that this rhythm can only be a ventricular tachycardia, most likely originating near or from the His-Purkinje system, resulting in a narrow QRS complex. Sinus rhythm was restored after intravenous administration of 300 mg of amiodarone. A narrow QRS ventricular tachycardia (VT) is not unusual, and has previously been described in patients with ischaemic heart disease [1, 2]. It has been reported in cases of idiopathic VT but mostly originates from structural heart disease in the His-Purkinje area, and has therefore been called fascicular tachycardia [3, 4]. In a selected group of 106 patients with VT, Hayes et al. reported five patients who had a QRS duration of less than 110 ms [5]. Four of these five patients underwent electrophysiological mapping during surgery and the focus of their VT was mostly mapped to the ventricular septum, close to the proximal conduction system, as with the location of the infarction in our patient. In this case, narrow QRS VT mimicked a supraventricular tachycardia. The various presentations of the P waves in the three consecutive ECGs (retrograde 1:1 conduction, retrograde Wenckebach and AV dissociation) made this a compelling case.

The effect of lidocaine and amiodarone on prevention of ventricular fibrillation in patients undergoing coronary artery bypass grafting.

Ventricular fibrillation is common after aortic declamping in patients undergoing open heart surgery. This situation has a negative impact on morbidity and mortality. The aim of this prospective study was to compare the effect of administering lidocaine versus amiodarone before aortic declamping during elective coronary bypass grafting, paying close attention to when the initial effect of amiodarone sets in. In this double blind, prospective, randomized, controlled study, 86 patients who were candidates for elective coronary artery bypass grafting were recruited into three groups: group lidocaine (group L, n=29); group amiodarone (group A, n=27); and group placebo (group P, n=30). Group L patients received 1.5 mg/kg of lidocaine 2 minutes before aortic declamping and group A patients received 300 mg of amiodarone intravenously 15 minutes before release of the aortic cross clamp. The primary endpoints were the incidence of ventricular fibrillation and the number of shocks required to terminate ventricular fibrillation. The frequency of ventricular fibrillation occurrence was significantly higher in group P (70%) when compared with group A (37%) and group L (38%) (P=.017). There was no statistically significant difference between the amiodarone and the lidocaine groups regarding ventricular fibrillation. However, when ventricular fibrillation occurred, the percentage of patients requiring electrical defibrillation was significantly higher in both group L and group P when compared with group A (P=.023). We suggest that during coronary arterial bypass surgery, administration of an amiodarone regime before release of the aortic cross clamp, paying particular attention to the start of the initial effect of amiodarone, is no more effective than lidocaine for prevention from arrhythmia; however, amiodarone reduces the need for electrical defibrillation.

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

IntroductionWe compare the outcomes for patients who received esmolol to those who did not receive esmolol during refractory ventricular fibrillation (RVF) in the emergency department (ED). MethodsA retrospective investigation in an urban academic ED of patients between January 2011 and January 2014 of patients with out-of-hospital or ED cardiac arrest (CA) with an initial rhythm of ventricular fibrillation (VF) or ventricular tachycardia (VT) who received at least three defibrillation attempts, 300mg of amiodarone, and 3mg of adrenaline, and who remained in CA upon ED arrival. Patients who received esmolol during CA were compared to those who did not. Results90 patients had CA with an initial rhythm of VF or VT; 65 patients were excluded, leaving 25 for analysis. Six patients received esmolol during cardiac arrest, and nineteen did not. All patients had ventricular dysrhythmias refractory to many defibrillation attempts, including defibrillation after administration of standard ACLS medications. Most received high doses of adrenaline, amiodarone, and sodium bicarbonate. Comparing the patients that received esmolol to those that did not: 67% and 42% had temporary return of spontaneous circulation (ROSC); 67% and 32% had sustained ROSC; 66% and 32% survived to intensive care unit admission; 50% and 16% survived to hospital discharge; and 50% and 11% survived to discharge with a favorable neurologic outcome, respectively. ConclusionBeta-blockade should be considered in patients with RVF in the ED prior to cessation of resuscitative efforts.

Intraoperative interfascicular ventricular tachycardia: A rare occurrence

Intraoperative interfascicular ventricular tachycardia: A rare occurrence

Amiodarone is a cost-neutral way of preventing atrial fibrillation after surgery for lung cancer

Our aim was to estimate the costs and health benefits of routinely administered postoperative amiodarone as a prophylactic agent in reducing the risk of atrial fibrillation in patients undergoing surgery for lung cancer. This was a cost-effectiveness study, based on the randomized, controlled, double-blinded PASCART study, using avoidance of atrial fibrillation as the measure of benefit. Two hundred and fifty-four eligible, consecutively enrolled patients, undergoing surgery for lung cancer at the department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark, were included and randomized to receive either 300 mg of amiodarone or placebo (5% aqueous dextrose solution), administered intravenously over 20 min immediately after surgery, followed by 600 mg of amiodarone/placebo orally twice per day (8 a.m. and 6 p.m.) for the first five postoperative days. In the amiodarone group there were 11 cases of atrial fibrillation, compared with 38 in the control group (P < 0.001). There were no differences in the length of hospital stay or resources used. The mean total costs per patient were equal and amounted to €7288 per patient (P = 0.23). There were no signs of adverse developments referable to amiodarone in this prophylactic regime. For patients undergoing surgery for lung cancer, routine use of postoperative prophylactic intravenous bolus and five subsequent days of oral amiodarone therapy reduces the risk of atrial fibrillation in a cost-neutral manner.

Effect of stem cell therapy on amiodarone-induced liver injury in albino rats

Introduction Sustained liver injury causes the development of fibrosis. For patients with end-stage fibrosis (cirrhosis) with subsequent portal hypertension, liver failure, and hepatocellular cancer, liver transplantation is the only effective method of treatment. However, it is associated with several complications and side effects. Aim of the work The present study aimed to determine the possible effect of human cord blood mesenchymal stem cell therapy on liver injury using amiodarone as a model of induced liver damage in albino rats. Materials and methods Twenty-three adult male albino rats were divided into three groups: group I (control) included six rats that were given 0.5ml Tween 80 orally for 2 weeks, group II included 10 rats that were given 5.4mg of amiodarone orally for 2 weeks, and group III included seven rats that were injected with stem cells in the tail vein following confirmation of liver damage and held for 4 weeks before sacrifice. Liver specimens were processed. Sections were subjected to the following stains: H&E, Masson's trichrome, and Prussian blue. Immunohistochemical studies were carried out for CD44 and human APF. Digital image analysis was used to determine the area % of collagen fibers and the optical density of α-fetoprotein-positive cells. The results were compared statistically. Results In group II, congested dilated blood sinusoids were observed. Some hepatocytes showed dark nuclei. Some hepatocytes appeared with dark nuclei and a strong acidophilic cytoplasm; others were ballooned. Mallory bodies were observed. Some portal areas showed intense mononuclear cellular infiltration. Extensive collagen fibers existed around some central veins and portal tracts and increased area % of collagen fibers was observed. Most histological findings were improved in group III. In addition, multiple-positive α-fetoprotein immunostained cells were detected and proved morphometrically by their increased mean optical density in comparison with group II. Conclusion It can be concluded that cord blood mesenchymal stem cell therapy induces amelioration in morphological changes associated with amiodarone-induced liver injury, provided therapy is initiated early in the development of the injury.

Amiodarone Significantly Decreases Atrial Fibrillation in Patients Undergoing Surgery for Lung Cancer

Postoperative atrial fibrillation occurs in 5% to 65% of patients undergoing thoracic surgery. Although postoperative atrial fibrillation often is regarded as a temporary, benign, operation-related problem, it is associated with a twofold to threefold increase in risk of adverse events, including transient or permanent stroke, acute myocardial infarction, and death. A total of 254 consecutively eligible enrolled patients undergoing surgery for lung cancer were included in this randomized, controlled, double-blinded trial. Patients received 300 mg of amiodarone or placebo intravenously over 20 minutes immediately after surgery and an oral dose of 600 mg of amiodarone or placebo twice daily during the first 5 postoperative days. The patients in the amiodarone prophylaxis group had a reduction in the risk of atrial fibrillation of 23% (12 to 31); number needed to treat was 4.4 (3.1 to 7.8). A total of 38 in the control group and 11 in the amiodarone group experienced atrial fibrillation (p<0.001). Adverse effects were observed in 10 patients equally distributed in both trial arms. Postoperative prophylaxis with a high dose of oral amiodarone after an intravenous bolus infusion is a safe, practical, feasible, and effective regimen for patients with lung cancer undergoing surgery. It significantly reduced the incidence of postoperative atrial fibrillation.

THIS MONTH IN Anesthesiology

In-training examination scores and three other factors were predictive. See the accompanying Editorial View on page 6 Spinal fentanyl concentration did not predict speed of onset or duration of labor analgesia.How should surgical patients be managed based on the available evidence?Prolonged prone positioning increases intraocular pressure.Naloxone and alternative nonopioid antagonists are discussed.Although perioperative β-blockade decreases cardiac events, it also increases perioperative stroke and mortality. In this retrospective study, the records of all noncardiac, nontransplant surgical patients over 1 yr were retrieved to investigate if β-blockade limits the cardiac reserve to compensate for acute surgical anemia. Of 4,387 patients, 26% received β-blockers within the first 24 hr of surgery. Major acute cardiac events (MACE) were defined as myocardial infarction, nonfatal cardiac arrest, and in-hospital mortality. MACE occurred approximately two times more frequently in β-blocked patients compared with β-blocker naive patients. This difference was restricted to those patients with hemoglobin decreases exceeding 35% of the baseline value. β-blocked patients do not appear to tolerate acute surgical anemia. See the accompanying Editorial View on page 12 Administration of oral amiodarone reduces atrial fibrillation (AF) after cardiac surgery; however, the hemodynamic safety and efficacy have not been studied in the absence of a preoperative loading dose. In this single-center, double-blind, double-dummy, randomized controlled trial, patients undergoing valvular surgery received either an intravenous loading dose of 300 mg of amiodarone or placebo in the operating room, followed by an infusion of 15 mg/kg per 24 hr for 2 days. Overall AF occurred more frequently in the perioperative intravenous amiodarone group compared with placebo and was associated with older age, recent myocardial infarction, preoperative angina, and use of a calcium channel blocker preoperatively. In patients undergoing cardiac valvular surgery, intravenous amiodarone increased the risk of AF during cardiac valvular surgery.A common cause of chronic pain and disability is neck pain and facet joint arthropathy accounts for the majority of cases. Diagnostic blocks of the nerves that innervate the cervical facet joint pain may result in false-positive results. The objective of this randomized, double-blind study was to evaluate the accuracy of medial branch blocks and effect of varying injectate volumes. All patients (n = 24) received cervical medial branch blocks (0.5 or 0.25 ml of bupivacaine and contrast). Aberrant spread was observed more frequently in patients in the 0.5-ml group and was most commonly observed (57%) when an injection at C3 engulfed the third occipital nerve. Among the 86 nerve blocks, foraminal spread occurred in 5 instances using 0.5 ml and in 2 cases with 0.25 ml. No significant difference in any outcome measure was observed between the prone and lateral positions. Reducing the volume during cervical medial branch blocks may improve precision and accuracy.

Perioperative Intravenous Amiodarone Does Not Reduce the Burden of Atrial Fibrillation in Patients Undergoing Cardiac Valvular Surgery

Atrial fibrillation is a common complication after cardiac surgery. Postoperative atrial fibrillation is associated with increased risks of morbidity and mortality, and, therefore, preventive strategies using oral amiodarone have been developed but are often unpractical. Intravenous amiodarone administered after the induction of anesthesia and continued postoperatively for 48 h could represent an effective strategy to prevent postoperative atrial fibrillation in patients undergoing cardiac valvular surgery. Single-center, double-blinded, double-dummy, randomized controlled trial in patients undergoing valvular surgery. Patients received either an intravenous loading dose of 300 mg of amiodarone or placebo in the operating room, followed by a perfusion of 15 mg . kg(-1) . 24 h(-1) for 2 days. The primary endpoint was the development of atrial fibrillation occurring at any time within the postoperative period. One hundred twenty patients were randomly assigned (mean age was 65 +/- 11 yr). Overall atrial fibrillation occurred more frequently in the perioperative intravenous amiodarone group compared with the placebo group (59.3 vs. 40.0%; P = 0.035). Four preoperative factors were found to be independently associated with a higher risk of developing postoperative atrial fibrillation: older age (P = 0.0003), recent myocardial infarction (<6 months; P = 0.026), preoperative angina (P = 0.0326), and use of a calcium channel blocker preoperatively (P = 0.0078) when controlling for groups. In patients undergoing cardiac valvular surgery, a strategy using intravenous amiodarone for 48 h is not efficacious in reducing the risk of atrial fibrillation during cardiac valvular surgery.