Management of paroxysmal atrioventricular nodal reentrant tachycardia in the critically ill surgical patient

Objectives: Paroxysmal atrioventricular nodal reentrant tachycardia is an infrequently encountered supraventricular arrhythmia that continues to present difficult management problems in the critically ill surgical patient. The purpose of this study was to evaluate the efficacy of a new treatment algorithm involving the sequential administration of different classes of antiarrhythmic agents until conversion to sinus rhythm was achieved. Design: Nonrandomized, consecutive, protocol-driven descriptive cohort. Setting: University hospital surgical and trauma intensive care unit (ICU). Patients: During an 11-month period, we prospectively evaluated all hemodynamically stable patients who sustained new-onset atrioventricular nodal reentrant tachycardia. Interventions: Vagal maneuver, followed by the rapid, sequential infusion of antiarrhythmic agents (i.e., adenosine, verapamil, and esmolol, respectively) until the arrhythmia was terminated. Measurements and Main Results: Twenty-seven patients (4% of all admissions) were evaluated, including 16 trauma patients (Injury Severity Score of 20 ± 8) and 11 general surgical patients (Acute Physiology and Chronic Health Evaluation II score of 17 ± 7). Time from ICU admission to onset of atrioventricular nodal reentrant tachycardia was 4.5 ± 5 days (median 2.5). Arrhythmia termination was achieved in all patients within minutes (mean 13 10 [SD]). Incremental sequential adenosine administration alone, however, was successful in effecting conversion to sinus rhythm in only 44% of initial episodes of atrioventricular nodal reentrant tachycardia (95% confidence interval 21% to 67%). A total of 14 (52%) patients developed 38 relapses of paroxysmal supraventricular tachycardia in the ICU after initial conversion to sinus rhythm. These relapses required additional antiarrhythmic therapy. Adenosine was only effective in 34% of the relapses (95% confidence interval 17% to 53%). Seven (50%) of these 14 patients developed multiple relapses. However, only two patients were receiving suppressive calcium-channel or β-adrenergic receptor blockade at the time of relapse. Conclusions: The use of a multiagent algorithm was effective for the initial conversion of new-onset atrioventricular nodal reentrant tachycardia to sinus rhythm in critically ill surgical and trauma patients. This preliminary report suggests that adenosine has marginal efficacy in the critically ill surgical or trauma patient. Given the high frequency of relapses, regardless of the agents used to achieve initial control, suppression therapy for the arrhythmia during the period of maximal cardiovascular stress is essential.