Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Dear editor,
Atrial fibrillation (AF) is frequent in shock patients admitted to the intensive care unit (ICU) [1, 2] and is associated with increased mortality [1]. Several mechanisms are involved in the development of AF in the context of acute circulatory failure, including hypovolemia and β1-adrenergic stimulation in response to endogenous catecholamine production as well as norepinephrine infusion [3]. Atrial fibrillation impairs left ventricular filling and consecutively stroke volume, and in fine potentially aggravates circulatory failure.
Pharmacological options to control AF-related tachycardia are limited. Calcium channel blockers are not frequently used because of long-term negative inotropic effects. Amiodarone is the most used drug but its optimal dosage to fine tune heart rate remains an issue, as well as its potential lung toxicity, especially in case of acute respiratory disease. Landiolol is a beta-blocker with highly β1 selective activity, used either in AF patients either to control heart rate or to prevent supraventricular arrhythmia occurrence in the context of cardiac surgery. Landiolol has an ultrashort half-life of 4 min and weaker negative inotropic effect compared with other intravenous β-blockers [4]. A recent randomized controlled trial in patient with sepsis/septic shock developing tachyarrhythmia showed that Landiolol infusion efficiently reduced heart rate without any significant hemodynamic side effect [5].
Anzeige
Here, we described in critically ill patients admitted to the ICU for SARS-CoV-2 infections presenting with AF, our experience of Landiolol use in terms of efficacy and safety.
Methods
In our 18-bed intensive care unit, we prospectively collected data from adult patients admitted for SARS-CoV-2 infections with persistent AF. When heart rate was over 120 bpm, Landiolol was started at a minimum dose of 0.2 µg/kg/min and progressively increased by steps of 0.2–0.4 µg/kg/min every hour to achieve 20% reduction in heart rate, without bolus. Hemodynamic parameters were recorded every 2 h during the first 24 h of drug infusion.
Results
Fifteen consecutive patients with SARS-CoV-2 infection were treated with Landiolol during a 6-month period. Median age was 70 [67–72] years old, 27% were female, and median SOFA score was 11 [7–12]. Six patients (6/15, 40%) had a history of chronic AF, and the other had recent AF resistant to electric cardioversion. Median left ventricular (LV) function was 55% [50–57] (Table 1) and no patient had LV ejection fraction < 40%. All included patients underwent invasive mechanical ventilation support and eleven (11/15, 73%) required norepinephrine. Median time between ICU admission and Landiolol initiation was 2 [0–5] days. Landiolol infusion was started at 0.2 µg/kg/min and dosage reached 3.9 [1.6–7.0] µg/kg/min at 24 h. Overall heart rate reduction was 23% (115 [108–117] vs 150 [138–160] bpm; p < 0.01, Wilcoxon signed-rank test), without any negative impact on global hemodynamic or tissue perfusion parameters (Table 1). Interestingly, during Landiolol infusion, norepinephrine need decreased in 9/11 patients (81%), and mean norepinephrine dose significantly decreased (0.7 [0.2–1] vs 1 [0.4–1.5] µg/kg/min; p = 0.04, Wilcoxon signed-rank test) (Fig. 1).
Table 1
Global hemodynamic and tissue perfusion parameters before and after (H24) Landiolol initiation
Patient characteristics
n = 15
Age (years old)
70 [67–72]
Women, n (%)
4 (27)
SOFA
11 [7–12]
Left ventricular ejection fraction (LVEF) (%)
55 [50–57]
LVEF ≥ 60% (n)
4/15
LVEF ≥ 50% and < 60% (n)
8/15
LVEF ≥ 40% and < 50% (n)
3/15
Time between ICU admission and injection (days)
2 [0–5]
Comorbidities, n (%)
Arterial hypertension
8 (53)
Diabetes mellitus
4 (27)
Vascular disease
5 (33)
Norepinephrine, n (%)
11 (73)
Mechanical ventilation, n (%)
15 (100)
Hemodynamic kinetics
H0
H24
p
Global hemodynamics
Heart rate (bpm)
150 [138–160]
115 [108–117]
< 0.01
Systolic blood pressure (mmHg)
115 [99–130]
120 [108–125]
0.70
Diastolic blood pressure (mmHg)
58 [51–74]
60 [53–66]
0.71
Mean arterial pressure (mmHg)
79 [69–89]
76 [72–88]
0.76
Norepinephrine dose (µg/kg/min)
1 [0.4–1.5]
0.7 [0.2–1]
0.04
Tissue perfusion parameters
Index capillary refill time (s)
2 [1.5–2.5]
2 [1.6–2.5]
0.75
Mottling score n (%)
0.62
0–1
12 (80)
13 (87)
2–3
1 (7)
2 (13)
> 4
2 (13)
0 (0)
Arterial lactate level (mmol/L)
3.2 [2–4.9]
2.2 [1.7–2.8]
0.05
×
Discussion
In this observational uncontrolled study, Landiolol was safely used to lower heart rate in critically ill patients with AF with normal or moderately altered cardiac function. Given that most patients under mechanical ventilation for SARS-CoV-2 infections received norepinephrine and that some of them had moderate left ventricular systolic function, Landiolol infusion was started at very low doses and maximal infusion rate at 24 h was lower than reported in studies on non-critically ill patients [6]. Using this protocol, hemodynamic tolerance was excellent without any significant arterial hypotension or alteration in peripheral tissue perfusion. Moreover, we observed a decrease in norepinephrine need after Landiolol initiation. Additional studies are required to investigate the potential beneficial mechanisms of Landiolol on global hemodynamics.
Anzeige
Acknowledgements
Not applicable.
Ethics approval and consent to participate
Not applicable for monocenter observational study.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests. H.A.O. declares having received fees for medical trainings from the laboratories AMOMED.
Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Wer ihn je erlebt hat, wird ihn nicht vergessen: den Schmerz, den die beim Öffnen oder Schließen des Reißverschlusses am Hosenschlitz eingeklemmte Haut am Penis oder Skrotum verursacht. Eine neue Methode für rasche Abhilfe hat ein US-Team getestet.
Der optimale Ansatz für die Blutdruckkontrolle bei Patientinnen und Patienten mit akutem Schlaganfall ist noch nicht gefunden. Ob sich eine frühzeitige Therapie der Hypertonie noch während des Transports in die Klinik lohnt, hat jetzt eine Studie aus China untersucht.
Zwar scheint es laut einer Studie aus den USA und Kanada bei der Reanimation von Kindern außerhalb einer Klinik keinen Unterschied für das Überleben zu machen, ob die Wiederbelebungsmaßnahmen während des Transports in die Klinik stattfinden oder vor Ort ausgeführt werden. Jedoch gibt es dabei einige Einschränkungen und eine wichtige Ausnahme.
Eine ältere Frau trinkt regelmäßig Sennesblättertee gegen ihre Verstopfung. Der scheint plötzlich gut zu wirken. Auf Durchfall und Erbrechen folgt allerdings eine Hyponatriämie. Nach deren Korrektur kommt es plötzlich zu progredienten Kognitions- und Verhaltensstörungen.
Update AINS
Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.