What is the summary of the New England Journal of Medicine (NEJM) article on refractory ventricular fibrillation (V fib)?

From the Guidelines

The most effective approach to managing refractory ventricular fibrillation (VF) involves a stepwise approach, starting with high-quality CPR and early defibrillation, followed by advanced interventions if initial attempts fail, as recommended by the 2018 American Heart Association guidelines 1. The management of refractory VF requires a comprehensive approach, including medication recommendations such as epinephrine 1mg IV every 3-5 minutes, amiodarone 300mg IV bolus followed by 150mg if needed, and lidocaine 1-1.5mg/kg IV, as supported by the 2018 evidence summary 1. Key considerations in the management of refractory VF include:

• The primary objective of antiarrhythmic drug therapy is to facilitate successful defibrillation and reduce the risk of recurrent arrhythmias 1
• Establishing vascular access to enable drug administration should not compromise the performance of CPR or timely defibrillation 1
• The optimal sequence of ACLS interventions, including administration of antiarrhythmic drugs during resuscitation, and the preferred manner and timing of drug administration in relation to shock delivery are still not known 1 The use of amiodarone or lidocaine may be considered to treat shock-refractory ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest, as recommended by the 2018 American Heart Association focused update on advanced cardiovascular life support 1. For truly refractory cases, considerations may include double sequential defibrillation using two defibrillators simultaneously or vector change defibrillation by repositioning pads, as well as the use of mechanical CPR devices to provide consistent compressions during prolonged resuscitation, and early consideration of extracorporeal membrane oxygenation (ECMO) for eligible patients, ideally within 60 minutes of arrest.

From the FDA Drug Label

1 INDICATIONS & USAGE Amiodarone hydrochloride injection is indicated for initiation of treatment and prophylaxis of frequently recurring ventricular fibrillation (VF) and hemodynamically unstable ventricular tachycardia (VT) in patients refractory to other therapy.

14 CLINICALSTUDIES ...The acute effectiveness of intravenous amiodarone in suppressing recurrent VF or hemodynamically unstable VT is supported by two randomized, parallel, dose-response studies of approximately 300 patients each

The NEJM article on refractory v fib is not directly mentioned in the provided drug labels. However, the labels do discuss the use of amiodarone in treating refractory ventricular fibrillation (VF) and ventricular tachycardia (VT).

• Key points:
  • Amiodarone is indicated for initiation of treatment and prophylaxis of frequently recurring VF and hemodynamically unstable VT in patients refractory to other therapy 2.
  • The acute effectiveness of intravenous amiodarone in suppressing recurrent VF or hemodynamically unstable VT is supported by two randomized, parallel, dose-response studies 2. No direct information about an NEJM article is provided in the drug labels.

From the Research

Refractory Ventricular Fibrillation Treatment

• Refractory ventricular fibrillation is defined as VF that persists despite three defibrillation attempts 3, 4
• Current advanced cardiac life support (ACLS) guidelines recommend defibrillation for the management of ventricular fibrillation (VF) and pulseless ventricular tachycardia 3, 5
• However, the best resuscitation strategy for patients with refractory VF remains unclear 3, 4

Therapies for Refractory Ventricular Fibrillation

• Esmolol, a β-blocker, has been shown to be effective in terminating refractory ventricular fibrillation in some cases 3, 4
• Dual sequential defibrillation (DSD) is another therapy that has been used to treat refractory VF, with some studies showing promising results 4, 5
• Vector change defibrillation and left stellate ganglion block are also being investigated as potential therapies for refractory VF 4
• Urgent coronary angiography, extracorporeal membrane oxygenation, and novel strategies for managing refractory ventricular fibrillation arrest are also being explored 6

Challenges and Future Directions

• Further evidence is required to establish the efficacy of these therapies and to develop standardized treatment protocols for refractory VF 4, 5
• Pharmacists and other healthcare professionals should be aware of the supporting evidence, safety considerations, and logistical challenges of utilizing these treatments during cardiac arrest 4, 7