What's the best anesthetic medication to use during ventricular tachycardia (VT) storm?

Anesthetic Management During Ventricular Tachycardia Storm

Amiodarone is the best anesthetic medication to use during ventricular tachycardia storm due to its superior efficacy in terminating refractory ventricular arrhythmias and improving survival compared to other agents. 1, 2

First-Line Pharmacological Management

Amiodarone Administration

• Initial dose: 150 mg IV over 10 minutes
• Follow with continuous infusion of 1 mg/min for 6 hours
• Maintenance infusion of 0.5 mg/min thereafter 3, 1
• For breakthrough episodes: Additional 150 mg supplemental infusions (mixed in 100 mL D5W infused over 10 minutes) 2

Rationale for Amiodarone

1. Superior efficacy in terminating VT and preventing recurrence compared to lidocaine (78% vs 27% immediate VT termination) 4
2. Higher survival rates to hospital admission compared to lidocaine (22.8% vs 12.0%) 5
3. Effective in patients with or without severe heart failure or acute myocardial infarction 3
4. Reduces number of life-threatening arrhythmias, required shocks, and episodes of symptomatic sustained VT 3

Alternative Agents Based on Clinical Scenario

For Hemodynamically Stable Monomorphic VT

1. Procainamide: 10-17 mg/kg IV at 20-30 mg/min

   • First choice for patients without severe heart failure or acute MI 3, 1
   • Higher conversion rates than lidocaine 6

2. Sotalol: 1.5 mg/kg IV over 5 minutes

   • Effective for stable monomorphic VT, including in patients with acute MI
   • Avoid in patients with prolonged QT interval 3

For Polymorphic VT/Torsades de Pointes

• Magnesium Sulfate: 1-2 g IV bolus if associated with prolonged QT interval 3
• Beta-blockers: High-dose therapy (particularly propranolol) for electrical storm 1

Important Clinical Considerations

Concurrent Management

• Correct electrolyte abnormalities:
  • Maintain potassium >4.0 mEq/L
  • Maintain magnesium >2.0 mg/dL 1
• Address underlying causes:
  • Urgent coronary revascularization if evidence of ischemia
  • Correct acid-base disturbances
  • Evaluate for drug toxicity 1

Monitoring During Administration

• Continuous ECG monitoring
• Blood pressure monitoring (watch for hypotension)
• Central venous access preferred for amiodarone concentrations >2 mg/mL 2
• Do not exceed initial infusion rate of 30 mg/min for amiodarone 2

Cautions and Contraindications

• Amiodarone: Risk of hypotension (less with newer formulations without vasoactive solvents) 3
• Procainamide: Avoid in severe heart failure or acute MI 3, 1
• Lidocaine: Less effective than amiodarone or procainamide (only 20% conversion rate) 7

Refractory VT Storm Management

• Consider electrical cardioversion if pharmacological management fails 3
• For drug-refractory polymorphic VT: Consider β-adrenoceptor blockade, intra-aortic balloon pumping, and emergency PTCA/CABG surgery 3
• Consider expert consultation for persistent wide-complex tachycardias 3, 1
• Evaluate for catheter ablation if VT storm is resistant to medical treatment 1

Amiodarone has demonstrated the most consistent evidence of effectiveness for VT storm with the best survival outcomes, making it the preferred anesthetic agent in this critical scenario.