From the Guidelines
In a VT storm, the best benzodiazepine to use is not explicitly stated, but based on the available evidence, midazolam or lorazepam can be considered as adjunctive sedatives alongside an opiate for deep sedation, as suggested by the adapted algorithm for critically ill cardiovascular patients 1. When managing VT storm, it's crucial to prioritize reducing sympathetic tone and anxiety, which can perpetuate the arrhythmia.
- Benzodiazepines like midazolam or lorazepam can be used to achieve this, with dosages of 2-5 mg IV for midazolam and 1-2 mg IV for lorazepam.
- These medications should be used as part of a comprehensive treatment plan, including antiarrhythmic medications, beta-blockers, and potentially sedation or general anesthesia in refractory cases.
- The use of benzodiazepines in VT storm is supported by their ability to decrease sympathetic outflow from the central nervous system, reduce anxiety-induced catecholamine release, and provide mild sedation, which can help break the cycle of recurrent VT episodes, as implied by the study on sedation in the coronary intensive care unit 1.
- However, it's essential to monitor respiratory status and blood pressure when administering benzodiazepines, as they can cause respiratory depression and hypotension, especially in hemodynamically compromised patients.
- The study also notes that non-benzodiazepine sedatives are preferred due to their salutary effect on liberation from mechanical ventilation, delirium, and length of stay in ICU, but in the context of VT storm, benzodiazepines may still be considered as adjunctive therapy 1.
From the FDA Drug Label
The use of benzodiazepines, like lorazepam injection, is ordinarily only one step of a complex and sustained intervention which may require additional interventions (e.g., concomitant intravenous administration of phenytoin). For the treatment of status epilepticus, the usual recommended dose of lorazepam injection is 4 mg given slowly (2 mg/min) for patients 18 years and older.
The best benzo to use during VT storm is lorazepam (IV), with a recommended dose of 4 mg given slowly (2 mg/min) for patients 18 years and older 2.
- Key considerations:
- Lorazepam injection is only one part of a complex intervention that may require additional treatments.
- The patient should be closely monitored for respiratory depression and other adverse effects.
- Ventilatory support should be readily available.
From the Research
Benzo Options for VT Storm
- There are no specific benzodiazepines mentioned in the provided studies as the best option for use during a VT storm.
- The studies primarily focus on the comparison between catheter ablation and antiarrhythmic drugs, such as amiodarone and sotalol, for the management of ventricular tachycardia in patients with implantable cardioverter-defibrillators 3, 4, 5, 6, 7.
Antiarrhythmic Drugs for VT
- Amiodarone is associated with a significantly reduced rate of VT recurrence compared to control 4.
- Sotalol is associated with an increased risk of VT recurrence compared to amiodarone 4.
- Catheter ablation is also effective in reducing VT recurrence and ICD shocks 3, 5, 7.
Catheter Ablation for VT
- Catheter ablation has been shown to be more effective than antiarrhythmic drug therapy as a first-line therapy in patients with ventricular tachycardia 5.
- Early catheter ablation performed at the time of ICD implantation significantly reduces the composite primary outcome of VT recurrence, cardiovascular hospitalization, or death 7.