Haemodynamically stable - Neonatal Intensive Care Drug Manual

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Neonatal Intensive Care Drug Manual
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bet | 177/654 | Sana | 03.01.2022 | Hajmi | 1,5 Mb. | | #14803 |
Haemodynamically stable: Antiarrhythmic therapy — if the vagal manoeuvre does not convert SVT that is haemodynamically stable to normal rhythm, an intravenous (IV) catheter should be placed for the administration of antiarrhythmic drugs. Adenosine is the drug of choice for acute management of SVT; procainamide and amiodarone are sometimes given for tachycardia that is refractory to adenosine. For SVT that is refractory to adenosine, choices for IV antiarrhythmic therapy include procainamide and amiodarone. Digoxin is not usually used because of the delay in achieving therapeutic levels and the narrow therapeutic margin with the risk of serious toxicity. In addition, digoxin should not be given if WPW syndrome is suspected, since it may potentiate accessory pathway conduction.
Sanatini et al 2012 [12] in a RCT of 61 infants <4 months with SVT (atrioventricular reciprocating tachycardia or atrioventricular nodal re-entrant tachycardia excluding Wolff-Parkinson-White) compared digoxin (loading dose 30 microgram/kg/day, maintenance 10.5 microgram/kg/day) versus propranolol (0.5 mg/kg as a single dose then 1.0 mg/kg/dose 8-hourly). SVT recurred in 19% of patients on digoxin and 31% of patients on propranolol (P = 0.25). No first recurrence occurred after 110 days of treatment. The 6-month recurrence-free status was 79% for patients on digoxin and 67% for patients on propranolol (P = 0.34), and there were no first recurrences in either group between 6 and 12 months. There were no deaths and no serious adverse events related to study medication.
Hornik et al 2014 [13] in a retrospective cohort of infants with SVT from the Pediatrix Medical Group neonatal ICU database compared 342 infants exposed to digoxin versus 142 infants exposed to propranolol. The incidence rate of treatment failure was 6.7/1,000 infant-days of exposure to digoxin and 15.4/1,000 infant-days of exposure to propranolol. Treatment failure was higher on propranolol when compared with that on digoxin (adjusted hazard ratio, 1.97; 95% CI 1.05–3.71). Hypotension was more frequent during exposure to digoxin versus propranolol (39.4 vs 11.1/1,000 infant-days; p <0.001). There was no difference in frequency of other clinical adverse events.
Bolin et al 2017 [14] reported a retrospective cohort of infants with SVT from the Pediatric Health Information System database admitted at ≤2 days of age with structurally normal hearts and treated with an antiarrhythmic medication. 2,657 neonates were identified with a median gestational age of 37 weeks (interquartile range 34 to 39). Digoxin and propranolol were most commonly prescribed; digoxin use steadily decreased to 23% of antiarrhythmic medication administrations over the study period, whereas propranolol increased to 77%. Multivariable comparisons revealed that the odds of mortality for neonates on propranolol were 0.32 times those on digoxin (95% CI 0.17 to 0.59; p <0.001). Propranolol for the neonate with SVT is associated with lower in-hospital mortality and hospital costs compared with digoxin.
Recommendation: ANZCOR recommendation for pharmacological management of specific dysrhythmias in the paediatric advanced life support guideline is that, for SVT, adenosine is the drug of choice. Amiodarone may be used to treat haemodynamically stable or unstable SVT. Alternative drugs are procainamide, digoxin, a beta blocker or a calcium channel blocker. Calcium channel blockers should not be used to treat SVT in infants and should be avoided or used cautiously in children because they may induce hypotension and cardiac depression.[15]
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