Successful Conversion of Post-Cardiac Surgery Electric Storm in a Child.

Background: The management of ventricular electrical storm can prove to be a challenge for the clinician given its complexity and life threatening consequences. Case characteristics: 8-year-old boy with repeated life-threatening polymorphic ventricular tachycardia following aortic valve replacement surgery. Intervention: Defibrillated 45 times in addition to multiple antiarrhythmic drugs. Outcome: Conversion to stable sinus rhythm with normal neurological outcome. Message: Electric storm can be controlled by combination of multiple intravenous antiarrhythmic drugs.

Therapeutic Applications of Vasopressin in Pediatric Patients.

Context: Reports of successful use of vasopressin in various shock states and cardiac arrest has lead to the emergence of vasopressin therapy as a potentially major advancement in the management of critically ill children. Objective: To provide an overview of physiology of vasopressin, rationale of its use and dose schedule in different disease states with special focus on recent advances in the therapeutic applications of vasopressin. Data Source: MEDLINE search (1966-September 2011) using terms “vasopressin”, “terlipressin”, “arginine-vasopressin”, “shock”, “septic shock”, “vasodilatory shock”, “cardiac arrest”, and “resuscitation” for reports on vasopressin/terlipressin use in children and manual review of article bibliographies. Search was restricted to human studies. Randomized controlled trials, cohort studies, evaluation studies, case series, and case reports on vasopressin/terlipressin use in children (preterm neonates to 21 years of age) were included. Outcome measures were analysed using following clinical questions: indication, dose and duration of vasopressin/terlipressin use, main effects especially on systemic blood pressure, catecholamine requirement, urine output, serum lactate, adverse effects, and mortality. Results: 51 reports on vasopressin (30 reports) and terlipressin (21 reports) use in pediatric population were identified. A total of 602 patients received vasopressin/terlipressin as vasopressors in various catecholamine-resistant states (septic - 176, post-cardiotomy - 136, other vasodilatory/mixed shock - 199, and cardiac arrest - 101). Commonly reported responses include rapid improvement in systemic blood pressure, decline in concurrent catecholamine requirement, and increase in urine output; despite these effects, the mortality rates remained high. Conclusion: In view of the limited clinical experience, and paucity of randomized controlled trials evaluating these drugs in pediatric population, currently no definitive recommendations on vasopressin/terlipressin use can be laid down. Nevertheless, available clinical data supports the use of vasopressin in critically ill children as a rescue therapy in refractory shock and cardiac arrest.