Colentina University Hospital, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania; University Hospital of Sabadell (University Autonoma of Barcelona), Plaça Cı́vica, Campus de la UAB, Barcelona, Spain; Oslo University Hospital Ullevål, Norway; Institute of Clinical Sciences, University of Oslo, Søsterhjemmet, Oslo, Norway; Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy; Universitaetsmedizin Mannheim, Medizinische Klinik, Mannheim, Germany; Department of Medical Sciences, University of Turin, Citta’ della Salute e della Scienza Hospital, Turin, Italy; Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Cardiology, Eskisehir Osmangazi University, Büyükdere Mahallesi, Odunpazarı/Eskişehir, Turkey; Molecular and Clinical Sciences Research Institute, St. George’s, University of London, London, UK; Copenhagen University Hospital (Holbæk Hospital), Holbæk, Institute for Clinical Medicine, Copenhagen University, Copenhagen, Denmark; Department of Health Science and Technology, Aalborg University, Aalborg, Denmark; Institute of Cardiovascular Sciences, University of Birmingham, Centre For Cardiovascular Sciences, City Hospital, Birmingham, UK; Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark; Heart and Vascular Center, Semmelweis University, Budapest, Hungary; Saiseikai Akumamoto Hospital, Kumamoto, Japan; Department of Medicine, Duke Clinical Research Institute, Durham, USA; School of Medicine, Belgrade University; Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia; Aarhus University Hospital, Klinisk Farmakologisk Enhed, Aalborg, Denmark; Department of Pharmacology, School of Medicine, Universidad Complutense Madrid, Madrid, Spain; Department of Medicine Cardiology, Klinikum Ludwigsburg, Ludwigsburg, Germany; Department of Cardiology, University Hospital Basel, Basel, Switzerland; Medizinische Klinik IKardiologie, Angiologie, Pneumologie, Wiesbaden, Germany; Barts Heart Centre, Trustee Arrhythmia Alliance and Atrial Fibrillation Association, London, UK; Department of Cardiology, University Hospital Centre Sestre milosrdnice, Croatia; Cardiology Department, Olv Aalst, Belgium; Uniwersytet Medyczny w Łodzi, Kierownik Kliniki Kardiologii

Antiarrhythmic drugs-clinical use and clinical decision making: a consensus document from the European Heart Rhythm Association (EHRA) and European Society of Cardiology (ESC) Working Group on Cardiovascular Pharmacology, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and International Society of Cardiovascular Pharmacotherapy (ISCP).

https://www.ubccriticalcaremedicine.ca/academic/jc_article/Mgmt%20afib%20in%20critically%20ill%20Crawford%20Crit%20Care%20Clin%202007%20(Sept-25-08).pdf

Cardiac Arrhythmias: Management of Atrial Fibrillation in the Critically Ill Patient

Objective: To evaluate safety and effi cacy of diltiazem versus amiodarone for conversion of atrial arrhythmias in non-cardiac post-surgical critically ill patients. Design: A cohort study of non-cardiac post surgical patients admitted to the surgical intensive care unit with new-onset atrial tachyarrhythmias which were treated by protocol. In the fi rst year patients were treated with diltiazem, and amiodarone was used in the second year.

https://www.criticalcareshock.org/files/Original%20-%20Diltiazem%20versus%20Amiodarone%20for%20New-Onset%20Atrial%20Arrhythmias%20in%20Non-Cardiac%20Post%20Surgical%20Patients-%20A%20Cohort%20Study.pdf

Diltiazem versus Amiodarone for New-Onset Atrial Arrhythmias in Non-Cardiac Post Surgical Patients: A Cohort Study

Sir, We read with interest the case of acute lung injury (ALI) after total cystectomy by Skroubis et al. (1). The authors appropriately implicate amiodarone given for the treatment of post-operative atrial fibrillation. However, given that it is uncommon for a relatively small dose (1500 mg in this case) to cause ALI, it was logical, as undertaken by the authors, to first exclude the other causes of post-operative acute respiratory distress syndrome, of which there are many ‘imitators’ (2). One that might also have been considered, but was not mentioned, is blood transfusion. Transfusion-related acute lung injury (TRALI) or possible TRALI cases (3), occurring within 6 h of transfusion, share many of the clinical features described in this case, and might have contributed to this patient’s ALI. As total cystectomy may be associated with significant intraand post-operative blood loss, it would have been useful for the authors to clarify whether any blood products had been given within 6 h of the onset of dyspnoea, tachypnoea and hypoxaemia on the second day of amiodarone treatment.

Acute lung toxicity after total cystectomy

Atrial fibrillation is the most common complication occurring after coronary artery bypass graft surgery. The purpose of this article was to examine the incidence of, risk factors related to, and complications caused by postoperative atrial fibrillation. The pathophysiology and treatment of atrial fibrillation and postoperative atrial fibrillation will also be discussed.

Amiodarone use to prevent postoperative atrial fibrillation after cardiac surgery.

Sir, We read with interest the report by Skroubis et al. about the occurrence of amiodarone-induced pulmonary toxicity (APT) in a patient suffering from post-operative atrial fibrillation (1). We would like to highlight certain other issues regarding APT. From the report by the authors, it is clear that the lowest exposure of amiodarone so far known to have caused lung toxicity after extrathoracic surgery is 1500 mg intravenously (i.v.). Data available so far indicate that APT can occur at a low daily dose of 200 mg after a minimal exposure of 3 months (2). The disparity in the literature may contribute to the wide variation in the clinical practice of physicians caring for patients receiving amiodarone (3). Certain studies have concluded that both oral as well as high dose i.v. amiodarone is safe for cardiac surgery (4—6). In one such trial where patients received a total oral dose of 4.8 g amiodarone prior to surgery, no acute pulmonary toxicity was reported in patients randomly assigned to amiodarone (4). Similarly another study concluded that low-dose amiodarone (200 mg/day) was safe for cardiac surgery (5). There was no mention about pulmonary toxicity in a study by Kuralay et al. where high-dose amiodarone was used for prophylaxis against supraventricular tachyarrhythmia after coronary surgery in chronic obstructive pulmonary disease patients, a group definitely at risk for APT (6). Given the small numbers involved, the above-mentioned studies have to be interpreted with caution (7). Furthermore such trials often exclude sick patients and concentrate on elective cases, excluding those most likely to require amiodarone, who are those most likely to develop APT/ARDS and those for whom amiodarone may be the most harmful (7). For these reasons it may be clear that, in sick patients, acute APT may be more common than realized (7). Therefore amiodarone has to be used cautiously in the ICU setting as there are no ‘gold standards’ for confirming the diagnosis nor any established treatment modalities available in the management of APT. It is also of interest to note that one of the mechanisms implicated in APT is a free radical effect of the drug (7). Free radicals are derived from amiodarone’s influence on mitochondria and the well-recognized NADPH oxidase family of pulmonary and immunologic enzymes that synthesize superoxide anions involved in defence and lung signalling (7). This effect may be exacerbated by the influence of high oxygen partial pressures that synergize with amiodarone-induced radicals to increase lung damage (7). Hence it is reasonable to speculate that patients with activating polymorphisms in NADPH oxidase subunits or inactivity in superoxide dismutase, for example glucose 6 phosphate dehydrogenase (G6PD) deficiency, may be at risk of APT.

Amiodarone‐induced acute lung toxicity in an ICU setting

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Amiodarone‐induced acute lung toxicity in an ICU setting