Follow up of 200bpm

Follow up from the previous post regarding a young lady with heart gone crazy beating at 200bpm suddenly just 4 hours post partum. 

Thank God, the patient survived and extubated well, and managed to continue her further monitoring and treatment in general ward outside ICU. 

What we did was unique and physiologically plausible. We do not have Ivabradine, thus we started trial of IV Labetalol boluses which shown improved blood pressure when the heart slowed down, so confirmed it's tachycardia induced hypotension. Following that, we started Labetalol infusion on top of vasopressor inotropic agents. Slowly, we managed to get the heart rate down to 160bpm and decided to overlap with oral Bisoprolol. Labetalol and vasopressor infusion were managed to wean off 12 hours later and slowly we got her off from ventilator 48 hours later. 

Felt relieved when the young mother was able to get out from the 200bpm pathology heart. What a case, given me an extraordinary experience. My supervisor had not encounter any case like this, it was her first encounter with the 200bpm heart that continued for 48 hours before we managed to get the heart rate controlled. 

Thank God again, indeed prayer works......

Extremely refractory SVT -> Focal atrial tachycardia

12//02/26 morning, greeted by my colleague who was stressing out the whole night because of one maternal case, 25 year old Myanmar lady, referred from private hospital, who developed extreme narrow complex tachycardia 4 hours post spontaneous vaginal delivery at private hospital. Multiple treatments given, including IV Adenosine, Cardioversion multiple times, IV Digoxin loading doses, IV Verapamil, the heart still beating like nobody business at the rate of 200bpm. Blood pressure was also fluctuating and patient needed to be intubated and sedated to ease further treatments. The only drug that was responsive was Esmolol boluses where the HR down to 140bpm and BP improved to 150/90 with visible diastolic wave seen at arterial line wave. 

13/02/26 evening, heart rate still persistently beating at 200bpm. Our center does not have in-house cardiologist and case was discussed with cardiologist from another nearby tertiary hospital. Also, not much respond was observed following cardio's management plan. The only definitive plan was for further cardio TCA once patient can be stabilized and extubated. But, I doubt that time will come if we do not slow down the crazily beating heart. 

Met with patient's husband, who she married in 2023, together work in a restaurant since 2023. Husband was very sad after hearing the bad news of patient's condition. 

Found few case reports used Ivabradine. I remembered Klang intensivist practices giving Ivabradine for fast atrial fibrillation which was not the indication of Ivabradine. I guess he must have the reason of continue using Ivabradine. Even neonate who had refractory focal atrial tachycardia treated with Ivabradine, avoided radiofrequency ablation. 

Hope we can get Ivabradine and administer it to this Myanmar lady, who has a baby waiting for her. We are out of treatment alternative. Sad case......

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Report of a patient with refractory atrial tachycardia whose heart rate was controlled using ivabradine . https://pmc.ncbi.nlm.nih.gov/articles/PMC8918960/ 

Use  of  ivabradine  in  supraventricular  tachycardia  caused  by  refractory  focal  atrial tachycardia in neonates to avoid radiofrequency ablation. https://mansapublishers.com/ijch/article/view/1861/1467

Refractory Atrial Tachycardia and Ivabradine in a Case of Catecholaminergic Polymorphic Ventricular Tachycardia. https://www.authorea.com/users/871783/articles/1252596-refractory-atrial-tachycardia-and-ivabradine-in-a-case-of-catecholaminergic-polymorphic-ventricular-tachycardia

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Donating 450cc of blood cell

HB today 13.8

BP 140/90

HSI blood bank

Comeback blog

Planning to be back on blogging track cause blogging/ journaling force me to recall my memories and pen it down, during the process, make me rethink, grab the lessons and save it in the blog, at least the record in blog is long lasting 🙂‍↕️

So.....it's my 5 months into the second year training of critical care field at the new hospital HSI. Had encountered numerous cases. Let me list down the cases that I have seen so far:

1- Trauma cases: TBI, polytrauma ended up in hip disarticulation (total 2 cases- unilateral disarticulation and bilateral disarticulation. Unilateral younger 15 year old patient still alive the last I checked, and another 20+ yo lady passed away recently)

2- Severe ARDS 

3- Maternal sepsis (ARDS pneumonia, pancreatitis)

4- Starvation ketoacidosis 

5- DKA

6- Fluid overload with CKD 

7- Acute coronary syndrome (mostly NSTEMI)

8- Morbid obesity with fluid overload 

9- Severe metabolic acidosis incompatible to life but patient managed to pull through and still alive (2 patients)

10- Young teenager 30 kg 13 yo girl underlying myelomeningocele defaulted followup since young and came with uremic status epilepticus due to advanced CKD with hydronephrosis. 

11- Traumatic intubation 

12- Catastrophic extubation- young obese boy with status epilepticus

13- Burn 

14- TENS with underlying ultra resistance status epilepticus 

15- Super geriatric critically ill patient 

16- Intraabdominal sepsis 

17- Dengue fever

18- Malaria 

19- Airway diseases (AECOAD, AEBA)

20- Myasthenia crisis 

It will be never-ending lifetime studying and learning. Thanks to my supervisors for constantly reminding me that there's lot more to read up and not to slack around 🥴