20090910 Jet Treatment Protocol

JET Treatment Protocol: 1) Confirm Diagnosis: a. Heart rate >170 bpm. b. AV dissociation c. Ventricular rate > Atrial rate 2) Confirm that JET needs treatment…if the patient is “hemodynamically stable” with JET, just observe. (You can worsen hemodynamics by trying to treat JET which did not need treatment). 3) Control fever, institute hypothermia (~35-36° C)…Treatment of fever, turn down humidifier temperature on the ventilator to 35° C and cooling blanket… in that order. If actively cooling, adequate sedation and muscle relaxants will be needed to prevent shivering – especially if temperatures < 35° C are aimed. 4) Reduce circulating catecholamines: a. Reduce Dopamine dose…perhaps other catecholamines that are being infused. b. Adequate pain control, sedation and muscle relaxation as needed. 5) Medications: a. Amiodarone i. Bolus doses: 2.5 mg/kg/dose over 10 minutes, Wait for 20-30 minutes (max. 60 min) to determine response. ii.Repeat to a maximum of 10 mg/kg iii.Consult EP of further loading (to a max of 15 mg/kg) is felt necessary. b. Amiodarone infusion i. Determine that the infusion is necessary. If needed, use a range of 3.5 mcg/kg/min – 7 mcg/kg/min (≈ 5mg/kg/day – 10 mg/kg/day). ii.Consult EP service if doses higher than 7 mcg/kg/min is felt necessary. 6) Use fluid boluses/Calcium infusions if needed to treat hypotension caused by Amiodarone – if appropriate for the baby’s condition. 7) Atrial Pacing: a. If the junctional rate comes down below 150 or 140, you may A-pace at a rate 10-20/min above the junctional rate. When you set the pacemaker, watch and document that atrium is captured, AV conduction exists and QRS complex follows. b. Also, document the response to pacing…there should be some improvement in hemodynamics with addition of AV synchrony. Use this improvement to reduce any other catecholamine infusions. c. If there is no AV conduction (either not present or can’t be ascertained), set the pacemaker for DDD pacing…remember to check Page 1 of 4

on AV interval and PVARP settings (If you don’t know what these are, please get someone who knows. Don’t guess!). 8) Second-line medications are not usually needed. Consult EP service regarding Procainamide or other medications. (See Annotated Bibliography in next page)

Page 2 of 4

Annotated Bibliography: 1) Kovacikova, L. et al. Amiodarone as first line of therapy for postoperative junctional ectopic tachycardia. Ann Thorac Surg 2009;88:616-23. Very useful prospective study of 40 patients with a pre-determined protocol. Treatment protocol: Boluses of 2 mg/kg of Amiodarone infused over 5-10 min. Repeat if no response upto max. 10 mg/kg. If needed, (discretion of physician) infusion at 10-15 mcg/kg/min. If recurs after initial response, repeat bolus dose of 2mg/kg. Second-line therapy – cooling to 31-35°C. Definition of response: Sinus rhythm or decrease in JET rate to allow atrial pacing. 45% responded to Amiodarone alone. Cooling was added in the remaining patients. 2) Cecchin, F. Commentary on Kovacikova L. et al. article. Ann Thorac Surg 2009;88:623-4. 3) Walsh, E.P. et al. Evaluation of a staged treatment protocol for rapid automatic junctional tachycardia after operation for congenital heart disase. J Am Coll Cardiol 1997;29:1046-53. Reduction of catecholamines, Correction of fever, Atrial pacing, Digoxin, Phenytoin, Propranolol or Verapamil. Procainamide or Hypothermia (33-35°C) and combined Procainamide and hypothermia in that order. Definition of control: Sustained reduction of HR < 170 bpm within 2 hrs. This is not followed in many centers. Exposes the patient to multiple medications before coming to Procainamide. Digoxin was clearly ineffective. Difficult to tell one intervention from the other. 4) Batra A.S. et al. A prospective analysis of incidence and risk factors associated with junctional ectopic tachycardia following surgery for congenital heart disease. Pediatr Cardiol 2006;27:51-6. Prospective study of 336 postoperative admissions. 8% incidence. High risk operations were arterial switch, AV canal repair and Norwood repair. Univariate analysis, higher incidence of arrhythmia with younger patients (mean 2.75 yrs vs. 5.38 yrs), longer bypass time and higher inotrope score. Multivariate analysis identified only longer bypass time as risk factor to develop arrhythmia. JET is not necessarily related to surgery in His bundle area. 5) Hoffman, T. et al. Postoperative junctional ectopic tachycardiac in children: Incidence, risk factors, and treatment. Ann Thorac Surg 2002;74:1607-11. Retrospective analysis from CHOP. Incidence: 5.6% for all surgical admissions. 36% TAPVR repair, 14% TOF repair, 13% VSD repair and 9% in BT shunt. Risk factors by univariate analysis: Bypass time > 75 min, age < 6 month and Dopamine infusion. Multivariate analysis: Age < 6 months and Dopamine infusions remained as risk factors for development of JET. Treatment was varied and was not fully studied. 6) Haas, N.A. Camphausen, C.K. Impact of early and standardized treatment with amiodarone on therapeutic success and outcome in pediatric patients Page 3 of 4

with postoperative tachycarrhythmia. J Thorac Cardiovasc Surg 2008;136:1215-22. Definition of early institution of Amiodarone therapy is starting Amiodarone within 60 minutes of onset of JET. “Late” is after 60 minutes of onset. Bolus dose of 5 mg/kg infused over 1 hr. Followed by infusion or additional 1-2 boluses of 5 mg/kg if needed. Maximum infusion rate 5-15 mcg/kg/min (≈ 721 mg/kg/day). “Early” group had earlier rate control achieved earlier (156 min vs. 408 min), sinus rhythm sooner (400 min vs. 1038 min) and shorter ICU stay (3.3 days vs. 5.3 days).

Page 4 of 4