title: Acute Management of Refractory and Unstable Pediatric Supraventricular Tachycardia.
abstract: To characterize the management of acute pediatric supraventricular tachycardia (SVT), placing special emphasis on infants, patients refractory to adenosine (refractory SVT), and patients with hypotension, poor perfusion, or altered mental status (unstable SVT).
  
  
  
  Retrospective cohort study of patients 0-18 years of age without congenital heart disease who presented to our pediatric hospital from January 2003 to December 2012 for the treatment of acute SVT. Multiple logistic regression was applied to identify whether age was a risk factor for different SVT therapies. Model fit and residuals also were examined.
  
  
  
  We identified 179 episodes for SVT. First dose of adenosine was effective in 72 (56%) episodes, and a second dose was effective in 27 of 54 (50%) episodes, leaving 27 (15%) episodes with refractory SVT. The response to the first dose of adenosine increased proportionally with age (OR 1.13, 95% CI 1.05-1.2). Only 1 of 17 episodes in infants responded to the first dose of adenosine. Refractory SVT was more frequent in infants vs older children (χ2= 5.9 [1 df], P = .01). Unstable SVT was present in 13 episodes and was treated with adenosine and antiarrhythmics. Synchronized cardioversion was performed on 3 patients, 2 patients with unstable SVT, and 1 with refractory SVT.
  
  
  
  In children with SVT, young age is associated with decreased response to the first dose of adenosine and increased odds of adenosine-refractory SVT. In the treatment of unstable SVT, medical management with various antiarrhythmics before cardioversion may have a role in a subset of patients. Synchronized cardioversion rarely is performed for acute SVT.
authors.affiliation: Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh, Pittsburgh, PA.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Lewis
authors.affiliation: Department of Pediatrics, Division of Cardiology, University of Pittsburgh, Pittsburgh, PA.
authors.forename: Gaurav
authors.initials: G
authors.lastname: Arora
authors.affiliation: Center for Research on Healthcare, University of Pittsburgh, Pittsburgh, PA.
authors.forename: Dana L
authors.initials: DL
authors.lastname: Tudorascu
authors.affiliation: Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh, Pittsburgh, PA.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Hickey
authors.affiliation: Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh, Pittsburgh, PA.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Saladino
authors.affiliation: Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh, Pittsburgh, PA. Electronic address: manomd@upmc.edu.
authors.forename: Mioara D
authors.initials: MD
authors.lastname: Manole
mesh_terms: D000241:Adenosine / Q000627:therapeutic use*; D000293:Adolescent; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D004554:Electric Countershock / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D012189:Retrospective Studies; D013617:Tachycardia, Supraventricular / Q000188:drug therapy* / Q000628:therapy
chemical_list: D000889:Anti-Arrhythmia Agents; D000241:Adenosine
keywords: infants; pediatric; refractory SVT; supraventricular tachycardia; tachyarrhythmia; unstable SVT