(173) A Last-Ditch Effort: Glycopyrrolate Infusion for Refractory Bradyarrhythmia

Introduction: Severe bradyarrhythmia is a life-threatening condition, particularly when refractory to guideline directed first-line treatments. The literature shows a lack of evidence comparing the effectiveness of glycopyrrolate to other IV chronotropes in treating refractory bradyarrhythmia. While glycopyrrolate is typically used to counteract the muscarinic effects of neostigmine, it may also prove useful in the standard treatment of symptomatic bradyarrhythmia. Here we present a case of a patient who failed first-line chronotropes and was successfully treated with glycopyrrolate.

Description: A 68-year-old male with no known past medical history was found unresponsive by EMS. Upon presenting to the emergency department, he was found to be in PEA/asystole. ACLS was immediately initiated, and ROSC achieved after 20 minutes. The patient was intubated and transferred to the ICU. His TSH was 60.51 with an undetectable T4 and he was treated as a case of myxedema coma with IV levothyroxine. His clinical course was complicated by persistent symptomatic bradyarrhythmia. Given conduction abnormalities associated with hypothyroidism and concerns of AV asynchrony medical management with chronotropes was preferred over transcutaneous pacing. Treatment attempts with Dopamine, Isoproterenol, Albuterol, Epinephrine, Aminophylline, and scopolamine patches failed to resolve the bradyarrhythmia. Atropine pushes were given with an adequate but non-sustained response. Pushes with glycopyrrolate, however, had a very promising effect on his hemodynamics, including heart rate, cardiac output, and oxygenation. Given its short half-life pharmacy assisted to compound a glycopyrrolate drip which was titrated to 0.05mg/hr with a sustained adequate response in hemodynamics.

Discussion: While glycopyrrolate has been investigated in the past to reverse bradyarrhythmia perioperatively, its application in non-operative settings has never been explored. Given the lack of literature, further studies investigating novel pharmacological agents in the management of bradyarrhythmia should be considered, specifically in the critical care setting. To our knowledge this is the first attempt to utilize glycopyrrolate drip for refractory bradyarrhythmia in a non-operative setting.