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Electrical Cardioversion of Supraventricular Arryhthmia Patient with Septic Shock

Supraventricular arrythmia (SVA) is a very common cardiac rhythm problem experienced by patients in intensive care unit (ICU), which both pharmacological and non-pharmacological treatment could treat. Recently, electrical cardioversion has been proven in improving haemodynamic and functional status. We report a case of 59 years old female patient with VA and septic shock with unstable haemodynamic that was immediately improved after electrical cardioversion. The electrical cardioversion (preferably biphasic) is identified in the patient with an absence of oppositions and is more suitable in combination with antiarrhythmic agent. Case Report Electrical Cardioversion of Supraventricular Arryhthmia Patient with Septic Shock A. Pramitha


Introduction Case Presentation
The characteristics of septic shock is the afterload that is reduced, unstable filling conditions, catecholamine surge, chronotropic dysregulation, and left ventricle (LV) diastolic and systolic dysfunction; all of them could lead to rhythmic disorders [1] . The occurrence of supraventricular arrhythmias is associated with a less favourable prognoses in septic shock [2] . Among the general residents of ICU, the occurrence of SVA mostly occurred in septic shock patients. Maintenance of diastolic ventricular filling and sinus rhythm are the priorities for those in critical condition. [2] Due to limited studies concerning electrical cardioversion for SVA in septic shock patients, this paper aims to report one case that overviews the efficacy and safety of electrical cardioversion for SVA in septic shock patients. ICU. There were no significant complications.

Discussion
Because of the non-responsive hypotension to the preload correction, septic shock diagnosis is conducted according to the conditions set for systemic inflammatory syndrome (SIRS). It is found to be related to the data of cardiac arrhythmias in patients with critical conditions [3] . Previous studies showed that there is greater likelihood of various cardiac arryhthmia exhibition in patients having moderate to severe sepsis [4] . The majority of this study was focused on the management and outcomes of SVA in septic shock patient population.
Amongst the population of general ICU, the SVA incident had significant increase in the septic shock patients, and it tends to be connected with both prognoses of both short and long-term worsening condition. [1] There  [7] . In pneumococal infections, the activation of the receptor inducing platelet-activating factor that was done by the bacterial cell serves similar role [8] .
Endotoxins, such as lipopolysaccharide of Gram-negative bacteria may help in contributing to the arrhythmia onset, which is probable to be caused by the Toll-like receptor mediated action it has [9] . SIRS could cause the increase in demand of metabolism and intracellular derangement, including dysfunction of mitochondria. Cardiac arrhythmias could be promoted through the effects of inflammatory mediators.
In patients with septic conditions, the associated diastolic dysfunction occurred frequently (up to 61.8%) [8] . Compared to systolic dysfunction, diastolic dysfunction is a predictor of mortality that is independent. There is a surging risk of massive fluid resuscitation and worsening of tissue edema and hypoperfusion, or in other words, inadequate expansion volume in suffering severe diastolic dysfunction that exist before admission. [2] In order to fix the low resistance of vascular in septic shock, the administration of catecholamine is proarrythmogenic. Multivariate analysis had been reported to show insignificant 12-month benefit in March 2020 | Vol 1 | Article 3 cardioverting septic shock patients to sinus rhythm (HR 0.67, P = 0.113). Arrhythmia is close in relation to sepsis rather than parallel to the correction of the previous preload. It is also closely related to pressure of targeted perfusion. Although the initiation of vasopressors in septic shock with profound hypotension early is suggested [10] , this has to be done with adequate parallel preload examination [11] . The correct administration time of vasopressin to lower a high dosage of vasopressors could tamper with the predisposition to arrhythmias in septic shock [12] . Thus, careful and repetitive echocardiographic examination of either cardiac function and the status of intravascular volume could be considerable approach.
However, it has to be noted that the replacement of suboptimal volume could lead to a higher sympathetic tone, which also leads to greater endogenous adrenergic stimulation, along with the urgent necessity for exogenous catecholamines.
Both states, such as fluid overload and hypovolaemia, are the factors triggering the development of arrhythmias.
The routine of ICU is affected by gradual haemodynamic monitoring incorporating echocardiography. Echocardiography also helps in deciding whether a patient having unknown history of arrhythmia is to be cardioverted. If echocardiography is not used, findings of ECG of a structural heart disease, for example the low R waves in precordial leads, profound ischaemic changes or atrioventricular blockade is found. [2] It should be understood that most of patients had atrial fibrillation and could be easier to be cardioverted electrically, in the meantime, re-entrant SV tachycardia might be cardioverted by vagal manoeuvres similar to carotid sinus massage. It is more likely to miss some patients with SV arryhtmias, such as flutter, who were electrically cardioverted instead of administration of antiarryhthmics-that is if we search according to the medical history of antiarrhythmic medication [6] .
In the long term medication, the repetition effects of antiarrhythmics have been reported to lead into the tendency to provide rate control rather than therapy of rhythmic control.
Nevertheless, the overlap between rhythm and rate control may be an important point as proved in the recent study on perioperative AF, where the same antiarrhythmic agents are included by the two modalities and similar percentage of electrical cardioversion in 25% of the patients is presented [13] .