March 1, 2015 • Volume 4 • Number 5 cases-anesthesia-analgesia.org 49 Copyright © 2015 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000000124 E lectrical storm (ES) is a life-threatening syndrome that is characterized by recurrent, hemodynamically unstable ventricular tachycardia (VT) or ibrillation. 1 ES presents a major clinical challenge because it is often unresponsive to conventional drug therapy; conventional antiarrhythmic drugs often fail to maintain sinus cardiac rhythm and can have negative inotropic effects that worsen cardiac function. 1,2 Multiple attempts at electrical cardiover- sion or deibrillation are necessary to stabilize the cardiac rhythm while the patient is awaiting more invasive, deini- tive treatment, such as ablation of irritable foci, surgical sym- pathectomy, and cardiac transplantation. Efforts to reduce mortality and temporize the morbidity of recurrent painful deibrillation after maximal medical therapy have targeted the efferent sympathetic nervous system to the heart. 3 The sympathetic nervous system appears to play a signiicant role in the genesis and maintenance of ES. 4 Sympathetic blockade can be performed in the periphery at the adrenergic receptor or cervical sympathetic ganglion or in the central neuraxis of the high thoracic spinal cord. Signiicant decreases in arrhythmias, along with reduced 1-week mortality, have been associated with such interven- tions for ES. The effects are temporary with stellate gan- glion blockade and thoracic epidural blockade with local anesthetic, 2,3,5 and they are permanent with surgical thoracic sympathetic denervation. 6 We describe a critically ill patient who developed ES after placement of an implantable car- dioverter-deibrillator (ICD) for congestive heart failure and a low ejection fraction. The ES was managed temporarily with a continuous left-sided C7 cervical ganglion block with local anesthetic and was treated with permanent neurolysis of these ganglia. We obtained verbal approval for possible publication from the legal designee of the patient, but we have been unable to contact the patient or designee for written con- sent. However, our local IRB determined that such consent is not required for a single-patient case report. CASE DESCRIPTION A 60-year-old man with a history of coronary artery dis- ease, 5-vessel coronary artery bypass grafting in the pre- vious decade, and ischemic cardiomyopathy presented to an outside hospital with syncopal episodes, angina, and dyspnea of several weeks duration. Cardiac catheterization revealed patent vessels. A single-chamber ICD was placed. Immediately afterward, multiple episodes of sustained VT occurred. Standard antiarrhythmic drugs, including esmo- lol, lidocaine, and amiodarone, along with ventricular antit- achycardia pacing, failed to terminate the VT. During transport to our tertiary care center, the patient became hypotensive and lost consciousness. Six attempts at external deibrillation were made without success. On arrival, the condition of the patient deteriorated to pulse- less electrical activity, prompting endotracheal intubation, mechanical ventilation, and cardiopulmonary resuscitation. After hemodynamic stabilization, the patient underwent revision of an improperly positioned ICD right ventricular lead and implantation of a dual-chamber ICD. The condition of the patient declined despite this inter- vention. Vasopressor and inotropic drugs (dopamine, vasopressin, and epinephrine) and an intra-aortic balloon pump device were used to support arterial blood pressure. The VT continued into the next day after the lead revision. Radiofrequency ablation was attempted at the earliest fas- cicular potential, located in the anterior and anteroseptal parts of the left ventricle, which appeared on electrophysi- ological studies to have been a trigger source for the VT epi- sodes. However, after the ablation, the patient had multiple premature ventricular contractions and continued to have multiple episodes of spontaneous, sustained polymorphic Electrical storm (ES) is a syndrome characterized by recurrent ventricular ibrillation or tachy- cardia. It is a major clinical challenge and is often unresponsive to conventional drug therapy; instead, its treatment requires multiple attempts at electrical deibrillation. Sympathetic hyper- activity is an important modulator of ventricular arrhythmias, including ES. We report a case of ES treated safely and effectively with pharmacologic sympathectomy involving diagnostic con- tinuous stellate ganglion blockade with local anesthetic followed by therapeutic neurolysis. This technique reduced ES in a patient for whom conservative medical and interventional procedures were ineffective. (A&A Case Reports. 2015;4:49–51.) From the Department of Anesthesiology, University of Florida, Gainesville, Florida. Accepted for publication August 25, 2014. Funding: Divisional Funding. Andre P. Boezaart received royalties from Telelex Medical Inventor. Robert W. Hurley received research funding from Boston Scientiic, Medtronic, St. Jude Medical, and Pizer SCS companies fund the UF Pain Medicine Fellowship. Pizer sponsors a nonpharmaceutical randomized controlled trial. The remaining authors declare no conlicts of interest. This report was previously presented, in part, at the ASRA 2013. Address correspondence to Robert W. Hurley, MD, PhD, Department of Anesthesiology, Medical College of Wisconsin, 959 N. Mayfair Rd., Wauwatosa, WI 53226. Address e-mail to tjkuderer@mcw.edu. Stellate Ganglion Local Anesthetic Blockade and Neurolysis for the Treatment of Refractory Ventricular Fibrillation David F. Hulata, MD, Linda Le-Wendling, MD, Andre P . Boezaart, MD, PhD, and Robert W. Hurley, MD, PhD