Cohort study to assess the prevalence of prolonged QT and arrhythmias in critically ill patients during the early phase of the COVID-19 pandemic

INTRODUCTION

Patients with SARS-CoV-2 infection may present cardiovascular involvement including myocarditis, arrhythmias and QT interval prolongation. Our objective was to evaluate the impact of COVID-19 and its treatment on ventricular repolarization and development of arrhythmias in critically ill patients.

METHODS

Retrospective cohort study of critically ill COVID-19 patients during a 3-month period in whom at least one ECG was available. Relevant clinical data and specific treatment administered for COVID-19 were recorded. Prolonged QTc was considered prolonged when it measured ≥ 460 ms in women and ≥450 ms in men. The incidence and type of arrhythmias during the same period were recorded.

RESULTS

A total of 77 patients with a mean age of 62 ± 13 years, 20 women and 57 men, were evaluated. Sixty percent of the patients were hypertensive, 52% had a BMI > 30, and 70% developed acute renal failure during admission. Some 56% of the patients presented QTc prolongation. Forty-four percent presented some type of arrhythmia during their stay in the ICU, 21% of which were atrial arrhythmias. Overall mortality was 53%, with no differences between patients with or without prolonged QTc.

CONCLUSIONS

In our series, a high proportion of critical patients with COVID-19 presented prolonged QTc and arrhythmias. The factors involved have been related to the elevation of cardiac biomarkers, the myocardial involvement of the virus and concomitant medication received in the ICU.

Lipid emulsions in the treatment of intoxications by local anesthesics and other drugs. Review of mechanisms of action and recommendations for use

Intravenous lipid emulsions (ILEs) have been used widely for the treatment of local anesthetic (LA) poisoning and have been proposed as a treatment for intoxication by other drugs. However, the degree of evidence for this kind of therapy is not strong, as it comes mostly from clinical cases. The aim of this narrative review is to describe the proposed mechanisms of action for ILEs in poisoning by LA and other drugs and to evaluate recent studies in animals that support the recommendations for their use and the experience in humans that support the use of ILESs in both LA and other drug poisoning. For this purpose, a search was performed in the Embase, Medline and Google Scholar databases covering relevant articles over the last 10 years. In the case of AL poisoning, we recommend applying the protocols dictated by international guidelines, knowing that the degree of evidence is not very high. In poisoning by other drugs, ILEs are recommended in serious situations induced by liposoluble xenobiotics that do not respond to standard treatment.

Liver transplant with controlled donors after circulatory death with normothermic regional perfusion and brain dead donors: A multicenter cohort study of transfusion, one-year graft survival and mortality

BACKGROUND

Controlled donation after circulatory death (cDCD) has expanded the donor pool for liver transplantation (LT). However, transfusion requirements and perioperative outcomes should be elucidated. The aim of this multicenter study was to assess red blood cell (RBC) transfusions, one-year graft and patient survival after LT after cDCD with normothermic regional perfusion (NRP) compared with donors after brain death (DBD).

METHODS

591 LT carried out in ten centers during 2019 were reviewed. Thromboelastometry was used to manage coagulation and blood product transfusion in all centers. Normothermic regional perfusion was the standard technique for organ recovery.

RESULTS

447 patients received DBD and 144 cDCD with NRP. Baseline MCF Extem was lower in the cDCD group There were no differences in the percentage of patients (63% vs. 61% p = 0.69), nor in the number of RBC units transfused (4.7 (0.2) vs 5.5 (0.4) in DBD vs cDCD, p = 0.11. Twenty-six patients (6%) died during admission for LT in the DBD group compared with 3 patients (2%) in the cDCD group (p = 0.15). To overcome the bias due to a worse coagulation profile in cDCD recipients, matched samples were compared. No differences in baseline laboratory data, or in intraoperative use of RBC or one-year outcome data were observed between DBD and cDCD recipients.

CONCLUSIONS

cDCD with NRP is not associated with increased RBC transfusion. No differences in graft and patient survival between cDCD and DBD were found. Donors after controlled circulatory death with NRP can increasingly be utilized with safety, improving the imbalance between organ donors and the ever-growing demand.

Lipid emulsions in the treatment of intoxications by local anesthesics and other drugs. Review of mechanisms of action and recommendations for use

Intravenous lipid emulsions (ILEs) have been used widely for the treatment of local anesthetic (LA) poisoning and have been proposed as a treatment for intoxication by other drugs. However, the degree of evidence for this kind of therapy is not strong, as it comes mostly from clinical cases. The aim of this narrative review is to describe the proposed mechanisms of action for ILEs in poisoning by LA and other drugs and to evaluate recent studies in animals that support the recommendations for their use and the experience in humans that support the use of ILESs in both LA and other drug poisoning. For this purpose, a search was performed in the Embase, Medline and Google Scholar databases covering relevant articles over the last 10 years. In the case of AL poisoning, we recommend applying the protocols dictated by international guidelines, knowing that the degree of evidence is not very high. In poisoning by other drugs, ILEs are recommended in serious situations induced by liposoluble xenobiotics that do not respond to standard treatment.

A multicenter and observational study of the Ambu™ AuraGain™ laryngeal mask in adult patients

PURPOSE

The main objective of this study was to evaluate the performance of the Ambu™ AuraGain™ device by determining its main parameters of use and complications.

METHODS

A total of 250 adult ASA physical status i to iii patients from five hospitals in Spain who received general anaesthesia with a supraglottic airway (SGA) device were enrolled in this study.

RESULTS

The primary outcome was analysed for 244 patients and a median OLP of 32 cm H2O (IQR 28-36 cm H2O) was obtained. Insertion was achieved at first attempt in 85% of cases, and overall in 98% of cases, in a median time of 15 s (12-22.5). We applied manoeuvres in 61% of patients to facilitate the process. Ventilation was effective in 97.2% of the interventions (95% CI 0.99-0.94) throughout the procedure. Insertion of the gastric tube was easily performed in 99.6% of the patients, and the vocal cords were viewed by fibrobronchoscopy in 96.3% of cases. Logistic regression analysis identified the use of sizes smaller than those recommended as a risk factor for low OLP (< 25 cm H2O). The main complication recorded was the presence of blood when withdrawing the SGA device (15%).

CONCLUSIONS

Our results confirm that the use of AuraGain allows airway management in a reliable and effective way achieving high OLP and low incidence of associated complications, establishing it as a useful alternative in the routine clinical setting of anaesthesiologists. AuraGain performance was consistent in all five centres.

Recommendations on Testing Before Outpatient Dermatologic Surgery

INTRODUCTION

Short-duration ambulatory surgery for the removal of skin tumors under local anesthesia is increasingly common in dermatology. Preoperative assessment has traditionally targeted the identification of any unknown diseases or other health conditions that might lead to changes in plans for anesthesia or surgery. Hospitals and specialists differ greatly in the tests they order in patients about to undergo outpatient dermatologic surgery given that hardly any finding would be likely to contraindicate or lead to changes in the procedure. This study aimed to provide guidance for those ordering tests before outpatient dermatologic surgery.

METHODS

In 2017 our hospital developed a protocol to standardize preoperative testing for outpatient dermatologic surgery. We designed an observational, descriptive, retrospective analysis of tests ordered for patients scheduled for such surgery before and after the protocol was applied.

RESULTS

Fewer tests were ordered after the protocol was introduced. We detected no statistically significant differences in relation to type of surgery planned or postoperative complications.

CONCLUSIONS

Patients about to undergo outpatient dermatologic surgery under local anesthesia who have no unusual health risks may not require preoperative testing.

Radiological study to evaluate the spreading of two volumes (10 vs. 20ml) of radiological contrast in the block of cutaneous branches of intercostal nerves in medial axillary line (BRILMA) in a porcine experimental model

OBJECTIVE

Interfascial blocks of the thoracic wall are being developed as an alternative to central blocks in breast surgery. However, there are few studies that have evaluated the anatomical extension of the local anaesthetic. The objective of this study was to analyse, using fluoroscopy, the spreading of two volumes (10 vs. 20ml) of radiological contrast in the serratus-intercostal plane block in an experimental pig model.

MATERIAL AND METHODS

Ten Large-White breed pigs were selected to have a bilateral ultrasound serratus-intercostal plane block performed, with the administering of 10ml and 20ml of iopamidol in the right and left hemithorax, respectively. The spreading of contrast was analysed by fluoroscopy. The Spearman test correlation was used to evaluate the relationship between the administered volume and radiological spreading. A value of P<.05 was considered significant.

RESULTS

Twenty anaesthetic blocks were performed, being able to analyse 18 of them. The administration of 10ml of contrast was associated with a mean spreading of 2.28±0.31 (95% CI; 2.01-2.54) intercostal spaces, while the administration of 20ml showed a spreading of 3±0.25 (95% CI; 2.81-3.18) intercostal spaces. There was a significant correlation between the injected volume and the spreading of the contrast (Spearman correlation coefficient of 0.81; P=.0001).

CONCLUSION

The results showed a spreading of volume subject to the serratus-intercostal plane block, although not maintaining a 1:1 ratio. Doubling the volume increased the blocked segments by 31%. These findings, if corroborated in the clinical practice, would allow a more precise adjustment in the anaesthetic volume administered.

Desflurane versus propofol in post-operative quality of recovery of patients undergoing day laparoscopic cholecystectomy. Prospective, comparative, non-inferiority study

OBJECTIVE

Recently, the evaluation of postoperative results has focused on the opinion of the patient as of great relevance. Our objective was to evaluate the quality of recovery by questionnaire (QoR-15) in patients undergoing laparoscopic cholecystectomy, comparing desflurane versus a total intravenous technique with propofol (TIVA). A non-inferiority hypothesis was proposed between both techniques.

MATERIAL AND METHODS

Prospective longitudinal cohort study in patients undergoing laparoscopic cholecystectomy in which multimodal management was applied including low pneumoperitoneum pressures, deep neuromuscular block and pain prevention strategy and PONV. Anaesthesia maintenance was performed with either desflurane or propofol at the discretion of the anaesthesiologist. QoR-15 was evaluated pre-and 24hours after surgery.

RESULTS

Sixty-one patients were evaluated: 29 in the desflurane group and 32 in the TIVA group with no differences in demographic parameters, ASA grade, and preoperative QoR-15 questionnaire. The duration of the intervention was superior in TIVA group, 55 ± 15 vs. 45 ± 9min in desflurane group; p =.05. The desflurane group received more fentanyl than the TIVA group: 200 ± 65 vs. 113 ± 38μg; p =.05. No differences in pain, PONV or time of stay between groups. QoR-15 at 24h decreased 7% relative to baseline, with no differences between groups.

CONCLUSIONS

The quality of recovery evaluated by the patient was as favourable in the patients of the desflurane group as in those of the TIVA group in patients undergoing laparoscopic cholecystectomy as outpatients.

Air-Q® versus LMA Fastrach™ for fiberoptic-guided intubation: A randomized cross-over manikin trial

INTRODUCTION

Airway management is still a major cause of anesthesia-associated morbidity and mortality. Supraglottic devices are recommended in difficult airway management guidelines. The aim of this study was to compare the performance of the Air-Q^® and the LMA Fastrach™ for fiberoptic guided tracheal intubation.

METHODS

Thirty-three anesthesia trainees participated in this randomized crossover study. Time to insert the dedicated airways (insertion of the airway into the manikin and delivery of two breaths), time to tracheal intubation (fiberoptic-guided tracheal intubation), time to remove the dedicated airway (removal of the Air-Q^®/LMA Fastrach™ over the tracheal tube) and the opinion of the ease of use of the anesthesia trainees were measured.

RESULTS

There was 100% success rate for tracheal intubation with both devices on the first attempt. Time to insert the dedicated device and deliver two breaths was 10±3s for the Air-Q^® and 11±3s for the LMA Fastrach™, P=.07. Time taken to intubate the trachea was shorter with the air-Q^®, 38±15 s, than with the LMA Fastrach™, 47±19s, P=.017. Overall procedure time was significantly shorter with the Air-Q^® as compared with the LMA Fastrach™, with a mean time of 74±21s and 87±28s respectively, P=.002. Air-Q^® removal was considered easier than LMA Fastrach™ removal, P=.005. There were no tube dislodgements during the removal of the dedicated airways.

CONCLUSIONS

Inexperienced anesthesia residents can perform fiberoptic-guided intubation through Air-Q^® and LMA Fastrach™ in a clinically acceptable time with high success.

End-tidal desflurane concentration for tracheal extubation in adults

OBJECTIVE

To determine the end-tidal desflurane concentration required for tracheal extubation in anaesthetised adults.

MATERIAL AND METHODS

After hospital Ethics Committee approval, eighteen ASA I-II adult patients (19-65 years of age), who had been scheduled for elective ambulatory surgery were included in the study. Anaesthesia was induced with propofol 2.5mg.kg^-1, fentanyl 2μg.kg^-1, and rocuronium 0.6mg.kg^-1 for intubation. Maintenance of anaesthesia was provided by desflurane in oxygen and air (40:60), and remifentanil at 0.05-0.25μg.kg^-1.min¹. Neuromuscular function was monitored with train-of-four (TOF) nerve stimulation and acceleromyography. At the end of the surgery neuromuscular blockade was reversed with sugammadex 2-4mg.kg^-1 in accordance with the TOF ratio. The concentration of desflurane at which extubation was attempted was determined by using Dixon's up-and-down method with 0.5% as a step size. Smooth extubation was defined as one without coughing, teeth clenching, gross purposeful movements, and no breath-holding or laryngospasm within 1min of tracheal extubation.

RESULTS

It was found that the end-tidal concentration of desflurane was 3.17±0.18% (95% CI: 3%-3.35%) for successful extubation in 50% of adults.

CONCLUSION

Extubation in patients receiving desflurane may be feasible at 0.62 minimum alveolar concentration.

Analysis of the temporal regression of the QRS widening induced by bupivacaine after Intralipid administration. Study in an experimental porcine model

OBJECTIVE

The principal mechanism of cardiac toxicity of bupivacaine relates to the blockade of myocardial sodium channels, which leads to an increase in the QRS duration. Recently, experimental studies suggest that lipid emulsion is effective in reversing bupivacaine cardiac toxicity. We aimed to evaluate the temporal evolution of the QRS widening induced by bupivacaine with the administration of Intralipid.

MATERIAL AND METHODS

Twelve pigs were anesthetized with intravenous sodium thiopental 5mg kg(-1) and sevoflurane 1 MAC (2.6%). Femoral artery and vein were canalized for invasive monitoring, analysis of blood gases and determination of bupivacaine levels. After instrumentation and monitoring, a bupivacaine bolus of 4-6 mg kg(-1) was administered in order to induce a 150% increase in QRS duration (defined as the toxic point). The pigs were randomized into two groups of six individuals. Intralipid group (IL) received 1.5 mL kg(-1)of IL over one minute, followed by an infusion of 0.25 mL kg min(-1). Control group (C) received the same volume of a saline solution. The electrocardiographic parameters were recorded, and blood samples were taken after bupivacaine and 1, 5, 10 and 30 minutes after Intralipid/saline administration.

RESULTS

Bupivacaine (4.33±0.81 mg/kg in IL group and 4.66±1.15 mg/kg in C group) induced similar electrocardiographic changes in both groups; mean maximal percent increase in QRS interval was 184±62% in IL group, and 230±56% in control group (NS). Lipid administration reversed the QRS widening previously impaired by bupivacaine. After ten minutes of the administration of IL, the mean QRS interval decreased to 132±56% vs. 15±76% relative to the maximum widening induced by bupivacaine, in IL and C group, respectively.

CONCLUSION

Intralipid reversed the lengthening of QRS interval induced by the injection of bupivacaine. Time to normalization of electrocardiographic parameters can last more than 10 minutes. While the phenomena of cardiac toxicity persist, resuscitation measures and adequate monitoring should be continued until adequate heart conduction parameters are restored.

Preoperative tests recommendations in adult patients for ambulatory surgery

Anesthetic assessment traditionally included a series of laboratory tests intended to detect undiagnosed diseases, and to ensure that the patient undergoes surgery following safety criteria. These tests, without a specific clinical indication, are expensive, of questionable diagnostic value and often useless. In the context of outpatient surgery, recent evidence suggests that patients of any age without significant comorbidity, ASA physical status gradei and grade ii, do not need additional preoperative tests routinely. The aim of the present recommendations is to determine the general indications in which these tests should be performed in ASA gradei and grade ii patients undergoing ambulatory surgery.

[Multicentre epidemiological study of anaesthetic techniques in inguinal hernia surgery in Spain]

OBJECTIVE

Despite renewed interest in the management of anaesthesia during inguinal hernia surgery, there is a lack of data on trends in anaesthesia in Spain. The purpose of this study was to analyse the different anaesthetic techniques used in inguinal hernia surgery and their association with recovery, hospital stay, complications, and satisfaction with the technique.

PATIENTS AND METHODS

Ours was a multicentre, descriptive, cross-sectional epidemiological study performed at 20 Spanish hospitals. Each centre included 12 patients who underwent elective inguinal hernia repair. Data were collected on patient characteristics, clinical history, anaesthetic technique, post-operative recovery, and complications.

RESULTS

Data were collected on 238 patients, most of whom (91%) were ASA I or II, with a mean age of 57 years (25-84). Day surgery was performed in 47% of cases; 26% as one-day surgery, and the rest as inpatient surgery. Spinal anaesthesia was the most widely used technique (60%), followed by general anaesthesia (27%), and local anaesthesia with sedation (13%) (pP<.0001). Discharge was within 6 hours with general anaesthesia and local anaesthesia in 94% and 100% of cases, respectively, compared with 68% for spinal anaesthesia (001). No differences were observed between anaesthetic techniques in terms of adverse effects, except for urinary retention in 10 male patients (mean age 68 years) all of whom had received spinal anaesthesia.

CONCLUSIONS

Spinal anaesthesia is the most commonly used technique in Spain for inguinal hernia repair, although it is associated with a longer hospital stay (greater than 6h in 32% of cases) and a high incidence of urinary retention than other anaesthetic methods, in particular those with local infiltration. These techniques should be more vigorously implemented in daily practice.

[Dual atrioventricular nodal conduction and arrhythmia with severe hemodynamic alterations during liver retransplantation]

We report the case of a man who developed tachycardia caused by atrioventricular reentry related to dual nodal conduction during liver retransplantation. The hemodynamic alterations were severe. Arrhythmia and altered cardiac conduction are potential complications of liver transplantation. The development of tachyarrhythmias--atrial fibrillation as well as episodes of supraventricular and ventricular tachycardia and bradycardia--have been described. Such arrhythmias tend to occur particularly during reperfusion of the graft. Risk factors implicated are the severe ion imbalances, acid-base imbalance, and hypothermia that accompany the reperfusion of a new organ. A review of the possible pathogenic and etiological mechanisms that lead to arrhythmia in patients with end-stage liver disease is provided.

Comparative effects of thiopental and propofol on atrial vulnerability: electrophysiological study in a porcine model including acute alcoholic intoxication †

BACKGROUND

Atrial tachyarrhythmias (AT) frequently complicate the perioperative period. Alcohol intoxication is a recognized causative factor for dysrrhythmias. We studied the effects of propofol and thiopental on atrial electrophysiology and vulnerability to AT in a closed-chest porcine model in which AT are facilitated by ethanol.

METHODS

Thirty-eight pigs were randomly assigned to thiopental (T-group, n=19) or propofol (P-group n=19). All animals were assigned to undergo a right atrial electrical stimulation protocol (RASP) at baseline. Thirty pigs were assigned to undergo additional RASP during ethanol infusion, while the remaining eight were assigned to undergo additional RASP during saline infusion (control group). We analysed effective refractory period (ERP), and intra-atrial conduction interval (ICI) (between atrial sites 4 cm apart), at several cycle lengths (CL).

RESULTS

There were no significant differences at baseline. During ethanol infusion, propofol produced a greater rate-dependent decrease in excitability, manifested by a longer minimum paced CL with 1:1 atrial capture: 145 (11) vs 164 (27) ms in the T- and P-group, respectively (P=0.01). Propofol was associated with a greater rate-related slowing in conduction: difference between ICI at CL of 300 ms and ICI at minimum CL: 30 ms in P-group and 22 ms in T-group (P<0.03). In the P-group we observed a longer duration of induced arrhythmias (145 (131) vs 74 (91) s, P<0.03) and a higher proportion with atrial flutter (AFl) (76 vs 19%, P<0.001).

CONCLUSIONS

Propofol in this model was more arrhythmogenic than thiopental, as manifested by a longer duration of induced arrhythmias, particularly AFI.

[Blood reflux through the catheter when trying catheterization of the subclavian vein is not a reliable sign in case of hemothorax]

A 36-year-old man suffered chest and neurovascular trauma, soft-tissue injury to the left arm, and trauma to facial bones and extremities. He was hemodynamically unstable and responded poorly to blood transfusion and vasoactive medication. Pneumothorax was suspected. When a tube was inserted into the left hemithorax, 1500 mL of blood was drained. A chest film revealed hemothorax and a contusion on the left lung, but no rib fractures. An attempt to catheterize the left subclavian vein yielded reflux, and blood was then transfused. The patient continued to be highly unstable and an additional 1000 mL of blood was drained. Exploratory thoracotomy revealed a ruptured subclavian vein, location of the venous catheter in the pleural cavity, and a fracture of the first left rib. After chest injury leading to hemothorax, reflux upon catheterization of the ipsilateral subclavian vein is not a sure sign of correct tip placement. Additional means for checking placement, such as assessing pressure wave morphology, should be used. A fracture of the first rib, which may not be evident on a chest x-ray, often causes a vascular lesion and thoracic hemorrhage. Incorrect insertion of a subclavian catheter may then follow.

Response to clamping of the inferior vena cava as a factor for predicting postreperfusion syndrome during liver transplantation

Postreperfusion syndrome (PRS) is an important cause of hemodynamic deterioration during orthotopic liver transplantation (OLT). We retrospectively studied 94 patients who had undergone OLT in an effort to establish whether the hemodynamic response to clamping of the inferior vena cava (IVC) could be used to predict hemodynamic behavior on reperfusion of the grafted liver. PRS was defined as a decrease in the mean arterial pressure of more than 30% below the baseline value for more than 1 min during the first 5 min after reperfusion of the graft. The patients were divided into two groups: those who developed PRS (PRS group) and those who did not (non-PRS group). We analyzed hemodynamic response before (dissection stage) and after (anhepatic stage) clamping of the IVC. Based on multivariate analysis methods (logistic regression), the percentage of change in the vascular resistance index from before clamping to after clamping of the IVC was an indicator of the risk of developing PRS, with an adjusted odds ratio of 1.04 for each unit of change (ENTER method, P = 0.01). In the non-PRS group, clamping of the IVC was followed by a 47.1% decrease in the cardiac index, compared with a 27.9% decrease in the PRS group (P < 0.05). The systemic vascular resistance index (SVRI) increased by 49% in the PRS group, as opposed to 85.7% in the non-PRS group (P < 0.05). PRS occurred in only 17.5% of patients in whom the SVRI increased by more than 50%. We conclude that the integrity of the vasoconstrictive response (increase in the peripheral vascular resistance greater than 50%) as measured immediately after clamping of the IVC correlates with occurrence of PRS.

Alcohol concentration determines the type of atrial arrhythmia induced in a porcine model of acute alcoholic intoxication

Alcohol abuse has long been suspected clinically to cause paroxysmal atrial tachyarrhythmias. However, such a relationship has never been conclusively proven, partly due to the lack of experimental evidence. Although atrial fibrillation (AF) is the most common atrial arrhythmia attributed to acute alcoholic ingestion, atrial flutter has occasionally been noted. We analyzed the possible role of alcohol in initiation and/or maintenance of a variety of atrial tachyarrhythmias in a closed-chest porcine model. Nine pigs underwent nine endocardial right atrial stimulation protocols (RASP) at baseline and 17 RASPs after increasing doses of ethanol (first infusion 1,230 mg/kg, second infusion 870 mg/kg) by means of one multipolar catheter advanced under heavy sedation from the femoral vein. Each RASP included 1, 2, and 3 extrastimuli, and rapid pacing at 5 times diastolic threshold. Venous ethanol concentrations were measured (HPGC method) every 10 minutes and at the time of arrhythmia induction. Atrial tachyarrhythmias were induced in 4 of 9 baseline RASPs, and lasted for a mean of 21 seconds, and in 16 of 17 RASPs after alcohol lasting for a mean of 357 seconds. Only fibrillation was observed at the baseline RASP. The atrial tachyarrhythmias induced after alcohol were AF in 11 RASPs and atrial flutter in 5 RASPs (in 5 animals). The mean venous ethanol concentration at the time of the longest arrhythmia induced for each RASP were 200 +/- 89 mg/dL for RASP inducing fibrillation and 292 +/- 40 mg/dL for RASP inducing flutter (P < 0.05). Flutter tended to be sustained (> 1 minute in duration) more often than fibrillation (4 of 5 flutter vs 2 of 11 fibrillation P < 0.05). In three experiments, atrial flutter persisted for > 10 minutes and was terminated by overdrive atrial pacing. We concluded: (1) in this closed-chest porcine model, an ethanol infusion facilitates a variety of atrial arrhythmias related to the ethanol concentration; (2) flutter tended to be sustained, and its termination by overdrive pacing suggests the possibility of an alcohol induced reentrant mechanism; and (3) the higher concentration required for atrial flutter, exceeding that usually seen in humans, may help to explain the rarity of atrial flutter in clinical alcohol intoxication.