Hypotension Requiring Vasopressor Support Research Articles

Perfusion index as an early predictor of hypotension during advanced oncothoracic operations (pilot study)

Introduction. Current standards of intraoperative monitoring significantly reduce the response time to a decrease in blood pressure, but do not include methods for predicting changes in hemodynamics to avoid the effects of systemic hypoperfusion.The objective was to evaluate the usefulness of determining the perfusion index for predicting the development of hypotension and its earlier correction during advanced oncothoracic operations.Materials and methods. A prospective open-label observational study was conducted, which included 100 patients who underwent elective oncothoracic surgery. Standard monitoring was established, as well as continuous monitoring of the perfusion index. The perfusion index value was recorded immediately before induction. The patients were divided into 2 groups: in the 1st group (n = 37), patients experienced a decrease in blood pressure, requiring vasopressor support; in the 2nd group (n = 63), no vasopressor support was required.Results. A moderate linear relationship was revealed with a correlation coefficient (r) equal to (–0.68), p < 0.001, and a strong non-linear relationship with a coefficient (ρ) equal to (–0.95), p < 0.001. To identify the relationship model, polynomial regression analysis was performed. A prognostic formula for the use of vasopressors was calculated depending on the preoperative level of perfusion index. At the next stage, a classification tree for analyzing the data array was used. The entire d data array (n = 100) is randomly divided into training (n = 70) and test samples (n = 30). It was revealed that hypotension requiring vasopressor support occurred in patients whose initial perfusion index was ≤ 2.85. ROC analysis determined an AUC of 0.952 (95% CI: 0.888–1.016).Conclusion. A low PI value before induction of anesthesia during advanced oncothoracic operations can be used to monitor the functional activity of the autonomic nervous system and predict intraoperative hypotension. Patients with a baseline PI ≤ 2.85 have a higher risk of developing hypotension during advanced oncothoracic surgery compared with those with a baseline PI ≥ 2.85. The effectiveness of the method in patients with concomitant pathologies has not been tested.

Circumferential correction of spinal deformity and instability secondary to bacterial spondylodiscitis

BackgroundSpinal deformity as a sequela of non-tuberculous spondylodiscitis is a rarely discussed clinical entity. Sagittal plane deformity, segmental instability, and persistently active infection overlap in these patients resulting in severe restriction in activity and quality of life. The presence of multiple medical co-morbidities restricts surgical options but nonoperative care may be ineffective and result in persistent, refractory discitis for years. We describe our experience with vertebrectomy and long-segment fixation for patients with post-infectious thoracic or lumbar deformity. MethodsA retrospective chart review of 23 consecutive patients who underwent vertebrectomy and long-segment fixation for thoracic or lumbar deformity secondary to nontuberculous bacterial spondylodiscitis was performed. Pre-, peri- and postoperative data is compiled and analyzed with a focus on the perioperative management algorithm to safely perform an extensive reconstruction in this very sick patient population. ResultsExtremely low preoperative quality of life was evident with 87% (20/23) of patients bedridden primarily due to pain despite 70% (16/23) of patients being strong enough to ambulate (Frankel D or E). Most patients (87%) already had an identified infection under adequate treatment either through blood cultures, prior biopsy or decompressive surgery. A single-stage posterior-only was the primary surgical approach utilized in the majority (83%) of cases. Complications were present in 100% of patients, most commonly perioperative anemia and hypotension requiring vasopressor support and aggressive blood product replacement. One in-hospital mortality occurred secondarily to pulmonary embolism. Mean preoperative segmental angle was 18±10 degrees of kyphosis which was corrected to 1±9 degrees of lordosis (p=0.001). The mean correction of the segmental angle was 19 degrees (standard deviation 23 degrees). Visual analogue scale scores improved from a pre-operative value of 8.8±0.9 to a post-operative value of 2.5±1.4 (p<0.001), which was obtained at the last outpatient follow-up (mean 631 days after surgery). Full self-care including ambulation was achieved in 18/23 (78%) patients, and the infection was successfully treated in 22/23 (96%) patients after long-term antibiotics. ConclusionsPatients with refractory spondylodiscitis on appropriate care and antibiotics are typically considered extremely poor surgical candidates despite non-operative care often being ineffective. Post-infectious deformity may also be so severe as to preclude a limited surgical treatment strategy. This study suggests that extensive circumferential reconstruction for deformity secondary to bacterial spondylodiscitis can be effective in restoring these extremely sick patients to self-care and ambulatory status.

FRI207 Challenges Of Pheochromocytoma Management In A Heart Failure Patient

Abstract Disclosure: M. Novitskaya: None. M. Sonbol: None. S. Jafri: None. J. Monye: None. E. Japp: None. Introduction: Successful management of pheochromocytoma in patients with heart failure requires a careful balance between blood pressure control and appropriate perioperative volume resuscitation. Clinical Case: A 38-year-old male with heart failure with reduced ejection fraction (EF 15-20%), HTN, and polysubstance use disorder presented with dyspnea and subsequent in-house PEA arrest. Whole body CT showed an incidental 7.3 cm left adrenal mass. Laboratory work-up was notable for elevated plasma free metanephrines 47.30 nmol/L (n&amp;lt;0.89) and normetanephrines 39.8 nmol/L (n&amp;lt;0.49). Medical management of presumed pheochromocytoma was initiated with doxazosin. Left and right heart catheterization showed elevated intracardiac filling pressures (mmHg): RA 10, RV 66/5 (12), PA 55/29 (43), PCWP 35. Subsequent coronary angiogram was aborted due to hypertensive emergency and flash pulmonary edema for which he required IV hydralazine 20 mg, furosemide 80 mg, labetalol 30 mg, verapamil 5 mg, nitroglycerin 800 mg bolus then gtt at 100 mcg/min to achieve hemodynamic stability. He reached the preoperative BP goal after up titration of doxazosin to 12 mg daily and carvedilol to 25 mg twice daily. He subsequently underwent left adrenalectomy. Intraoperatively, the patient’s abdomen was insufflated to 13 mmHg given his reduced EF, and he received 2 L crystalloid prior to adrenal vein division. After a left adrenalectomy, he developed hypotension despite receiving an additional 3 L crystalloid, and was started on norepinephrine, epinephrine, and vasopressin gtt. Postoperatively, he remained intubated for two days due to distributive shock. With continued diuresis, mean arterial pressure recovered to &amp;gt;65 mmHg and he was extubated. He was successfully discharged on metoprolol succinate 25 mg, spironolactone 25 mg and losartan 25 mg daily. Clinical Lessons: Preoperative management of pheochromocytoma involves alpha-adrenergic blockade followed by beta-adrenergic blockade to target a BP of &amp;lt;130/80. A high sodium diet is recommended after adequate alpha-adrenergic blockade, and volume resuscitation is started preoperatively due to vasodilation after adrenalectomy. Successful management of patients with pheochromocytoma and heart failure requires extra attention to BP and volume status. Our patient’s case was complicated by severe HTN during cardiac catheterization resulting in flash pulmonary edema, and postoperative hypotension requiring vasopressor support due to loss of circulating catecholamines. His estimated risk of morbidity/mortality from adrenalectomy was &amp;gt;25% due to these factors. Multidisciplinary collaboration among endocrinologists, cardiologists, anesthesiologists, surgeons, and perfusionists is crucial to optimize patient outcomes. This patient case adds to the literature in presenting a positive adrenalectomy outcome in a patient with heart failure. Presentation: Friday, June 16, 2023

Outcome of critically ill patients with systemic lupus erythematosus from a medical intensive care unit in Southern India.

Systemic lupus erythematosus (SLE) has become the most prevalent autoimmune condition requiring admission in the intensive care units (ICU) in the last two decades. Here we analysed the clinical outcomes of SLE patients admitted to our ICU between 2011 and 2021, and studied the prognostic role of high-density lipoprotein (HDL) and procalcitonin in those enrolled after August 2019. Systemic lupus erythematosus (ACR/SLICC 2012) were enrolled, 72 retrospectively and 30 prospectively. Data on indications for ICU admission, complications, infections, and disease activity were recorded. Outcome was mortality at 90days (prospective) whereas in the retrospective analysis outcome was hospital discharge or death in hospital. Serum HDL and procalcitonin (PCT) was estimated in the prospectively enrolled 30 patients and compared with 30 non ICU-SLE patients. Indications for ICU admissions were respiratory causes in 78/102 (76.5%) patients; for haemodynamic monitoring and for invasive procedures in the remaining. Pneumonia was the primary reason for mechanical ventilation, followed by diffuse alveolar haemorrhage (DAH). Eighty-three (81.3%) patients died; infections (n = 54) and SLE related causes (n = 29). APACHE-II >16 (p = .026), lymphopenia (p = .021), infection (p = .002), creatinine >1.3mg/dL (p = .023), and hypotension requiring vasopressor support (p = .006) emerged as significant predictors of non-survival on multivariable analysis. HDL (mg/dL) day 1 was significantly lower in SLE-ICU patients compared to non ICU-SLE (31.8 ± 14.3 vs 38.8 ± 11.4mg/dl); p = .045. On day 1, PCT (ng/mL) in SLE-ICU was significantly higher when compared to non-ICU SLE; median (IQR): 0.53 (0.26-5.27) versus 0.13 (0.05-0.47), p < .001), respectively. It was also significantly higher on day 5 in SLE-ICU than non-ICU SLE (median (IQR): 4.18 (0.20-14.67) versus 0.10 (0.08-0.46), p = .004. The mortality of SLE patients admitted to the ICU in this study is high, and infections were the principal reason for death. Baseline low HDL and higher procalcitonin are potential biomarkers to identify critically ill SLE patients.

Prognostic Model for Vasopressor Requirement After Retroperitoneal Adrenalectomy for Pheochromocytoma: A Retrospective Study

To evaluate the risk factors for postoperative vasopressor requirement among patients with pheochromocytoma undergoing retroperitoneal adrenalectomy. The primary outcome was postoperative hypotension requiring vasopressor support. A single-center retrospective observational study. At a university hospital. Adults who underwent unilateral adrenalectomy for pheochromocytoma between October 2015 and February 2020. None. Overall, 201 patients were included. Postoperative vasopressor requirements were observed in 39 (19.4%) patients, and were associated with baseline coronary artery disease (CAD) (odds ratio [OR] 6.21, 95% CI) 2.48-15.52; p=0.0001), maximal systolic blood pressure (maxSBP) >195 mmHg (OR 3.71, 95% CI 1.53-8.95; p=0.0035), and >5.1-fold increase in the upper limit of normal values for baseline adrenergic activity (OR 4.9, 95% CI 1.93-12.55; p=0.0008). The area under the receiver operating characteristic curve of the predictive model was 0.804 (95% CI 0.742-0.856). A MaxSBP >195 mmHg, baseline adrenergic activity >5.1-fold increase in the upper limit of normal values, and baseline CAD could predict postresection requirements for vasoactive support. Prospective multicenter international studies are required to develop and validate universally accepted predictive models for postoperative complications in patients after adrenalectomy for pheochromocytoma.

Initial evaluation of extracorporeal immunomodulatory therapy for the treatment of critically ill COVID-19 infected patients

Severe COVID-19 infection results in significant immune dysregulation resulting from excessive recruitment and activation of neutrophils. The aim of this study was to confirm feasibility, initial safety and detect signal of efficacy of a non-propriety device delivered using an intermittent extra-corporeal system (LMOD) allowing leucocytes modulation in the setting of Severe COVID-19 infection. Twelve patients were recruited. Inclusion criteria were > 18 years age, confirmed COVID-19, acute respiratory distress syndrome requiring mechanical support and hypotension requiring vasopressor support. Primary end point was vasopressor requirements (expressed as epinephrine dose equivalents) and principle secondary endpoints related to safety, ability to deliver the therapy and markers of inflammation assessed over five days after treatment initiation. LMOD treatment appeared safe, defined by hemodynamic stability and no evidence of white cell number depletion from blood. We demonstrated a significant decrease in vasopressor doses (−37%, p = 0.02) in patients receiving LMOD therapy (despite these patients having to tolerate an additional extracorporeal intermittent therapy). Vasopressor requirements unchanged/increasing in control group (+ 10%, p = 0.48). Although much about the use of this therapy in the setting of severe COVID-19 infection remains to be defined (e.g. optimal dose and duration), this preliminary study supports the further evaluation of this novel extracorporeal approach.

S2421 A Dark Omen: Acute Esophageal Necrosis Associated With COVID-19

Introduction: Black esophagus, also known as acute esophageal necrosis (AEN), is a rare clinical entity with an estimated prevalence of 0.01 to 0.28 percent of cases in endoscopy series. It can present with striking endoscopic findings characterized by diffuse circumferential black discoloration of the esophagus terminating at the gastroesophageal (GE) junction. It is mostly associated with tissue hypoxia due to low flow vascular states and corrosive injury in the setting of severe illness. Patients typically present with gastrointestinal bleeding. We present a rare case of a black esophagus in the setting of severe Coronavirus-19 (COVID-19) infection. Case Description/Methods: A 75-year-old male with diabetes and chronic kidney disease presented after a mechanical fall with a prolonged down time of 13 hours. He was found to have acute on chronic renal failure with rhabdomyolysis. He was initially stable however later developed respiratory failure from COVID-19 requiring steroids and ultimately ventilator support. His course was further complicated by new onset atrial fibrillation for which he received anticoagulation, worsening renal function requiring hemodialysis and significant hypotension requiring vasopressor support. In the intensive care unit, patient was noted to have melena with a significant drop in hemoglobin, he underwent an esophagogastroduodenoscopy which showed diffuse continuous black discoloration of the esophageal mucosa with abrupt transition at the GE junction consistent with black esophagus with multiple ulcers in stomach and duodenum (Figure). Patient was kept on IV proton pump inhibitors and anticoagulation was discontinued. Given worsening multiorgan failure, he was transitioned to comfort measures only and passed away the next day. Discussion: Black esophagus or AEN is a rare but concerning finding on endoscopy which must be recognized early and managed aggressively in order to improve clinical outcomes. In our patient AEN was likely due to a combination of hypoperfusion and hypoxia in the setting of severe COVID-19 infection with multiorgan failure. AEN could be seen more frequently in patients with severe COVID-19 infections who are frequently anticoagulated due to the associated prothrombotic state with increased risk of GI bleeding. It is important for physicians to be aware of AEN as a possible etiology of GI bleeds in these patients.Figure 1.: 'Black esophagus' - Acute esophageal necrosis.

Diabetes mellitus is associated with increased risk of positive qSOFA score but not with increased ICU admission in patients undergoing ureteral stent placement for ureteral stone and suspected infection.

Patients presenting with an obstructing ureteral stone and urinary tract infection (UTI) are at risk for severe infectious complications. Historically, diabetes mellitus (DM) was considered a risk factor for the development of septic shock in these patients. This study aimed to evaluate DM's impact on risk of septic shock in ureteral stent placement for ureteral stone and presumed UTI. An institutional review board-approved, retrospective review was performed at two institutions. All patients who met the following criteria from July 2016 to April 2020 were included in the study: emergency department visit with obstructing ureteral stone, concern for UTI, and ureteral stent placement. The primary outcome of interest was the development of postoperative septic shock defined by sepsis with hypotension requiring vasopressor support for at least one hour. The study cohort was made up of 187 patients. Median age was 61 (range 16-91). Males represented 40.1% (n=75) of the population, while DM was present in 26.2% (n=49). Thirty-five of 143 patients (18.7%) met the criteria for postoperative septic shock. Quick Sequential Organ Failure Assessment (qSOFA) criteria were met by 11 (22.4%) patients with DM compared to 13 (9.5%) of patients without DM (p=0.026). This difference did not translate into significant differences in use of vasopressors, with DM cohorts requiring pressors in 11 (22.4%), and 241 (17.5%) in non-DM (p=0.523). Purulent urine was more frequently described in patients with DM (22 [44.9%] vs. 342 [4.8%], p=0.011). Intensive care unit (ICU) admissions were similar between DM and non-DM at 13(27.1%) vs. 29 (21.2%), respectively (p=0.543). ICU stay and length of stay were similar between cohorts. In this multicenter study of patients who underwent ureteral stenting for ureteral stone and presumed UTI, DM was not associated with an increased risk of development of septic shock but was associated with an increased risk of positive qSOFA score.

Successful Thrombolytic Therapy in a Suspected Case of HeartMate 3 LVAD Thrombosis

IntroductionAlthough less common with the HeartMate 3 (HM3), pump thrombosis remains a life-threatening complication of durable left ventricular assist devices (LVAD). We present what we believe is the first case of suspected pump thrombosis in a patient with a HM3 LVAD that was successfully managed with tissue plasminogen activator (tPA).Case ReportA 22-year-old man who underwent HM3 implantation for end stage heart failure due to left ventricular non-compaction presented after experiencing two low flow alarms. His physical examination was notable for tachycardia at 125 beats per minute and an elevated Doppler mean blood pressure of 92 mm Hg. LVAD interrogation revealed low flows without power spikes (Figure 1A). Within 24 hours, he developed persistent hypotension requiring vasopressor support and multiple low flow alarms. Serial laboratory results were notable for rising LDH, peaking at 4,741 U/L and acute liver injury with AST 2,712 U/L, ALT 798 U/L and INR 5.2. Transthoracic echocardiography and computed tomography (CT) angiography did not reveal any obvious thrombus. Given this constellation of findings, pump thrombosis was suspected. Following multidisciplinary discussion, unfractionated heparin bolus and infusion were started. After an unremarkable head CT, heparin was stopped and systemic tPA was given at a dose of 5 mg over one minute followed by 10 mg over 10 minutes due to ongoing liver dysfunction. Heparin was resumed after PTT returned to therapeutic range. Immediately post tPA infusion, his LVAD flows improved from 2.3 L/min to 4.1 L/min (Figure 1B). Vasopressor support was quickly weaned. LDH, creatinine, and liver enzymes improved over the following days. Warfarin was resumed on day 14 of admission. He was discharged on aspirin, clopidogrel and warfarin.SummaryThrombolytics may be a potential therapeutic option in select cases of HM 3 pump thrombosis. Further research is warranted to delineate LVAD parameters that facilitate early recognition of pump thrombosis and successful medical management. Although less common with the HeartMate 3 (HM3), pump thrombosis remains a life-threatening complication of durable left ventricular assist devices (LVAD). We present what we believe is the first case of suspected pump thrombosis in a patient with a HM3 LVAD that was successfully managed with tissue plasminogen activator (tPA). A 22-year-old man who underwent HM3 implantation for end stage heart failure due to left ventricular non-compaction presented after experiencing two low flow alarms. His physical examination was notable for tachycardia at 125 beats per minute and an elevated Doppler mean blood pressure of 92 mm Hg. LVAD interrogation revealed low flows without power spikes (Figure 1A). Within 24 hours, he developed persistent hypotension requiring vasopressor support and multiple low flow alarms. Serial laboratory results were notable for rising LDH, peaking at 4,741 U/L and acute liver injury with AST 2,712 U/L, ALT 798 U/L and INR 5.2. Transthoracic echocardiography and computed tomography (CT) angiography did not reveal any obvious thrombus. Given this constellation of findings, pump thrombosis was suspected. Following multidisciplinary discussion, unfractionated heparin bolus and infusion were started. After an unremarkable head CT, heparin was stopped and systemic tPA was given at a dose of 5 mg over one minute followed by 10 mg over 10 minutes due to ongoing liver dysfunction. Heparin was resumed after PTT returned to therapeutic range. Immediately post tPA infusion, his LVAD flows improved from 2.3 L/min to 4.1 L/min (Figure 1B). Vasopressor support was quickly weaned. LDH, creatinine, and liver enzymes improved over the following days. Warfarin was resumed on day 14 of admission. He was discharged on aspirin, clopidogrel and warfarin. Thrombolytics may be a potential therapeutic option in select cases of HM 3 pump thrombosis. Further research is warranted to delineate LVAD parameters that facilitate early recognition of pump thrombosis and successful medical management.

HYPONATREMIA SECONDARY TO VASOPRESSIN IN AN ECMO DEPENDENT PATIENT WITH SEVERE ARDS DUE TO COVID-19

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Vasopressin infusion induced hyponatremia is a rare phenomenon. It occurs especially when vasopressin is utilized as an adjunct vasopressor in non-septic shock states. 1 CASE PRESENTATION: 35-year-old Hispanic female without any comorbidities was hospitalized at our institution at the peak of COVID-19 pandemic in New York due to severe hypoxemic respiratory failure requiring ventilatory support and ultimately had to be placed on VV Extracorporeal membrane oxygen (ECMO) support for refractory ARDS. Patient required high doses of intravenous (IV) sedation while on ECMO, with ketamine, hydromorphone and versed. Subsequently, she developed worsening hypotension requiring vasopressor support with low to medium doses of nor-epinephrine (NE) infusion. Fixed dose vasopressin infusion was started in an effort to wean off NE infusion. Serum sodium trended down from 139 to 123 in following four days. Urine output (UOP) progressively dropped from >125 ml/hour to 1.035;calculated serum osmolarity-258;serum cortisol-4.7 and TSH-T4 of 0.948-0.8. Renal evaluation was obtained, vasopressin infusion was discontinued with a subsequent strong diuretic effect and a rapid correction in serum sodium. Patient was already on antibiotics for ventilator associated pneumonia, but shock was not attributed to sepsis considering patient was afebrile with a downtrend in leukocytosis preceding hyponatremia. DISCUSSION: Vasopressin is widely used for co-administration with catecholamines to obtain a dose sparing effect in septic shock. 1 Vasopressin due to an antidiuretic activity via renal V2 receptors can result in decreased in UOP with a secondary hyponatremic effect by causing a state of iatrogenic SIADH. 2 Developing hyponatremia shortly after vasopressin infusion and an anti-diuretic effect should be considered a strong indicator of vasopressin as an underlying etiology. CONCLUSIONS: Vasopressin use an adjunct vasopressor should be avoided in non-septic shock states to prevent a state of hyponatremia and a state of water intoxication. A state of volume overload may have a secondary negative impact on ventilator weaning. REFERENCE #1: Dunser MW, Mayr AJ, Ulmer H, et al. Arginine vasopressin in advanced vasodilatory shock.Circulation. 2003;107(18):2313-2319. REFERENCE #2: Miguel Salazar, Bee Bee Hu, Joyce Vazquez et al. Exogenous Vasopressin-Induced Hyponatremia in Patients with Vasodilatory Shock: Two Cas Reports and Literature Review. Journal of Intensive Care Medicine 2015;30(5) 253-258. DISCLOSURES: No relevant relationships by Zeeshan Hafeez, source=Web Response No relevant relationships by Sana Shahid, source=Web Response No relevant relationships by Abeer Zeeshan, source=Web Response

PD26-09 USING THE QUICK SEQUENTIAL ORGAN FAILURE ASSESSMENT SCORE TO PREDICT SEPTIC SHOCK AFTER URETERAL STENTING FOR PATIENTS WITH URETERAL STONE AND PRESUMED URINARY TRACT INFECTION

You have accessJournal of UrologyStone Disease: Surgical Therapy III (PD26)1 Sep 2021PD26-09 USING THE QUICK SEQUENTIAL ORGAN FAILURE ASSESSMENT SCORE TO PREDICT SEPTIC SHOCK AFTER URETERAL STENTING FOR PATIENTS WITH URETERAL STONE AND PRESUMED URINARY TRACT INFECTION Jason Lee, Christina Kottooran, Alan Yaghoubian, Nikil Uppaluri, Kate Hanson, Michael Borofsky, and Brian Eisner Jason LeeJason Lee More articles by this author , Christina KottooranChristina Kottooran More articles by this author , Alan YaghoubianAlan Yaghoubian More articles by this author , Nikil UppaluriNikil Uppaluri More articles by this author , Kate HansonKate Hanson More articles by this author , Michael BorofskyMichael Borofsky More articles by this author , and Brian EisnerBrian Eisner More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002019.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Recent studies have reported that qSOFA criteria may be superior to traditionally used SIRS criteria for prediction of urosepsis. The purpose of the current study was to compare qSOFA and SIRS criteria ability to predict septic shock in patients who present to the emergency department with an obstructing ureteral stone and concern for urinary tract infection. METHODS: An IRB-approved retrospective review was performed at two institutions. All patients who met each of the following criteria during the time period from July 2016 to April 2020 were included in the study: emergency department visit with obstructing ureteral stone, concern for urinary tract infection documented in consultation note, and ureteral stent placement. The primary outcome of interest was the development of post-operative septic shock defined by hypotension requiring vasopressor support for at least one hour. Patients who required vasopressor treatment prior to ureteral stenting were excluded from the analysis. All data were collected between the time of emergency room presentation to the time of stent placement. RESULTS: The study included 187 patients with a mean age of 58.8±18 and gender distribution of 60% female: 40% male. 35 of 143 patients (18.7%) met the criteria for postoperative septic shock. SIRS criteria were met for 103 patients (55.1%) for the entire cohort and 30 patients who experienced septic shock. qSOFA criteria were met for 24 patients (12.8%) in the entire cohort and 18 patients who experienced septic shock. Specificity for postoperative sepsis was significantly higher for qSOFA than for SIRS criteria (75 vs 29.1%, McNemar test p<0.001). Sensitivity was higher for SIRS criteria than for qSOFA (85.7 vs 51.4%, McNemar test p<0.01). qSOFA criteria had a significantly higher positive predictive value than SIRS (89.6% vs. 29.1%) while negative predictive values were similar (89.6 vs. 94%). CONCLUSIONS: qSOFA score demonstrated superior specificity and positive predictive value for post-operative septic shock than SIRS criteria in this study, whereas SIRS criteria demonstrated superior sensitivity. qSOFA score may be a useful tool for emergency evaluation of patients who present with ureteral stone and urinary tract infection. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e440-e441 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jason Lee More articles by this author Christina Kottooran More articles by this author Alan Yaghoubian More articles by this author Nikil Uppaluri More articles by this author Kate Hanson More articles by this author Michael Borofsky More articles by this author Brian Eisner More articles by this author Expand All Advertisement Loading ...

Predictors of prolonged hypotension requiring vasopressor support after resection of pheochromocytoma and paraganglioma.

Prolonged hypotension is a common complication after resection of pheochromocytoma (PCC) or paraganglioma (PGL). The objective of our study was to identify preoperative or intraoperative clinical factors that can predict prolonged hypotension after PCC/PGL resection. A total of 414 patients who underwent resection of PCC or PGL at our institution between January 2013 and January 2020 were included. Patients were divided into two groups according to whether or not vasopressor support was required postoperatively. Associations between preoperative and intraoperative variables and prolonged hypotension were evaluated. Two hundred and one (48.6%) patients had postoperative hypotension that required vasopressor support with a median duration of 20 h. Multivariable analysis demonstrated that increased 24-hurinary norepinephrine (NE) levels (odds ratio [OR] = 1.091, 95% confidence interval [CI]: 1.052-1.132, p < .001), longer operative time (OR = 1.008, CI: 1.004-1.011, p < .001)and lower preoperative phenoxybenzamine dose (OR = 0.336, CI: 0.150-0.753, p = .008) were predictors of prolonged hypotension. Moreover, operative time, body mass index, 24-hurinary level of NEand preoperative phenoxybenzamine dose were significantly correlated with the duration of postoperative vasopressor support. Increased urine NE level, longer operative timeand lower preoperative phenoxybenzamine dose were predictors of prolonged hypotension requiring vasopressor support. Clinicians can identify these factors to manage their patients better and prevent severe complications.

The use of doxazosin before adrenalectomy for pheochromocytoma: is the duration related to intraoperative hemodynamics and postoperative complications?

PurposeNo conclusion exists for the optimum duration of preoperative administration of doxazosin (DOX) before adrenalectomy for pheochromocytoma. The purpose of this study is to investigate whether perioperative hemodynamics and postoperative outcomes are related to the duration of DOX administration.MethodsIn total, 132 patients managed preoperatively with single α-receptor blocker DOX were enrolled. All patients underwent adrenalectomy for pheochromocytoma in the Department of Urology, Peking University First Hospital, between January 2001 and July 2019. Patients were divided into three groups based on the duration of preoperative administration of DOX: group A (≤14 days), group B (15–30 days), and group C (>30 days). Patient and tumor characteristics, intraoperative hemodynamics, and postoperative outcomes were recorded and compared.ResultsThese patients included 57 men and 75 women, with an average age of 48 years. Clinical characteristics, preoperative hemodynamics, medicine management and surgical approaches were comparable between the three groups. Among the three groups, we found that group C (>30 days) had the lowest intraoperative minimum heart rate [group A vs. group B vs. group C = 60 (52–67) vs. 59 (50–61) vs. 51.5 (50–58.75), p = 0.024] and highest risk of postoperative hypotension requiring vasopressor support [group A vs. group B vs. group C = 14 (20.3%) vs. 12 (27.9%) vs. 10 (50.0%), p = 0.032].ConclusionThe current study indicated that preoperative management of pheochromocytoma with single α-receptor blocker DOX for more than 30 days after final dose adjustment might lead to intraoperative bradycardia and more postoperative hypotension requiring vasopressor support. Thus, our study does not support long-term (over 30 days) preoperative administration of pheochromocytoma with single α-receptor blocker DOX in the final dose.

Acute Kidney Injury in COVID-19: Emerging Evidence of a Distinct Pathophysiology.

Acute Kidney Injury in COVID-19: Emerging Evidence of a Distinct Pathophysiology.

Cardiovascular Toxicity and Clinical Outcomes Following Chimeric Antigen Receptor T-Cell Infusion (CART) for Lymphoid Malignancies

<h3>Introduction</h3> CART-cell therapy is associated with dramatic efficacy in patients with relapsed/refractory diffuse large B-cell lymphoma and B-acute lymphoblastic leukemia. However, the efficacy of CART therapy is limited by potentially fatal toxicities including cytokine release syndrome (CRS) and neurotoxicity. Increasingly, emerging reports have suggested the potential for significant hemodynamic collapse following CART therapy. Yet, whether the occurrence of these hemodynamic shifts or any other cardiovascular disease (CVD) events have bearing on clinical outcomes after CART initiation is unknown. <h3>Methods</h3> We evaluated all patients treated with CART therapy for lymphoid malignancies at The Ohio State University James Comprehensive Cancer Center between 2016-2019 and assessed the incidence of CVD events and severe hemodynamic collapse [systolic blood pressure (SBP) cutoff of less than 80 mmHg]. We also evaluated the relationship of CVD events, hemodynamic collapse, and the presence of preceding CVD on overall survival (OS) and progression-free-survival (PFS) following infusion of CART cells utilizing univariate log-rank comparison. <h3>Results</h3> We evaluated 66 patients with 62% male and 38% female with an average age of 60 years (range 23-80). 49 (74%) patients received Yescarta and 17 (26%) patients received Kymriah. With a median follow-up time of 21 months, OS and PFS at 1 year were 72% and 43%, respectively, in concordance with previously reported ZUMA1 and JULIET survival rates. Overall, from 66 CART-treated patients, 14 (21.2%) developed incident CVD events, including 11 patients with arrhythmias and 2 with CHF. The median decrease in peak systolic blood pressure after infusion was 32 mmHg (IQR 22-47 mmHg), noted at a median of 4 days post-CART. Furthermore, after infusion, 17 (25.8%) saw falls in systolic pressure to < 80 mmHg, with 10 (15.2%) developing hypotension requiring vasopressor support. Three of these patients did not have any recovery of their hypotension and died. For patients who developed a SBP < 80 mmHg, there was a significantly impaired PFS at 30 days, 90 days, and 1 year (85%, 54%, and 0%, respectively) versus those who did not develop SBP < 80 mmHg PFS (100%, 83%, and 49%, respectively), p = 0.014 (figure). OS demonstrated similar results at 30 days, 90 days, and 1 year (85%, 54%, and 14%, respectively), compared to 100%, 83%, and 49.1%, respectively, p = 0.03. There was no difference in PFS or OS, based on the presence of neurotoxicity, steroid use, vasopressor use, preceding cardiovascular risk factors, or the development of other non-hypotension CVD events. <h3>Conclusion</h3> The development of significant early hypotension is associated with a marked decrease in survival among patients receiving CART therapy. Further understanding of this finding, and its relation to CRS is urgently needed in order to maximize the effectiveness of this novel anticancer therapy.

Carotid artery stenting in octogenarians: Clinical observation and follow-up

Objective To observe the safety and long-term efficacy of carotid artery stenting(CAS)in octogenarians with carotid stenosis. Methods Clinical data of patients aged 80 years or older undergoing CAS for carotid stenosis in our hospital between July 2008 and October 2017 were retrospectively analyzed.The perioperative treatment outcomes and mid- and long-term follow-up results were analyzed. Results A consecutive series of 61 patients(a median age of 81 years, 54 males)were enrolled.Of 61 patients, 23(37.7%)patients had symptomatic carotid artery stenosis.Sixty patients underwent unilateral CAS, one patient underwent bilateral CAS, and 26(42.6%)underwent other cerebrovascular interventional therapy during the same period.The technical success rate was 100.0%.During the perioperative period, the incidence of stroke was 6.6%(4/61), and no patient died.Eight(13.1%)patients had contrast-induced nephropathy, 4(6.6%)patients suffered from cardiac dysfunction, and 30(49.2%)patients had hypotension requiring vasopressor support postoperatively, and all of them recovered well when discharged from hospital.All patients were followed up for a median of 42 months(range 2-108 months, with an interquartile interval of 44 months). The incidence of stroke and death was 8.2%(5/61)within 30 days to 1 year after surgery.The median stroke-free survival was 72 months in patients with symptomatic carotid stenosis, and was 93 months in asymptomatic patients, with the statistically significant difference between the two groups(χ2=4.258, P=0.039). Conclusions Carotid artery stent implantation in octogenarians with carotid stenosis has a favorable safety and feasibility when performed in experienced centers, and the outcome of a mid- and long-term follow-up is good. Key words: Carotid stenosis; Stents; Stroke

Interferon Gamma, a Link between Hemophagocytic Lymphohistiocytosis and Dengue Fever Virus: A Literature Review of a Shared Inflammatory Pathway Resulting in Cytopenias and Potential Future Treatment Directions

Our patient was an elderly female, previously healthy, who presented with fever, anemia, thrombocytopenia, and enlarged spleen. Her complaints were progressive over the course of two months. She was treated with antibiotics with no improvement. Underlying lymphoproliferative disorder was suspected, and a bone marrow biopsy and aspiration was completed. While there was no evidence for lymphoproliferative disorder, there was hemophagocytosis. Further evaluation revealed ferritin 1,151 ng/mL, soluble IL2 receptor 32,186 u/mL, and natural killer activity was low. She was diagnosed with secondary hemophagocytic lymphohistiocytosis (HLH). During her evaluation, her condition acutely worsened; she became encephalopathic with hypotension requiring vasopressor support and respiratory failure. The patient was given etoposide with rapid improvement in overall clinical status though further cytopenias secondary to etoposide prevented further treatment. She was ultimately diagnosed with Dengue Fever Virus by IgM Antibody, 4.54, with positive result &gt;/= 2.84. A positive result is highly suggestive of acute disease, though cross reactivity is possible with other flavi viruses. The result was confirmed. The patient lived in a rural community in Eastern NC and had no travel history; the diagnosis was reported to the North Carolina public health department and the Center for Disease Control. Despite recognition and treatment of the HLH and Dengue fever, the patient died of complications. Both Dengue Fever and HLH cause significant morbidity and mortality. Their disease courses, while unique, do have some interesting parallels. They both can be associated with significant suppression of bone marrow function, frequently being associated with cytopenias. This is a major source of morbidity in both disease states. While Dengue Fever is a known, though rare, cause of HLH, it has not previously been reported in the continental United States. In this case report, we examine the known cytokine pathway activations in each disease state and their commonalities, focusing on bone marrow suppressive cytokines and subsequently suggesting mechanisms for targeted treatment of HLH. Even with our best treatments, in HLH, the associated mortality among all causes is around 42%. The mortality for untreated severe dengue is as high as 20% though with appropriate care, that is much improved at 1-2%. In HLH and Dengue, IL-1B, IFN-Ƴ, IL6, and TNF-α are increased. A common cytokine, IFN-Ƴ, directly affects bone marrow activity and can alter hematopoiesis. IFN-Ƴ is directly implicated in several bone marrow failure syndromes making it an attractive target to modulate. Based on results of an in vitro study of CD34+ hematopoietic stem cells (HSC) in the presence and absence of IFN-Ƴ in differing concentrations, IFN-Ƴ inhibited the ability of HSC to repopulate themselves though it did not affect their ability to differentiate. This was also shown in vivo in a mouse HSC transplant model with mirroring results. In our patient, it follows logical and chronological progression that her cytopenias worsened over time as her pool of CD34+ HSC was depleted. Additional studies of IFN-Ƴ and hematopoiesis suggest that IFN-Ƴ directly negatively affects the supportive bone marrow mesenchymal stoma cells which provide the cytokine environment that supports HSC repopulation. IFN-Ƴ is produced from the innate immune system via dendritic cells, natural killer (NK), and natural killer T (NKT) cell and in the adaptive immune system via Th1 T lymphocytes. IFN-Ƴ is a major activator of macrophages which in turn are responsible for secreting multiple other pro-inflammatory cytokines as previously mentioned. In Dengue, the innate immune system is activated via macrophage and dendritic cells. In HLH, IFN-Ƴ is primarily produced by T-cells. IFN-Ƴ is known to stimulate the janus kinase-STAT (JAK-STAT) signaling pathway in macrophages to increase inflammation. We suggest that modulation of the cytokines directly involved in the inflammatory syndrome might be considered. In summary, we report a case of Dengue fever with associated secondary HLH. This is the first report of Dengue fever in the continental United States in a person without travel history. In addition, this case report highlights the commonalities of the immune activation seen in both Dengue fever as well as secondary HLH and may indicate the potential for more targeted immunomodulation. Disclosures Liles: Imara: Other: PI on Clinical trial- Sickle cell ; Novartis: Other: PI on clinical trial Sickle cell ; Shire: Other: PI on clinical trial Sickle cell .

ACUTE COR PULMONALE AS THE INITIAL PRESENTATION OF LIMITED SYSTEMIC SCLEROSIS

SESSION TITLE: Medical Student/Resident Pulmonary Vascular Disease 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: Acute Cor pulmonale is a common presentation of severe pulmonary arterial hypertension (PAH). PAH affects up to 12% of patients with systemic sclerosis (SS) and associated with a poor prognosis. We present a case of a patient presenting with acute RV failure from severe pulmonary hypertension secondary to limited SS. CASE PRESENTATION: A 63-year-old African American female presented with worsening dyspnea. Past medical history was significant for COPD, severe pulmonary hypertension (PASP of 86 mmHg on previous echocardiogram), obesity and OSA. On arrival to the hospital, patient was tachypneic to 22 breaths/minute with a blood pressure of 92/70. Her oxygen saturation was noted to be 95% on 6L via nasal cannula. She suffered a syncopal episode while walking to the bathroom after being admitted to the hospital, which prompted a rapid response team to be alerted. Her blood pressure was 70/40 mmHg on arrival of the rapid response team (RRT). Pulmonary artery catheterization (PAC) was performed after point-of-care ultrasound suggested significant RV failure. PAC revealed RA 21mmHg, RV 109/20mmHg, PA 115/31 (mean of 62), PCWP 12 mmHg. TTE was performed revealing normal LV function, EF 60-65%. Abnormal septal motion and flat intraventricular septum consistent with RV overload, with an estimated PASP 103mmHg. While in the ICU, patient had continued hypotension requiring vasopressor support with norepinephrine. She was started on furosemide infusion to achieve diuresis. She was also started on intravenous epoprostenol as a pulmonary arterial vasodilator. Given her persistent hypotension and decreased cardiac output, a milrinone infusion was started as well. Despite these efforts, patient continued to deteriorate. The etiology for her decompensation remained unclear, she was noted to have significant worsening of her PASP on review of her previous echocardiography. She was started on a heparin infusion due to concerns for possible pulmonary embolism causing the acute decompensation. Further workup was pursued to evaluate for possible causes of PAH, given the decreased likelihood that her acute worsening was secondary to her history of OSA & COPD. Anti-centromere titers > 8 were revealed suggesting a diagnosis of limited SS. Unfortunately, patient’s clinical status continued to decline and patient expired. DISCUSSION: Acute cor pulmonale from PAH has an in-hospital mortality of 50% when requiring vasopressor and/or inotropic support. PAH affects up to 12% of patients with systemic sclerosis and is the leading cause of death in this patient population. Currently there are no guidelines on appropriate screening tools to identify patients with limited SS complicated by PAH. CONCLUSIONS: Acute cor pulmonale in the setting of SS portends a poor prognosis with associated 50% mortality. More studies are needed to identify strategies for early identification that will improve outcomes in this population. Reference #1: Chaisson et al. Systemic Sclerosis-Associated Pulmonary Arterial Hypertension. Chest. 2013;144(4):1346-1356. doi:10.1378/chest.12-2396. Reference #2: Jentzer et al. Pulmonary Hypertension in the Intensive Care Unit. J Intensive Care Med. 2016 Jul;31(6):369-85. doi: 10.1177/0885066615583652. DISCLOSURES: No relevant relationships by Navneet Kaur, source=Web Response No relevant relationships by Adnan Khalif, source=Web Response

Optimal Timing of Endoscopic Retrograde Cholangiopancreatography in Acute Cholangitis.

Acute cholangitis mandates resuscitation, antibiotic therapy, and biliary decompression. Our aim was to define the optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) for patients with acute cholangitis. Clinical data on all cases of cholangitis managed by ERCP were prospectively collected from September 2010 to July 2013. The clinical impact of the time to ERCP, defined as the time from presentation in the emergency department to the commencement of the ERCP, was determined. The primary outcome was length of hospitalization. Secondary outcomes included vasopressor use, endotracheal intubation, intensive care unit admission, and death. ERCP was successful in 182 (92%) of 199 patients with cholangitis. Length of hospitalization was significantly longer for patients undergoing ERCP at ≥48 versus <48 hours (median 9.1 vs. 6.5 d, P=0.004) even though patients having ERCP at ≥48 hours were less sick as indicated by less frequent intensive care unit admission [odds ratio,0.3; 95% confidence interval (CI), 0.2-0.6]. Multivariate analysis revealed that hospitalization increased by 1.44 days for every day ERCP was delayed (P<0.001). Comparison of ERCP≥72 versus <72 hours revealed odds ratios of 2.6 (95% CI, 1.0-7.0) for vasopressor requirement and 3.6 (95% CI, 0.8-15.9) for mortality. Time to ERCP did not impact technical success or procedural adverse events. ERCP should be performed within 2 days of presentation as a delay of 48 or more hours is associated with disproportionate increase in hospital stay. Delay>72 hours is associated with additional adverse outcomes including hypotension requiring vasopressor support.

Bordetella bronchisepticaPneumonia Post-Liver Resection in a Patient with Liver Cirrhosis and Cholangiocarcinoma

Background: Although Bordetella bronchiseptica is primarily an animal pathogen, cases of human disease caused by this pathogen have been published recently, most frequently pneumonia in immunocompromised patients. In human disease, transmission through animal vectors may play a key role. Although no standardized sensitivity testing is available for this pathogen in human disease, animal isolates are sensitive to most β-lactam antibiotics. Case Report: A 62-year-old Caucasian male with Child-Pugh class A cirrhosis caused by chronic hepatitis C infection underwent uneventful left lateral segmentectomy for a 3 cm cholangiocarcinoma. Within 48 h, he developed altered mental status, temperature of 39.4°C, leukocytosis (white blood cell count: 13,000/mm3), and dyspnea followed by hypotension requiring vasopressor support and intubation. Computed tomography (CT) scan demonstrated left lower lobe pneumonia. Empiric antibiotic therapy including vancomycin (1 g every 12 h) and piperacillin-tazobactam (3.5 g every 6 h) was initiated and his signs of sepsis resolved within two days. Bordetella bronchiseptica was cultured from sputum. Upon questioning, the patient reported close contact with several pet cats on the days prior to admission. Antibiotics were continued for a total of seven days and he was discharged in good condition doing well at his six-month follow-up. Conclusions: Immunocompromised patients may develop infection with Bordetella bronchiseptica especially if they are in close contact with animals known to be a reservoir of this pathogen. If diagnosed early and treated appropriately, the outcome is favorable.