Intravenous Vasopressors Research Articles

Mad honey poisoning presenting with syncopal attack: a case report.

The authors report a case of 62 years old male with mad honey poisoning who was presented to the emergency department with loss of consciousness and had bradycardia and hypotension on arrival. The patient received intravenous fluids, atropine, and vasopressor support and was closely monitored in the coronary care unit for 48h. Grayanotoxin I and II are believed to be primarily responsible for mad honey intoxication and act by persistent activation of voltage-gated sodium channels. Hypotension, dizziness, nausea, vomiting, and impaired consciousness are the common presentation of mad honey intoxication. Toxic effects are usually mild and close monitoring for 24-48h is sufficient but life-threatening complications like cardiac asystole, convulsions, and myocardial infarction have also been reported. Most cases of mad honey intoxication only need symptomatic treatment and close observation but the potential for deterioration and life-threatening complications must also be considered.

What is new and different in the 2021 Surviving Sepsis Campaign guidelines.

The Surviving Sepsis Campaign (SSC) International Guidelines for the Management of Sepsis and Septic Shock provide recommendations on the care of hospitalized adult patients with (or at risk for) sepsis. This review discusses what is new or different in the 2021 SSC adult sepsis guidelines compared to 2016. The guidelines include new weak recommendations for use of balanced fluid over saline 0.9%, use of intravenous corticosteroids for septic shock when there is ongoing vasopressor requirement, and peripheral initiation of intravenous vasopressors over delaying initiation in order to obtain central venous access. As before, there is astrong recommendation to initiate antimicrobials within 1 h of sepsis and septic shock, but there are now additional recommendations when the diagnosis is uncertain. The recommendation for initial fluid resuscitation in septic shock of 30 mL/kg crystalloid has been downgraded from strong to weak. Finally, there are 12 new recommendations addressing long-term outcomes from sepsis, including strong recommendations to screen for economic and social support and to make referrals for follow-up where available; use shared decision-making in post-intensive care unit (ICU) and hospital discharge planning; reconcile medications at both ICU and hospital discharge; provide information about sepsis and its sequelae in written and verbal hospital discharge summary; and to provide assessment and follow-up for physical, cognitive, and emotional problems after hospital discharge.

Oral Midodrine as an Adjunct in Rapid Weaning of Intravenous Vasopressor Support in Spinal Cord Injury.

Background Majority of acute cervical spinal cord injury end up requiring long-term stay in intensive care unit (ICU). During the initial few days after spinal cord injury, most patients are hemodynamically unstable requiring intravenous vasopressors. However, many studies have noted that long-term intravenous vasopressors remain the main reason for prolongation of ICU stay. In this series, we report the effect of using oral midodrine in reducing the amount and duration of intravenous vasopressors in patients with acute cervical spinal cord injury. Materials and Methods Five adult patients with cervical spinal cord injury after initial evaluation and surgical stabilization are assessed for the need for intravenous vasopressors. If patients continue to need intravenous vasopressors for more than 24 hours, they were started on oral midodrine. Its effect on weaning of intravenous vasopressors was assessed. Results Patients with systemic and intracranial injury were excluded from the study. Midodrine helped in weaning of intravenous vasopressors in the first 24 to 48 hours and helped in complete weaning of intravenous vasopressors. The rate of reduction was between 0.5 and 2.0 µg/min. Conclusion Oral midodrine does have an effect in reduction of intravenous vasopressors for patients needing prolonged support after cervical spine injury. The real extent of this effect needs to be studied with collaboration of multiple centers dealing with spinal injuries. The approach seems to be a viable alternative to rapidly wean intravenous vasopressors and reduce duration of ICU stay.

The Impact of Midodrine Tapering Versus Nontapering Regimens on the Clinical Outcomes of Critically Ill Patients: A Retrospective Cohort Study.

Midodrine has been used in the intensive care unit (ICU) setting to reduce the time to vasopressor discontinuation. The limited data supporting midodrine use have led to variability in the pattern of initiation and discontinuation of midodrine. To compare the effectiveness and safety of 2 midodrine discontinuation regimens during weaning vasopressors in critically ill patients. A retrospective cohort study was conducted at King Abdulaziz Medical City. Included patients were adults admitted to ICU who received midodrine after being unable to be weaned from intravenous vasopressors for more than 24 hours. Patients were categorized into two subgroups depending on the pattern of midodrine discontinuation (tapered dosing regimen vs. nontapered regimen). The primary endpoint was the incidence of inotropes and vasopressors re-initiation after midodrine discontinuation. The incidence of inotropes or vasopressors' re-initiation after discontinuation of midodrine was lower in the tapering group (15.4%) compared with the non-tapering group (40.7%) in the crude analysis as well as regression analysis (odd ratio [OR] = 0.15; 95% CI = 0.03, 0.73, P = 0.02). The time required for the antihypertensive medication(s) initiation after midodrine discontinuation was longer in patients who had dose tapering (beta coefficient (95% CI): 3.11 (0.95, 5.28), P = 0.005). Moreover, inotrope or vasopressor requirement was lower 24 hours post midodrine initiation. In contrast, the two groups had no statistically significant differences in 30-day mortality, in-hospital mortality, or ICU length of stay. These real-life data showed that tapering midodrine dosage before discontinuation in critically ill patients during weaning from vasopressor aids in reducing the frequency of inotrope or vasopressor re-initiation. Application of such a strategy might be a reasonable approach among ICU patients unless contraindicated.

Effect of the Red Bull Energy Drink on Perfusion-Related Variables in Women Undergoing Microsurgical Breast Reconstruction: Protocol and Analysis Plan for a Prospective, Multicenter Randomized Controlled Trial

Maintaining a sufficiently high systolic blood pressure is essential for free flap perfusion after microsurgical breast reconstruction. Yet, many women undergoing these procedures have low postoperative systolic blood pressure. Intravenous volume administration or vasopressors may be needed to maintain systolic blood pressure above a predefined threshold. However, excessive volume administration may lead to volume overload and flap stasis, and the postoperative use of vasopressors may be limited depending on institutional standards. Additional nonpharmacological measures to raise blood pressure might be beneficial. Evidence suggests that the Red Bull energy drink could raise blood pressure. It has been shown to increase systolic and diastolic blood pressure in healthy volunteers and athletes. The primary objective of this study is to determine the difference in systolic blood pressure between an intervention group receiving Red Bull and a control group receiving still water after microsurgical breast reconstruction. Secondary objectives include postoperative heart rate, 24-hour fluid balance, pain level, or necessity for revision surgery due to flap complications. The Red Bull study is a prospective, multicenter randomized controlled trial comparing the effect of postoperative ingestion of Red Bull energy drink against still water in female patients undergoing unilateral microsurgical breast reconstruction. A total of 250 mL of Red Bull (intervention group) or 250 mL of still water (control group) will be administered to the study participants 2 hours postoperatively as well as for breakfast and lunch on postoperative day 1, amounting to a total volume of 750 mL per 24 hours. Female patients between 18 and 70 years of age undergoing unilateral microsurgical breast reconstruction will be included. Exclusion criteria are a history of arterial hypertension, cardiac rhythm disorder, diabetes mellitus, gastric or duodenal ulcer, thyroid disease, and current use of antihypertensive or antiarrhythmic drugs or thyroid hormones, as well as intolerance to Red Bull. Recruitment for the study started in June 2020 and was completed in December 2022. There is evidence that the Red Bull energy drink increases blood pressure in healthy volunteers and athletes. We hypothesize that postoperative ingestion of Red Bull will increase systolic blood pressure in women after microsurgical breast reconstruction. Red Bull could hence be used as a nonpharmacological adjunct to vasopressors or volume administration in women with hypotensive blood pressure after microsurgical breast reconstruction. This paper describes the Red Bull study trial protocol and analysis plan. The information will increase the transparency of the data analysis for the Red Bull study. ClinicalTrials.gov NCT04397419; https://clinicaltrials.gov/ct2/show/NCT04397419. DERR1-10.2196/38487.

Effect of midodrine on the prognosis of patients with septic shock: a systematic review and meta-analysis.

This study aims to assess the efficacy and safety of midodrine on treating patients with septic shock. Literature search was conducted in PubMed, the Cochrane Library, and Embase. The Mantel-Haenszel method was used to calculate pooled relative risks (RRs) and 95% confidence intervals (95% CI). The mean differences (MD) or standardized mean difference (SMD) were calculated using the inverse variance for continuous variables. Data analysis was performed using Review Manager 5.3. A total of 6 studies were finally included in this meta-analysis. Adding midodrine to patients with septic shock was associated with a reduction in hospital mortality [risk ratio (RR) 0.76; 95% CI, 0.57-1.00; p=0.05] and intensive care unit (ICU) mortality (RR 0.59; 95% CI, 0.41-0.87; p=0.008). However, there were no significant differences in the duration of intravenous vasopressors [standardized mean difference (SMD) -0.18; 95% CI, -0.47-0.11; p=0.23], intravenous vasopressor reinstitution (RR 0.58; 95% CI, 0.19-1.80; p=0.35), the length of ICU stay [mean difference (MD) -0.53 days; 95% CI, -2.24-1.17; p=0.54], and the length of hospital stay (MD -2.40 days; 95% CI, -5.26-0.46; p=0.10) between midodrine group and intravenous vasopressor alone group. The additional use of midodrine might reduce hospital mortality and ICU mortality in patients with septic shock. More high-quality randomized controlled trials are needed to verify this conclusion.

Emerging concepts in the care of patients with cirrhosis and septic shock.

Septic shock impacts approximately 6% of hospitalized patients with cirrhosis and is associated with high rates of morbidity and mortality. Although a number of landmark clinical trials have paved the way for incremental improvements in the diagnosis and management of septic shock in the general population, patients with cirrhosis have largely been excluded from these studies and critical knowledge gaps continue to impact the care of these individuals. In this review, we discuss nuances in the care of patients with cirrhosis and septic shock using a pathophysiology-based approach. We illustrate that septic shock may be challenging to diagnose in this population in the context of factors such as chronic hypotension, impaired lactate metabolism, and concomitant hepatic encephalopathy. Furthermore, we demonstrate that the application of routine interventions such as intravenous fluids, vasopressors, antibiotics, and steroids should be carefully considered among those with decompensated cirrhosis in light of hemodynamic, metabolic, hormonal, and immunologic disturbances. We propose that future research should include and characterize patients with cirrhosis in a systematic manner, and clinical practice guidelines may need to be refined accordingly.

Abstract Number ‐ 101: Blood Pressure Interventions Are Most Common Reason for ICU Admission After MMA Embolization

Introduction Middle meningeal artery embolization (MMAE) is a minimally invasive technique that is increasingly performed for the treatment of chronic subdural hematomas. In comparison to prior surgical interventions, which often resulted in complications such as insufficient drainage or recurrence of rebleeding, MMAE has greatly reduced the need for multiple inpatient hospitalizations. Some authors have described managing minimally symptomatic patients with MMAE in the outpatient setting. Our practice, however, has been routinely admitting patients to the neuro‐intensive care setting after MMAE. The objective of this research is to analyze the frequency of ICU level interventions that were administered to patients after MMAE in the neuro‐intensive care unit in order to gain a better understanding of postoperative management and assess the potential for future management in the outpatient setting. Methods A consecutive series of MMA embolizations for cSDH were retrospectively reviewed from 2020 to 2022 at Valley Baptist Medical Center in Harlingen, TX, USA. Frequency of ICU specific interventions such as need for post procedural mechanical ventilation, need for intravenous vasopressor or antihypertensive medications was recorded. Additional data collected included patient clinical presentations, indications for treatment, additional neurosurgical intervention, length of ICU stay, and blood pressure parameters. Results A total of 50 MMA embolizations were performed during the study period. The average age of patients included in the study was 63 years old +/‐ 16 years with 30% being female. 34% patients did not receive any sort of ICU level intervention at all. Among the remaining who did, 32% required mechanical ventilation post procedurally. 14% needed a vasopressor and 48% required intravenous antihypertensives to maintain systolic blood pressure within goal parameters. Conclusions The most common reason for an ICU intervention after MMAE was for correction of blood pressure to maintain within specified goal. 34% of patients who underwent MMAE did not require any ICU level interventions afterwards. Further investigation is warranted, but current data suggests that liberalizing blood pressure parameters could potentially reduce the need for ICU utilization after MMAE. Assessment of various components of ICU level interventions administered to patients post‐MMAE allows for a better understanding on preventive measures that can be taken in the future to reduce length of inpatient stay post procedurally, which would reduce risk of iatrogenic complications, minimize spread of nosocomial infections, andoverall increase patient comfort.

Evaluating an advanced double intravenous vasopressor automated system to treat hypotension during spinal anesthesia for cesarean delivery: a randomized controlled trial

BackgroundThe optimal treatment of hypotension during spinal anaesthesia is uncertain. A novel double intravenous vasopressor automated (DIVA) system reduces hypotension compared to standard care, and was subsequently modified to an advanced-DIVA (ADIVA) system. The primary objective was to compare ADIVA versus DIVA on incidence of hypotension (systolic BP (SBP) < 80% baseline).MethodsWe conducted a randomized-controlled trial in women undergoing elective cesarean delivery under spinal anesthesia. SBP and heart rate were measured continuously using a Nexfin monitor. ADIVA delivered 25 μg phenylephrine (heart rate > 60 beats.min−1) or 2 mg ephedrine (heart rate < 60 beats.min−1) at SBP 90 to 110% of baseline, 50 μg phenylephrine or 4 mg ephedrine at SBP 80 to 90%, and 75 μg phenylephrine or 6 mg ephedrine at SBP < 80%. ADIVA calculated the trend of SBP; vasopressors were administered rapidly if SBP trended downward, or 30 s if SBP trended upward. In contrast, DIVA delivered 25 μg phenylephrine or 2 mg ephedrine at SBP 90 to 100% of baseline, and 50 μg phenylephrine or 4 mg ephedrine at SBP < 90%. Boluses were followed by a 10-s lockout. Other outcomes included hypertension (SBP > 120% baseline), vasopressor consumption, clinical outcomes, and performance measures from spinal anesthesia to fetal delivery.ResultsWe analyzed 94 parturients (ADIVA: n = 46, DIVA: n = 48), with no difference in the incidence of hypotension between ADIVA (78.3%) and DIVA (83.3%, p = 0.677). ADIVA had significantly higher proportion of hypotensive SBP readings, lower phenylephrine consumption and higher umbilical arterial pH. There was no difference in hypertension, bradycardia, ephedrine consumption, intravenous fluid volume, nausea/vomiting, Apgar scores, and umbilical venous pH or lactate. ADIVA maintained SBP higher above baseline with greater fluctuation than DIVA. ConclusionADIVA was associated with a greater proportion of hypotensive SBP readings, reduced phenylephrine consumption, and increased umbilical arterial pH than DIVA. Further research is needed to determine the optimal method of vasopressor delivery in parturients undergoing cesarean delivery.Trial registrationThis study was registered on Clinicaltrials.gov registry (NCT03620942) on 08/08/2018.

The Use of Midodrine as an Adjunctive Therapy to Liberate Patients from Intravenous Vasopressors: A Systematic Review and Meta-analysis of Randomized Controlled Studies.

Studies evaluating the role of midodrine as an adjunctive therapy to liberate patients with shock from intravenous (IV) vasopressors have yielded mixed results. The aim of our study was to evaluate the efficacy and safety of midodrine as an adjunctive therapy to liberate patients with shock from IV vasopressors. Electronic searches of the MEDLINE, EMBASE, and Cochrane databases through April 2022 for randomized controlled trials (RCTs) that evaluated the use of midodrine versus control in patients with shock and a low dose of IV vasopressors. The primary outcome was total IV vasopressor time, whilethesecondary outcomes includedtime-to-IV vasopressor discontinuation, IV vasopressor restart, intensive care unit (ICU) length of stay (LOS), hospital LOS, and incidence of bradycardia. The final analysis included four RCTs with a total of 314 patients: 158 in the midodrine group and 156 in the control group, with a weighted mean age of 64years (54.2% men). There was no significant difference in the total IV vasopressor time between the midodrine and control groups (standardized mean difference [SMD] - 0.53; 95% confidence interval [CI] - 1.38 to 0.32, p = 0.22; I2 = 92%). Also, there were no significant differences between the two groups in the time-to-IV vasopressor discontinuation (SMD - 0.05; 95% CI - 0.57 to 0.47, p = 0.09), IV vasopressor restart (19.3 vs. 28.3%; risk ratio [RR] 0.74; 95% 0.25-2.20, p = 0.59), ICU LOS (SMD - 0.49; 95% CI - 1.30 to 0.33, p = 0.24), and hospital LOS (SMD 0.01; 95% CI - 0.27 to 0.29, p = 0.92). However, compared with the control group, the midodrine group had a higher risk of bradycardia (15.3 vs. 2.1% RR 5.56; 95% CI 1.54-20.05, p = 0.01). Among patients with vasopressor-dependent shock, midodrine was not associated with early liberation of vasopressor support or shorter ICU or hospital length of stay. Adding midodrine increased the risk of bradycardia. Further large RCTs are needed to better evaluate the efficacy and safety of midodrine in liberating patients from IV vasopressors.

Role of Midodrine on Vasopressor Duration in Patients with Sepsis

Existing literature evaluating the off-label use of midodrine has focused primarily on postoperative hypotensive patients requiring a single vasopressor. This study aimed to evaluate the impact of midodrine on vasopressor duration and length of stay in patients receiving vasopressors for sepsis-related hypotension. This is an institutional review board-approved, single-center, retrospective analysis of critically ill patients with hypotension secondary to sepsis who received midodrine and intravenous vasopressors compared to those who received intravenous vasopressors alone. Patients were matched by Acute Physiology and Chronic Health Evaluation II score, suspected source of infection, and presence of bacteremia. One hundred patients were included in this analysis. The median duration of vasopressors in the midodrine group (n = 50) was 36 hours (interquartile range [IQR] 18.94-61.94) compared to 26 hours (IQR 13.75-59.88) in the vasopressor-only group (P = .127). Patients in the midodrine group were in the intensive care unit (ICU) for a median of 3.9 days compared to 2.6 days in the vasopressor-only group (P = .017). Midodrine patients had a median hospital length of stay 3.7 days longer than the vasopressor-only group (P = .008). Eight patients (16%) were discharged on midodrine without an indication for therapy. This report assesses the use of midodrine in patients with sepsis requiring one or more vasopressors. Initiation of midodrine did not decrease the time to vasopressor discontinuation. The evaluation of midodrine indication and potential for its discontinuation is an intervention pharmacists can target at the transition of care from the ICU.

209: EFFECT OF MIDODRINE IN COVID-19 PATIENTS WITH SEPTIC SHOCK ON TIME TO VASOPRESSOR DISCONTINUATION

Introduction: Patients with COVID-19 in the intensive care unit (ICU) often require prolonged use of intravenous (IV) vasopressors which become a barrier to intensive care unit (ICU) discharge. The goal of this study is to describe the effect of midodrine, an alpha-1 agonist, on time to IV vasopressor discontinuation in COVID-19 patients in the ICU. Methods: This study was an IRB-approved retrospective chart review conducted at a community, tertiary care hospital between January 2020 until November 2021. Eligible participants included hypotensive patients aged 18 years or older who were admitted to an ICU on at least 0.1 mcg/kg/min of norepinephrine for 24hrs with a diagnosis of septic shock and COVID-19. Pearson Chi-Square and Independent-Samples Mann-Whitney U Test were used to analyze baseline characteristics, ICU length of stay, and time to IV vasopressor discontinuation in patients that received at least one dose of midodrine and patients on comparable IV vasopressors not started on midodrine. Results: 70 patients were included in the study with 35 patients in the midodrine group and 35 patients in the control group. The median time to IV vasopressor discontinuation was 13 days for the midodrine group and 8 days for the control group (p < 0.001), but there were less patients started on a second IV vasopressor in the midodrine group. Median time of initiation of midodrine was 9 days and IV vasopressors were discontinued at a median of 4 days after starting midodrine. The mean ICU length of stay and Hospital length of stay were 26 days & 32 days in the midodrine group and 15 days & 21 days in the control group (p < 0.001). The average dose of midodrine was 10 mg per day. Conclusions: The initiation of midodrine in COVID-19 patients with septic shock was not found to decrease total time to IV vasopressor discontinuation. Although, there were less patients started on a second IV vasopressor in the midodrine group.

1215: EFFECT OF MIDODRINE ON LENGTH OF STAY IN ADULT PATIENTS WITH SEPTIC SHOCK

Introduction: Midodrine is increasingly used in critically ill patients with septic shock to facilitate weaning intravenous (IV) vasopressors and discharge from the intensive care unit. Despite a trend of increasing use, current data demonstrate mixed efficacy in liberation from vasopressors or reduction in length of stay (LOS). Our study aimed to evaluate real-world data on the effect of midodrine on LOS in patients admitted for septic shock. Methods: Our analysis used de-identified data from the Trisus Medication Compare platform (The Craneware Group, Deerfield Beach, FL) to identify adults with septic shock (ICD-10 code R65.21) and a dispensation for any vasopressor between 1/1/2019-3/31/2022. The primary objective was to compare average in-hospital LOS in patients receiving midodrine versus not. Subgroup analyses were performed in patients requiring invasive mechanical ventilation (IMV), renal replacement therapy (RRT), and two or more vasopressors. Secondary outcomes included 30-day all-cause readmission, bradycardia, and catheter-related bloodstream infection. Continuous and discrete outcomes were assessed using Kruskal-Wallis and Chi-square tests, respectively. Results: A total of 68,935 encounters were captured (midodrine, n=9,053; no midodrine, n=59,882). Diabetes mellitus, liver disease, chronic kidney disease, and heart failure were more common in patients who received midodrine, while hypertension was more common in those who didn’t. About 65.1% of patients required IMV. Patients receiving midodrine had higher use of RRT, two or more vasopressors, and IV hydrocortisone. The average in-hospital LOS was longer in patients receiving midodrine (22.6±25.6 vs 14.5±18.7 days), consistent across subgroup analyses. In addition, 30-day all-cause readmission was higher in those with a dispensation for midodrine (13.8%) vs those without (10.1%, p< 0.01). Surprisingly, more patients in the no midodrine group had bradycardia (3.0% vs 2.5%, p< 0.01), while more patients receiving midodrine developed catheter-related bloodstream infections (3.0% vs < 0.1%, p< 0.01). Conclusions: Use of midodrine in adults with septic shock was associated with longer hospital LOS and a higher 30-day readmission rate.

1245: EFFECT OF EARLY ALBUMIN USE FOR RESUSCITATION IN PATIENTS WITH CIRRHOSIS AND SEPTIC SHOCK

Introduction: The choice of resuscitation fluid remains debated for patients with septic shock. Patients with cirrhosis may benefit from albumin administration due to diminished endogenous production, reduced baseline blood pressures, and an impaired immune response. We hypothesized that receiving albumin as part of initial fluid resuscitation would improve the clinical outcomes of patients with cirrhosis and septic shock. Methods: This was a single center retrospective cohort study of adults with cirrhosis admitted for septic shock to the intensive care unit (ICU) between January 2007 to May 2017. Patients were stratified based on albumin administration within six hours of ICU admission. The primary outcome was percent shock-free time during ICU admission, with shock reversal time being discontinuation of all intravenous vasopressors for at least 24 hours. Results: Albumin was administered within the first six hours of ICU admission for 93 of the 148 patients (63%). The albumin group and non-albumin group had a similar percent shock-free time during ICU admission (37% vs. 41%, p = 0.33), which remained insignificant in a multivariable model (p = 0.98). Younger age, lower ICU admit SOFA score, and higher ICU admit hemoglobin were associated with improved percent shock-free time in the ICU. The total vasopressor dose in norepinephrine equivalents during ICU stay was higher in the albumin group (42.1 vs. 15.4 mg, p = 0.004). Mortality within 28 days of ICU admission (60% vs. 41%, p = 0.044) was higher in the albumin group, but mortality during ICU stay was similar (30% vs. 20%, p = 0.18). No differences were observed in the need for renal replacement therapy or mechanical ventilation. Conclusions: Albumin administration within the first six hours of ICU admission was not associated with improved shock-free time in the ICU, ICU mortality, or clinical outcomes of organ dysfunction in patients with cirrhosis and septic shock. Patients in the albumin group may have had greater severity of illness or refractory shock, reflected by the significantly higher vasopressor requirements, and been more likely to receive albumin. Further study is needed to assess the impact of albumin on clinical outcomes in patients with cirrhosis and septic shock.

942 PERCUTANEOUS TREATMENT OF ACUTE PULMONARY EMBOLISM: A CASE REPORT

Abstract Background Pulmonary embolism (P.E.) is defined as an acute occlusion/subocclusion of pulmonary vascular vessels with a ranging clinical manifestation. A reperfusion therapy (preferably systemic thrombolysis) represents the first line therapy for high-risk patients. However, a percutaneous treatment option should be considered when thrombolysis is contraindicated or has failed. Case report A 73 y.o. male, a former smoker with history of hypertension and dyslipidemia, was admitted for hemorrhagic stroke and was subsequently treated by neuro-surgical treatment. 7 days after admission, a cardiac arrest with pulseless electrical activity occurred but return of spontaneous circulation was rapidly achieved. For persistent hypotension vasopressor therapy was started. As first diagnostic work up, an EKG was performed showing sinus tachycardia and new onset of right bundle branch block; the echocardiography revealed a right ventricle dilatation with signs of pressure overload. At the computed tomography angiography of the pulmonary circulation, multiple and bilateral filling defects finally confirmed the diagnosis of acute high-risk P.E.. Given the absolute contraindication for thrombolysis and the good neurological prognosis, a catheter-directed therapy (CDT) was indicated by a multidisciplinary team evaluation. In the cath-lab, the angiography of pulmonary artery confirmed the presence of an occluding embolus in the left lower lobe artery and of a sub-occluding clot in the basal right lower lobe. Multiple aspirations were performed using a Flow Triever (Inari Medical, Irvine, CA) 20 Fr device advanced in the left and right pulmonary artery; a 16 Fr device, adopting child-in-mother technique, was also used, finally removing a large amount of thrombotic material (Fig.1). Restoration of the distal vascular segment perfusion was confirmed by a repeated angiography (Fig.2) and by the reduction of the invasive mean pulmonary artery pressure from 35 mmHg (pre-procedure) to 22 mmHg (post-procedure) (Fig.3). After the procedure, a rapid de-escalation of intravenous vasopressors was performed and the patient was transferred to the Intensive Care Unit, in stable conditions. Finally, the patient was discharged 7 days later, with the resolution of the EKG and echocardiography alterations. Conclusions The Flow Triever device for the interventional treatment of P.E. is a CE approved aspiration system (3 sizes aspiration catheters) including 3 catheters with self-expanding nitinol for mechanical clot fragmentation. Evidence on the safety and efficacy of CDT is limited to observational single studies, a few small randomized trials and small single-arm cohort studies. Outcomes depend on the chosen technique, patient characteristics and local expertise. In particular, the FLARE study showed a significant Right/Left Ventricle ratio reduction after the use of a Flow Triever system while keeping a low rate of complications. The FLASH study is ongoing and the interim analysis showed encouraging results. However, randomized studies focusing on clinical outcomes and comparing CDT to conventional standard therapy (i.e. systemic thrombolysis for high-risk PE and anticoagulation for intermediate risk disease) are needed.

Safety of Pill-in-the-Pocket Class 1C Antiarrhythmic Drugs for Atrial Fibrillation.

Guidelines recommend that initial trial of a "pill-in-the-pocket" (PIP) Class 1C antiarrhythmic drug (AAD) for cardioversion of atrial fibrillation (AF) be performed in a monitored setting because of the potential for adverse reactions. This study sought to characterize real-world, contemporary use of the PIP approach, including the setting of initiation and incidence of adverse events. This retrospective cohort study included all patients at the Hospital of the University of Pennsylvania treated with a PIP approach for AF between 2007 and2020. A total of 273 patients (age 56 ± 13 years; 182 [67%] male; CHA2DS2VASc score 1.1 ± 1.2) took a first dose of PIP AAD. Flecainide was used in 151 (55%) and propafenone in 122 (45%). The first dose of PIP AAD was taken in a monitored setting in 167 (62%). Significant adverse events occurred in 7 patients (3%), 2 of whom had taken the doseinamonitored setting. Significant adverse events included unexplained syncope (1 of 7), symptomatic bradycardia/hypotension(4 of 7), and 1:1 atrial flutter (2 of 7). All occurred in patients taking 300mg of flecainide (n=4) or 600mg of propafenone (n=3). Electrical cardioversion was performed in 29 (11%) patients because of failure of the AAD to terminate AF. One patient required intravenous fluids and vasopressors for 2 hours because of persistent hypotension andbradycardia. Two patients required permanent pacemakers for bradycardia. The remaining patients required no intervention. Our data support the current recommendation to initiate PIP AAD in a monitored setting because ofrare significant adverse reactions that can require urgent intervention.

Abstract 12130: Cardiac Arrest as a Result of Anaphylactic Reaction From MAb Infusion for COVID-19

Introduction: Anaphylaxis is a severe, life-threatening, systemic hypersensitivity reaction. Severe cases may result in complete obstruction of the airway and cardiovascular collapse. Monoclonal antibody (MAb) products with anaphylactic potential are being used to treat COVID-19 through an FDA Emergency Use Authorization (EUA). Case Presentation: An 86-year-old male was referred to our hospital for thoracentesis. Medical history was significant for CLL, Atrial fibrillation, and type 2 diabetes mellitus. He had completed a 3-dose vaccination series for COVID-19. On the physical he was eutensive, afebrile, and was noted to have diminished breath sounds at the right lower lobe. Chest Xray showed right sided moderate pleural effusion. EKG showed atrial fibrillation. Thoracentesis was performed without complication. After this procedure, the patient’s PCR for COVID-19 returned positive. He met the criteria for MAb infusion and was provided bebtelovimab 175 mg intravenously. One minute later the patient became unresponsive, cyanotic, and bradycardic to 38 beats per minute. ACLS protocol was administered and 1mg atropine provided. After 1 cycle, ROSC was achieved and the patient was endotracheally intubated due to persistent altered consciousness. The patient was transferred to the ICU requiring intravenous vasopressors and remained intubated for 24 hours. He was extubated to Bilevel NIV, and weaned in the ambient air. TTE was performed and showed severe pulmonary HTN and an EF of 60%-65%. He was provided diuresis and discharged from the ICU. Conclusion: Anti-SARS-CoV-2 MAbs have been used for patients with mild to moderate COVID-19 who are hospitalized for reasons other than COVID-19 per FDA EUA criteria. Such treatments have been known to cause anaphylaxis in the past, although due to a dearth of complications, they may be underappreciated. This case brings attention to the serious anaphylactic reactions that can be caused by MAb and demonstrates the need for observation with ACLS capable equipment post-infusion.

Midodrine therapy for vasopressor dependent shock in the intensive care unit: a protocol for a systematic review and meta-analysis

IntroductionIntensive care unit (ICU) lengths of stay are modified by ongoing need for haemodynamic support in critically ill patients. This is most commonly provided by intravenous vasopressor therapy. Midodrine has...

Question: Peripheral arterial pressure wave in the presence of ventricular asystole.

A 65-year-old man with no significant past medical history presented to the Emergency Department with respiratory failure. Investigations determined that this was secondary to COVID-19 pneumonia. He required intubation, mechanical ventilation, and was admitted to the intensive care unit. His admission was complicated with bacteraemia and ventilator-associated pneumonia, requiring treatment with intravenous antimicrobials and vasopressors. The Cardiology service was consulted on Day 22 of his admission for new recurrent episodes of sudden bradycardia and transient asystole, which occurred after position changes or endotracheal tube suctioning. Interrogation of telemetry recordings showed repeated episodes of sudden bradycardia and transient asystole of up to 12 s. These changes were in keeping with a vagal response pattern,1,2 with sudden prolongation of P-P and R-R intervals (Panel A) followed by complete atrioventricular block with no ventricular activation (Panel B) that spontaneously resolved after several seconds (Panel C). The review of concomitant radial arterial line tracing and O2 saturation reading revealed pressure waves and O2 saturation waves as shown in panels D, E, and F. Continuous telemetry is shown in Video 1.

MALPOSITION OF RIGHT INTERNAL JUGULAR VEIN CATHETER IN RIGHT AXILLARY VEIN: A RARE CASE DIAGNOSED BY BEDSIDE ULTRASOUND

MALPOSITION OF RIGHT INTERNAL JUGULAR VEIN CATHETER IN RIGHT AXILLARY VEIN: A RARE CASE DIAGNOSED BY BEDSIDE ULTRASOUND