Intravenous Vasopressors Research Articles

Trans-ocular brain impedance index for assessment of cerebral autoregulation in a porcine model of cerebral hemodynamic perturbation.

Cerebrovascular autoregulation (CA) is often impaired following traumatic brain injury. Established technologies and metrics used to assess CA are invasive and conducive for measurement, but not for continuous monitoring. We developed a trans-ocular brain impedance (TOBI) method that may provide non-invasive and continuous indices to assess CA. In this study, we monitored impedance metrics such as respiratory-induced impedance amplitude changes (dz) as well as a novel impedance index (DZx), which is a moving Pearson correlation between mean arterial pressure (MAP) and dz. Yorkshire swine were instrumented to continuously record ICP, MAP, and cerebral blood flow (CBF). TOBI was recorded by placement of standard ECG electrodes on closed eyelids and connected to a data acquisition system. MAP, ICP and CBF were manipulated utilizing an intravenous vasopressor challenge. TOBI indices (dz and DZx) were compared to the hemodynamic indicators as well as pressure reactivity index (PRx). During the vasopressor challenge, dz was highly correlated with ICP, CPP, and CBF (r = < -0.49, p < 0.0001). ICP, CPP, and CBF had a mean percent increase (standard deviation) from baseline of 29(23.2)%, 70(25)%, and 37(72.6)% respectively while dz decreased by 31(15.6)%. Receiver operator curve test showed high predictive performance of DZx when compared to PRx with area under the curve above 0.86, with high sensitivity and specificity. Impedance indices appear to track changes in PRx and hemodynamics that affect cerebral autoregulation. TOBI may be a suitable less invasive surrogate to PRx and capable of tracking cerebral autoregulation.

TO COMPARE THE NEED FOR INTRAVENOUS VASOPRESSOR (RESCUE) THERAPY FOR TREATING SPINAL ANAESTHESIA INDUCED HYPOTENSION AMONG PHENYLEPHRINE, EPHEDRINE AND CONTROL GROUPS.

The study was undertaken in the Department of Anaesthesiology, Gajra Raja Medical College, Gwalior. The study included 90 patients (age 20-35 years) undergoing elective caesarean section under spinal anaesthesia.&#x0D; Maximum hypotension was observed in control group. As compared to the control group, incidence of hypotension was significantly less in phenylephrine group as well as ephedrine group. Also comparing ephedrine and phenylephrine groups, although incidence of hypotension was low in phenylephrine group but it was not found to be significant.&#x0D; The incidence of hypotension was significantly low in phenylephrine group (p=0.000) and ephedrine group (p=0.005). But when phenylephrine and ephedrine groups were compared, although incidence of hypotension was low in phenylephrine group but it was not found to be significant (p=0.869).&#x0D; Keywords: Intravenous Vasopressor, Spinal Anaesthesia, Hypotension &amp; Phenylephrine.

Survival After In-Hospital Cardiac Arrest in Critically Ill Patients: Implications for COVID-19 Outbreak?

The coronavirus disease 2019 (COVID-19) outbreak is placing a considerable strain on U.S. healthcare systems by requiring both significant acute resources and endangering healthcare team members th...

A COVID-19 Young Girl Patient with Developing Pneumonia and Septic Shock Passing the Death

Rationale: Coronavirus disease is a current worldwide pandemic serious infection. Septic shock is a very common cause of death due to COVID-19 infection. There is a strong relationship between the severity of COVID-19 infection and death. COVID-19 infection is a well-known trigger for severe inflammatory changes and sepsis. Up till now, there is no well-known treatment for COVID-19. Patient concerns: A young girl COVID-19 patient admitted to the critical care unit with severe shock and developing pneumonia. Diagnosis: COVID-19 patient admitted to the critical care unit with COVID-19 young girl patient with septic shock and developing pneumonia. Interventions: Electrocardiography, arterial blood gas test, chest CT scan, central venous catheterization, and intravenous vasopressors infusion. Outcomes: Progressive dramatic clinical electrocardiography and radiological improvement had happened. Lessons: It denotes the role of anticoagulants, vasopressors, steroids, and antibiotics in the management of COVID-19 pneumonic infection and septic shock. C- reactive protein, lymphocytic count, liver enzymes, and CT chest may be used as a good laboratory guide for follow up for the inflammatory activity of COVID-19 patient. Blood pressure, respiratory rate, and O2 saturation are another strong guide for clinical for follow up in COVID-19 patients.

Code Blue During the COVID-19 Pandemic.

The surging COVID-19 pandemic has raised ethical and moral dilemmas that Western nations with first-rate medical care facilities rarely confront-how to best allocate standard life-saving medical resources when escalating demand outstrips supply. Sadly, these quandaries are familiar challenges in resource-poor countries. What makes this pandemic notable is that the scope and number of reported cases have been primarily in First World nations, raising questions in some settings about the use of emergency treatments like resuscitation care for in-hospital cardiac arrest (IHCA). This perspective reviews the debate around these ethical and moral dilemmas more broadly but focuses specifically on IHCA and the response of the medical community.

Genesis of Antibiotic Resistance (AR) LVIII: Discordant Antibiotic Stewardship contort Early Goal Directed Fluid Resuscitation therapy (EGDT) with higher incidence of Mortality in severe Sepsis: A global melee

A retrospective analysis of EGDT trials from 2000 to 2018 registered in national clinical trials is presented here: (PRISM‐U) Study group attributed that the sepsis cohort with Mycobacterium tuberculosis (MTB) bacteremia for higher rate of in‐hospital mortality. FEAST (ISRCTN69856593) trial observed that fluid resuscitation in children with sepsis significantly increased mortality (48‐hour) possibly due to impaired perfusion. SSSP trail (NCT01449916) showed that though hypoxemic respiratory failure as contributing factor for mortality in addition to tissue hypoperfusion as inclusion criteria of patients with hypovolemia but excluding the patients with severe respiratory distress when ventilator support is not readily available could have potentially improved the survival rate. ARISE (NCT00975793) presented their report on the effectiveness of EGDT compare to that of usual sepsis care had similar (~18%) mortality rate concluding that EGDT did not reduce all‐cause mortality at 90 days. PRISM (NCT02030158) reported that, EGDT miss the mark to relieve mortality rate compare to that of usual care cohort. ProCESS (NCT00510835) reported that among 1341 patients, of whom 439 were randomly assigned to protocol‐based EGDT, 446 to protocol‐based standard therapy, and 456 to usual care in which protocol‐based resuscitation of patients in whom septic shock was diagnosed in the ER did not improve outcomes. ProMISe (ISRCTN36307479) concluded that septic shock cohort identified early and treated with intravenous antibiotics and adequate fluid resuscitation, hemodynamic management according to a strict EGDT protocol showed that no difference in mortality rate by 90 days. The IMPreSS study group found that compliance with “all of the evidence‐based bundle metrics” had a 40 % reduction in the odds of dying in hospital with the 3‐h bundle and 36 % for the 6‐h bundle. ProCESS Investigators (NCT00793442, NCT00510835 ) showed that increase in leucocyte rolling and adhering to dysfunctional endothelial surface in the cohort of septic shock compare to that of control, attributed to an increase in endothelial permeability‐hemostasis as cause for mortality. SSSP‐2 (NCT01663701) reported that cohort with sepsis and hypotension, most of whom were positive for HIV, in a resource‐limited setting, a protocol for early resuscitation with administration of intravenous fluids and vasopressors increased in‐hospital mortality compared with usual care. MOSAICS Study Group attributed the high mortality rate in severe sepsis treatment for the variation in adhering to the “all of the evidence‐based bundle metrics” for sepsis treatment. GENESIS project comparing 6‐hour resuscitation bundle (RB) for severe sepsis cohort showed decreased mortality rate compare to that of no RB bundle. Taken together it is suggested that lack coherent antibiotic stewardship practices across the globe warrant immediate review during EGDT and implementation of such guidelines would likely improve the survival rate in both low and high resource setting.Support or Funding InformationSupported by the professional development funds by SWTJC to Subburaj Kannan

664 Risk Factors for the Development of Transaminitis in Pediatric Burn Patients Treated with Oxandrolone

Abstract Introduction Oxandrolone is an anabolic steroid that is the standard of care for burn patients experiencing hypermetabolism. Previous studies have demonstrated the benefits of oxandrolone, including increased body mass and improved wound healing. One of the common side effects of oxandrolone is transaminitis, occurring in 5–15% of patients, but little is known about associated risk factors with the development of transaminitis. A recent multicenter study in adults found that younger age and those receiving concurrent intravenous vasopressors or amiodarone were more likely to develop transaminitis while on oxandrolone. The purpose of this study was to determine the incidence and identify risk factors for the development of transaminitis in pediatric burn patients receiving oxandrolone therapy. Methods This was a multicenter, retrospective risk factor analysis that included pediatric patients with thermal burn injury (total body surface area [TBSA] &amp;gt; 10%) who received oxandrolone over a 5-year time period. The primary outcome of the study was the development of transaminitis while on oxandrolone therapy, which was defined as aspartate aminotransferase (AST) or alanine aminotransferase (ALT) &amp;gt;100 mg/dL. Secondary outcomes included mortality, length of stay, and change from baseline ALT/AST. Results A total of 55 pediatric patients from 5 burn centers met inclusion criteria. Of those, 13 (23.6%) developed transaminitis, and the mean time to development of transaminitis was 17 days. Patients who developed transaminitis were older (12 vs 6.4 years, p = 0.01) and had a larger mean %TBSA (45.9 vs 34.1, p = 0.03). The odds of developing transaminitis increased by 23% for each 1 year increase in age (OR 1.23, CI 1.06–1.44). The use of other concurrent medications was not associated with an increased risk of developing transaminitis. Renal function and hepatic function was not associated with the development of transaminitis. There was no significant difference in length of stay and mortality. Conclusions Transaminitis occurred in 23.6% of our study population and was associated with patients who were older and had a larger mean %TBSA burn. Older pediatric patients with larger burns who are receiving oxandrolone should be closely monitored for the development of transaminitis. Applicability of Research to Practice Future research is needed to identify appropriate monitoring and management of transaminitis in oxandrolone-treated pediatric burn patients.

Undiagnosed Pheochromocytoma Presenting as a Pancreatic Tumor: A Case Report.

Pheochromocytoma is a rare catecholamine-producing tumor of the adrenal gland. Patients with known pheochromocytoma undergoing surgery require preoperative treatment with alpha-blockers to reduce the risk of intraoperative complications related to catecholamine release. If undiagnosed, pheochromocytoma can lead to life-threatening surgical complications. We report the case of a patient with a suspected solid pseudopapillary neoplasm in the pancreatic tail, for whom pancreatoduodenectomy was scheduled. However, shortly after abdominal incision, hypertensive crisis developed and was followed by severe hypotension requiring intravenous vasopressors, which prompted discontinuation of the operation. Further diagnostic evaluation revealed marked elevations in urinary excretion of methylated catecholamines and suggested that the tumor was in fact a pheochromocytoma extending from the left adrenal gland. After preoperative treatment with doxazosin, the patient underwent lateral transperitoneal laparoscopic adrenalectomy, with no major complications and an uneventful postoperative course. The pathological report confirmed a diagnosis of pheochromocytoma. Due to the potential for life-threatening surgical complications in patients with pheochromocytoma not treated preoperatively with alpha-blockers, this tumor type should be included in the differential diagnosis of abdominal tumors of unknown origin.

Bundle Adherence of Intravenous Antibiotic Fluid Resuscitation and Vasopressor in Children with Severe Sepsis or Septic Shock.

ABSTRACTObjectiveThe aim of this study was to measure the effects of a bundle of interventions in children admitted with severe sepsis or septic shock in the first hour after diagnosis on mortality.Materials and methodsA retrospective study was conducted at a pediatric intensive care unit (PICU) between January 2014 and January 2016. Three interventions (intravenous [IV] antibiotic, fluid boluses, and vasopressor administration) applied in the first hour of severe sepsis or septic shock diagnosis were analyzed according to their adherence rates. The main outcome was mortality. Odds ratios were calculated.ResultsOf a total of 530 PICU admissions, 105 patients met the criteria for sepsis, 53 (50.5%) with severe sepsis and 52 (49.5%) with septic shock. Seventy-two (68.6%) patients received IV antibiotic within the first hour, 65 (61.9%) received IV fluid bolus, and 55 (53.3%) received a vasopressor drug. Fifty-two (49.5%) patients received concomitant IV antibiotics and fluid bolus. Blood cultures were collected before IV antibiotic administration in 87 (82.9%) out of 105 patients. Thirteen (12.4%) patients died, 1 with severe sepsis and 12 with septic shock. In a univariate analysis, the odds ratios for death and IV antibiotic were 6.39 (p value = 0.081, 95% CI = 0.795–51.465), 4.77 for fluid bolus between 21 and 40 mL/kg (p value = 0.013, 95% CI = 1.395–16.336), and 3.23 for vasopressor administration (p value < 0.0001, 95% CI = 1.734–6.018). In a multivariate analysis, the odds ratio of fluid bolus between 21 and 40 mL/kg was 42.66 (p value = 0.005, 95% CI = 3.117–583.841) and noradrenaline use was 23.93 (p value = 0.010, 95% CI = 2.124–269.750).ConclusionAdherence was observed for more than half of the single interventions as IV antibiotic, fluid resuscitation, and vasopressor administration in the first hour. The antibiotic administration alone was not associated with high mortality. Vasopressor administration was related to higher mortality but moderate fluid bolus was a protective factor associated with lower mortality.How to cite this articleBarboza CL, Valete COS, da Silva ARA. Bundle Adherence of Intravenous Antibiotic Fluid Resuscitation and Vasopressor in Children with Severe Sepsis or Septic Shock. Indian J Crit Care Med 2020;24(2):128–132.

Outcomes of Cardiopulmonary Resuscitation in Patients Who Experience a Cardiac Arrest While on Intravenous Vasopressor Support (S749)

Outcomes of Cardiopulmonary Resuscitation in Patients Who Experience a Cardiac Arrest While on Intravenous Vasopressor Support (S749)

P1297 Rupture of a Broken Heart: A rare case of acute mitral regurgitation due to papillary muscle rupture complicating Takotsubo cardiomyopathy

Abstract Clinical Case An 89-year old lady presented with symptoms of chest pain and dyspnea, without a significant cardiovascular history, regular medical therapy nor any cardiac risk factors. The electrocardiogram (ECG) demonstrated hyper-acute T waves, and moderate troponin T elevation which peaked at 998 ng/ml. Transthoracic echocardiography (TTE) demonstrated apical ballooning, with hyperdynamic function of the basal left ventricle (LV). These findings were suggestive of a diagnosis of Takotsubo’s cardiomyopathy (TTC), further supported by the coronary angiogram, which confirmed the absence of obstructive coronary artery disease. Notably, her symptoms had not occurred in the setting of emotional or physical stress. The initial recovery was uncomplicated, with no recurrence of symptoms, arrhythmias or cardiac failure. Five days after her presentation, she suddenly experienced severe chest pain and dyspnea associated with profound hypotension. The ECG demonstrated widespread, deep T wave inversion which had evolved over the preceding days, without new ischaemic ST segment changes. Bedside TTE demonstrated severe eccentric mitral regurgitation (MR) with an anteriorly directed jet, not present on earlier TTE, and a hyperdynamic LV. Stability was re-established with intravenous vasopressors, and subsequently with an intra-aortic balloon pump. Transoesophageal echocardiography to evaluate the aetiology of the acute MR demonstrated rupture of the antero-medial papillary muscle with a resultant flail posterior mitral valve leaflet. She was managed with a palliative, non-surgical approach following consideration of her advanced age, frailty, and wishes, and passed away the following day. Discussion TTC is characterized by transient LV impairment, typically due to apical ballooning, with a modest troponin elevation and ECG changes that can mimic acute myocardial infarction. There is, however, an absence of obstructive coronary artery disease. It is most common in post-menopausal females. The overall prognosis is favourable, but can be complicated by cardiac failure, ventricular arrhythmias, and thrombo-embolic phenomena, which carry a significant in-hospital mortality. Rarely, acute MR due to systolic anterior motion of the mitral valve with LV outflow tract obstruction can complicate TTC. Acute MR due to papillary muscle rupture, as in this case, is unusual and has only been reported on a few occasions. The mechanism is not well understood as this pathology is usually found in the context of myocardial infarction, which is excluded on coronary angiography as part of the diagnostic evaluation TTC. Two potential mechanisms have been proposed. As is the case in dilated cardiomyopathy, dilatation of the LV in TTC may create abnormal tension on the tendinae chordae and papillary muscle, or microvascular ischaemia, which has been postulated as a cause for TTC, either of which may then lead to spontaneous papillary muscle rupture. Abstract P1297 Figure.

101 “Could Venovenous ECMO be a Rescue Tool During Left Ventricular Assistant Device (LVAD) Implantation?”

48-year-old gentleman with past history of non-ischemic severely dilated cardiomyopathy, AF and S/P CRT-D who was transferred to us for consideration of advanced heart failure therapies. Cardiogenic shock with multi-organs dysfunction including renal failure, hepatic failure and cerebral hypo-perfusion in spite of high doses of intravenous inotropes and vasopressors. He was started on VA ECMO to provide full hemodynamic support as a bridge to decision and one-week later LVAD was inserted due to persistent requirement for high doses of inotropes and vasopressors despite VA ECMO (INTERMACS 1). Intraoperative, the technical component of LVAD implantation was uncomplicated but the patient developed severe and persistent hypoxia due to pulmonary oedema with associated difficulty in ventilation and his intraoperative TEE at that time showed moderate RV systolic dysfunction and moderate pulmonary HTN. The decision was made to initiate VV-ECMO which immediately improved his oxygenation, ventilation, RV systolic function and PA pressures. Frequent bedside echos were done to evaluate the pulmonary artery pressure and RV dimensions and systolic function to decide removal of VV ECMO. His VV ECMO has been successfully removed successfully in the 5th day. vv-ECMO provides respiratory without circulatory support and its use in acute respiratory failure showed improved survival rate. In our patient, vv-ECMO was very helpful to pass the acute respiratory failure phase. CRRT: Continuous Renal Replacement Therapy, CRT-D: Cardiac Resynchronization Therapy with Defibrillator Therapy, INTERMACS: Inter-agency Registry for Mechanically Assisted Circulatory Support, LVAD: Left Ventricular Assist Device.

P714 Contradicting the most basic tenet of black holes: light can, indeed, escape

Abstract A 69-year-old man with history of non-insulin-treated type 2 diabetes mellitus, arterial hypertension and mixed dyslipidemia presented to the emergency department with chest pain lasting for four days. Immediate twelve-lead electrocardiogram unveiled an inferior ST-segment elevation myocardial infarction (STEMI), prompting emergent coronary angiography, which, in turn, revealed two-vessel disease, specifically proximal ramus intermedius 60-70% stenosis and proximal right coronary artery acute occlusion. Culprit lesion was successfully managed with balloon angioplasty and a single drug-eluting stent implantation. Still, clinical course was noticeable for deterioration, under the form of cardiogenic shock, which required invasive ventilation and intravenous vasopressor support with norepinephrine. Despite biventricular systolic function relative preservation, transthoracic echocardiography disclosed inferior akinesis, right ventricle dilation, mild circumferential pericardial effusion and, particularly, a 2.3cm posteroinferior ventricular septal defect (VSD), in the setting of a 4.4cm2 pseudoaneurism, resulting in left-to-right shunting, quantified through maximal/mean trans-VSD pressure gradients of 84/44mmHg. Further imaging with transesophageal echocardiography and cardiac computed tomography angiography allowing the conception of a 3D-printed model was performed. Surgical correction of the defect followed, achieving partial anatomic success, namely with residual shunting, as of a left ventricular systolic pressure of 80mmHg and a right ventricular systolic pressure of 25mmHg. Patient survived, recovered and got discharged three weeks later. At one-year follow-up, he was hospitalized for acute decompensated heart failure (hemodynamic profile C) twice, with medication non-adherence reported as the main precipitating factor. In addition to a significant remaining left-to-right shunt (maximal velocity 3m/s), adverse cardiac remodeling was recognized, featuring left ventricular ejection fraction of 30-35%, severe functional mitral regurgitation, severe postcapillary pulmonary hypertension and de novo left bundle branch block (QRS duration of 197ms). Having been deemed clinically unsuitable for another surgical correction, patient underwent percutaneous VSD closure with both AmplatzerTM septal and muscular VSD occluders, with a suboptimal result. He is now on New York Heart Association class III heart failure and on the waiting list for both MitraClip and cardiac resynchronization therapy implantation. Reflecting numerous breakthroughs in the management of acute myocardial infarction, incidence of mechanical complications is on the decline. Nevertheless, when they occur, morbidity and mortality remain high. Acquired ventricular septal defects are no exception, demanding the best care from a tertiary hospital heart team. Abstract P714 Figure.

59: qSOFA: Modifications for identifying sepsis in obstetrical patients

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Recognizing the prognostic shortcomings of SIRS-based definitions, a new system termed Sequential Organ Failure Assessment (SOFA) was developed. Quick SOFA (qSOFA) was created to identify patients at risk for poor outcomes outside of the intensive care unit setting. While there is evidence that SOFA and qSOFA are superior to SIRS in non-pregnant patients, they have not been validated in the pregnant population. A retrospective cohort study was done examining pregnant patients admitted to a single institution with severe infections. The primary outcome was defined as a composite of any of the following adverse outcomes: ICU admission for > 48 hours, need for invasive monitoring (central line or arterial line), intubation, use of intravenous vasopressors or inotropes, and maternal death. Vital signs were collected during the time of triage. Receiver Operating Characteristic (ROC) curves were constructed based on all patients in the study population. The study patients were divided into two groups: those who did or did not develop the primary outcome of interest. Then various modifications of qSOFA were evaluated (with ROC curves) to determine if any could accurately predict which patients would develop the primary outcome. A total of 104 subjects were included in the analysis, with 32 subjects having the primary outcome of interest. The actual q-SOFA (RR > 22, SBP < 100 or altered mental status (AMS)) performs very poorly in pregnancy. ROC analysis found that values in pregnancy which predicted adverse outcomes were RR ≥35 or SBP< 85 or presence of AMS. The area under this ROC curve was 0.781, (p< 0.001, sensitivity 81.2%, specificity 75%). The current qSOFA criteria is a poor predictor of adverse outcomes in pregnant patients with sepsis. Adverse outcomes in pregnant patients were better predicted using RR ≥35, SBP< 85 or AMS. Using these values, modified criteria "qSOFA-P" could be used to better predict adverse outcomes in pregnant patients with sepsis.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Emergent airway management of the critically ill patient: current opinion in critical care.

To describe techniques to facilitate safe intubation in critically ill patients. Despite advances in the treatment of critically ill patients, endotracheal intubation remains a high-risk procedure associated with complications that can lead to appreciable morbidity and mortality. In addition to the usual anatomical factors that can predict a difficult intubation, incorporating pathophysiological considerations and crisis resource management may enhance safety and mitigate risk. Enhancing preoxygenation with high-flow oxygen or noninvasive ventilation, the early use of intravenous fluids and/or vasopressors to prevent hypotension and videolaryngoscopy for first pass success are all promising additions to airway management.Facilitating intubation by either sedation with paralysis or allowing patients to continue to breathe spontaneously are reasonable options for airway management. These approaches have potential advantages and disadvantages. Recognizing the unique challenges of endotracheal intubation in critically ill patients is paramount in limiting further deterioration during this high-risk procedure. A safe approach to intubation focuses on recognizing risk factors that predict challenges in achieving an optimal view of the glottis, maintaining optimal oxygenation, and minimizing the risks and benefits of sedation/induction strategies that are meant to facilitate intubation and avoid clinical deterioration.

Predictors and Clinical Outcomes of Vasoplegia in Patients Bridged to Heart Transplantation With Continuous-Flow Left Ventricular Assist Devices.

BackgroundThe presence of a durable left ventricular assist device (LVAD) is associated with increased risk of vasoplegia in the early postoperative period following heart transplantation (HT). However, preoperative predictors of vasoplegia and its impact on survival after HT are unknown. We sought to examine predictors and outcomes of patients who develop vasoplegia after HT following bridging therapy with an LVAD.Methods and ResultsWe identified 94 patients who underwent HT after bridging with continuous‐flow LVAD from 2008 to 2018 at a single institution. Vasoplegia was defined as persistent low vascular resistance requiring ≥2 intravenous vasopressors within 48 hours after HT for >24 hours to maintain mean arterial pressure >70 mm Hg. Overall, 44 patients (46.8%) developed vasoplegia after HT. Patients with and without vasoplegia had similar preoperative LVAD, echocardiographic, and hemodynamic parameters. Patients with vasoplegia were significantly older; had longer LVAD support, higher preoperative creatinine, longer cardiopulmonary bypass time, and higher Charlson comorbidity index; and more often underwent combined organ transplantation. In a multivariate logistic regression model, older age (odds ratio: 1.08 per year; P=0.010), longer LVAD support (odds ratio: 1.06 per month; P=0.007), higher creatinine (odds ratio: 3.9 per 1 mg/dL; P=0.039), and longer cardiopulmonary bypass time (odds ratio: 1.83 per hour; P=0.044) were independent predictors of vasoplegia. After mean follow‐up of 4.0 years after HT, vasoplegia was associated with increased risk of all‐cause mortality (hazard ratio: 5.20; 95% CI, 1.71–19.28; P=0.003).ConclusionsOlder age, longer LVAD support, impaired renal function, and prolonged intraoperative CPB time are independent predictors of vasoplegia in patients undergoing HT after LVAD bridging. Vasoplegia is associated with worse prognosis; therefore, detailed assessment of these predictors can be clinically important.

MIDODRINE-INDUCED BRADYCARDIA IN CRITICALLY ILL PATIENT

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Midodrine is alpha-1 agonist agent, which is used in the ICU to accelerate weaning off IV pressors. Midodrine may cause bradycardia which can worsen hypotension and increase the requirement for vasopressors. CASE PRESENTATION: A 67 years old female with a past medical history of Multiple Sclerosis and recurrent UTI, was admitted from a nursing home complaining of lower abdominal pain, dysuria, fever and chills for two days. She had a temperature of 101 F, Heart rate of 110 bpm and her BP was 90/60 mmHg. Her physical exam was remarkable for suprapubic and right costophrenic angle tenderness. Her UA was positive for bacteria and nitrates and a CT scan of the abdomen showed a 7 mm stone in the right ureteropelvic junction with hydronephrosis. The patient was treated with broad-spectrum antibiotics and a percutaneous right nephrostomy tube. However, the patient remained hypotensive requiring pressors. After 2 days the patient continued to be Norepinephrine dependent. She received 2 doses of Midodrine 5mg, 8 hours apart, shortly after the second dose the patient developed sinus bradycardia with HR of 40 bpm, and her vasopressor requirement increased. She was switched from Norepinephrine to Dopamine and Midodrine was stopped. The patient was off Dopamine within 18 hours and her heart rate stabilized in the 70s. DISCUSSION: Midodrine is an oral agent with alpha 1-agonist properties with the same mechanism of action as phenylephrine. The drug is indicated in hepatorenal syndrome, autonomic dysfunction, and dialysis-induced hypotension. Recently, Midodrine use in the ICU has been increasing as a way to liberate the patient from Intravenous vasopressors and shorten the ICU length of stay. Reflex bradycardia, is an uncommon side effect of Midodrine use through its effect on the baroreceptors, it`s usually transient and uncommon at therapeutic doses, however in our patient the bradycardia was prolonged and required the use of Dopamine. CONCLUSIONS: Midodrine can facilitate weaning from IV vasopressors; however bradycardia is a potential side effect that requires discontinuation of the drug and may prolong the need for vasopressors. Reference #1: L. Y. Wong. Severe Hypertension and Bradycardia Secondary to Midodrine Overdose. J Med Toxicol. 2017 Mar; 13(1): 88–90. Reference #2: Anstey et al Midodrine as adjunctive support for treatment of refractory hypotension in the intensive care unit: a multicenter, randomized, placebo-controlled trial (the MIDAS trial BMC Anesthesiology March 2017. Reference #3: Levine AR et al, Oral midodrine treatment accelerates the liberation of intensive care unit patients from intravenous vasopressor infusions. J Crit Care. 2013 Oct;28(5):756-62. DISCLOSURES: No relevant relationships by nagham jafar, source=Web Response No relevant relationships by William McGee, source=Web Response

1924 Bleeding Beyond the Line: Anorectal Melanoma as a Cause of Lower Gastrointestinal Bleeding

INTRODUCTION: Anorectal melanoma is a rare malignancy that can present as hematochezia similar to other gastrointestinal bleeding sources. The diagnosis of anorectal melanoma may be challenging given its rarity, nonspecific presentation, and need for histopathology, but accurate and timely diagnosis is essential given that associated bleeding may not respond to conventional treatments. CASE DESCRIPTION/METHODS: An 88-year-old male was admitted for septic shock after being found lethargic at his nursing facility. He was started on intravenous antibiotics and vasopressors and intubated for airway protection. Though slowly improving overall, on hospital day 6, he had 4 episodes of large red clots per rectum. Rectal examination showed bright red blood and a rubbery mass palpable on the posterior rectal wall without visible hemorrhoids. Due to the acute drop in hemoglobin to 6.3 g/dL, the patient was transfused 2 units of packed red blood cells, empirically started on intravenous pantoprazole, and administered parenteral Vitamin K and a dose of desmopressin. Over the next two days, the patient continued to have multiple bowel movements with blood clots requiring additional blood transfusions. Given these findings, the patient underwent flexible sigmoidoscopy. DISCUSSION: Flexible sigmoidoscopy revealed a 3 cm ulcerated mass in the distal rectum which involved the dentate line. Endoscopic hemostasis was not feasible, but a biopsy was obtained which showed malignant melanoma invading the lamina propria and muscularis with associated ulceration. Considering the patient's age, clinical status, and advanced dementia, the medical team and unrepresented patient committee agreed that it was ethically appropriate to not pursue further work-up or treatment of the patient's melanoma. Following medical stabilization, the patient was transitioned to home comfort care. This case illustrates a rare etiology of bright red blood per rectum and the importance of additional investigation in the setting of clinically significant anemia and/or inadequate response to conservative measures. Anorectal melanoma, similar to other rare disorders which can mimic internal hemorrhoidal bleeding, frequently requires endoscopic techniques for diagnosis and management. Despite this patient's clinical course and the generally poor prognosis of anorectal melanoma, early diagnosis can allow for surgical excision and/or adjuvant therapies that may provide a potentially curative outcome or delay disease progression and mitigate bleeding complications.

A HAIR OF THE DOG THAT BIT YOU: A CASE OF PASTEURELLA BACTEREMIA

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Pasteurella is a Gram-negative coccobacillus that is commonly transmitted from cat and dog bites, and causes a wide spectrum of diseases in humans. With more people keeping pets, there is an increased risk of possible infection with zoonotic organisms. Here, we present a case of septic shock caused by Pasteurella bacteremia. CASE PRESENTATION: A 59 year-old female with no known medical history and no medical follow-up presented with her dog following a motor vehicle accident. Vitals revealed hypotension, atrial fibrillation with rapid ventricular response, fever, and respiratory distress. Physical exam revealed multiple open wounds on her lower extremities with clinical signs of cellulitis. She was intubated for hypoxic respiratory failure and found to have combined distributive and cardiogenic shock, aortic stenosis and insufficiency, and pulmonary edema. The patient was admitted to the Intensive Care Unit where she received intravenous vasopressors, Vancomycin and Piperacillin/Tazobactam. Blood cultures were positive for gram-negative rods, and speciation revealed Pasteurella multocida. She was transitioned to Ceftriaxone and steadily improved. She was eventually weaned off vasopressor support, extubated, and transferred to the general medical floors. DISCUSSION: The most common infections caused by Pasteurella multocida are local wound infections following animal bites or scratches. Cats are the source of infection in 60-80% of cases and dogs in the majority of the remainder. While local skin infections are the most common result of Pasteurella multocida, bacteremia has been shown to occur in 25-50% of patients with pneumonia, meningitis, and septic arthritis. Severe Pasteurella infections are uncommon and appear more frequently in elderly patients and those with underlying chronic diseases such as cardiovascular disease, diabetes mellitus, AIDS, malignancy, cirrhosis and chronic kidney disease. Studies have shown 70% of systemic infections in those greater than 50 years of age and 21% in ages 20-50 years. In our patient’s case, it is suspected that the route of infection was via the skin, as the patient’s dog was witnessed to be licking her lower extremity wounds. Mortality in severe disease (i.e. septicemia) is estimated to be roughly 28%. This case is unique in that our patient had no signs of immunocompromise, but given undiagnosed coronary artery disease, she may have had increased susceptibility to developing severe infection. CONCLUSIONS: Adequate hygiene is essential in preventing transmission from pets. Due to the high mortality of severe Pasteurella infection, and the increasing number of pets, it is important to have a high suspicion for pet-related infections. Reference #1: Fajfar-Whetstone, C. J., et al. "Pasteurella multocida septicemia and subsequent Pasteurella dagmatis septicemia in a diabetic patient.” Journal of clinical microbiology 33.1 (1995): 202-204 DISCLOSURES: No relevant relationships by George Elkomos-Botros, source=Web Response No relevant relationships by Ayelet Hilewitz, source=Web Response No relevant relationships by Sameer Khanijo, source=Web Response

Clinical Implementation of Novel Spinal Cord Perfusion Pressure Protocol in Acute Traumatic Spinal Cord Injury at U.S. Level I Trauma Center: TRACK-SCI Study

We sought to report the safety of implementation of a novel standard of care protocol using spinal cord perfusion pressure (SCPP) maintenance for managing traumatic spinal cord injury (SCI) in lieu of mean arterial pressure goals at a U.S. Level I trauma center. Starting in December 2017, blunt SCI patients presenting <24 hours after injury with admission American Spinal Injury Association Impairment Scale (AIS) A-C (or AIS D at neurosurgeon discretion) received lumbar subarachnoid drain (LSAD) placement for SCPP monitoring in the intensive care unit and were included in the TRACK-SCI (Transforming Research and Clinical Knowledge in Spinal Cord Injury) data registry. This SCPP protocol comprises standard care at our institution. SCPPs were monitored for 5 days (goal ≥65 mm Hg) achieved through intravenous fluids and vasopressor support. AISs were assessed at admission and day7. Fifteen patients enrolled to date were aged 60.5 ± 17 years. Injury levels were 93.3% (cervical) and 6.7% (thoracic). Admission AIS was 20.0%/20.0%/26.7%/33.3% for A/B/C/D. All patients maintained mean SCPP ≥65 mm Hg during monitoring. Fourteen of 15 cases required surgical decompression and stabilization with time to surgery 8.8 ± 7.1 hours (71.4% <12 hours). At day 7, 33.3% overall and 50% of initial AIS A-C had an improved AIS. Length of stay was 14.7 ± 8.3 days. None had LSAD-related complications. There were 7 respiratory complications. One patient expired after transfer to comfort care. In our initial experience of 15 patients with acute SCI, standardized SCPP goal-directed care based on LSAD monitoring for 5 days was feasible. There were no SCPP-related complications. This is the first report of SCPP implementation as clinical standard of care in acute SCI.