Persistent Shock Research Articles

Shock persistency to material consumption, renewable and non-renewable energy resources? A (non)linear evidence from the highest carbon emitting countries

With the need to provide more evidence on the possibility of reducing material resources utilization and dependency i.e., improving material resources efficiency, this study considers 10 countries with the largest cumulative emissions over centuries (Brazil, Canada, China, France, Germany, India, Indonesia, Japan, the UK, and the USA) by employing the linear and non-linear unit root tests with the Fourier function and dataset that covers centuries (1850–2021). Specifically, domestic material consumption was implemented for the period 1970-2019, and 1965-2021 for renewable and non-renewable energy resources. Given the linearity and non-linearity evidence, the investigation reveals whether there is persistent or transitory shock in domestic material consumption, renewable energy (REC), and non-renewable energy sources (REC). For (linearity) unit root test evidence, there are transitory shocks in domestic material consumption only in China, France, Indonesia, and Japan, for China, France, India, Japan, England, and the USA in REC, and in all the countries except Brazil, Canada, Germany, and Indonesia for the NREC series. On the ground of (non-linearity) unit root test, the result reveals that shocks to non-renewable energy consumption are temporary only for Canada, Japan, and the USA and the shocks to renewable energy and domestic material consumptions are permanent in all the examined countries. Indeed, the outcome of these findings offers important knowledge to decision makers on how to carefully develop and implement transitory and persistence policy choices.

New Insights into the Persistent Shock Resistance of Anaerobic Granular Sludge Based on Quorum Sensing Regulation: A Novel Gene Regulatory Mechanism

New Insights into the Persistent Shock Resistance of Anaerobic Granular Sludge Based on Quorum Sensing Regulation: A Novel Gene Regulatory Mechanism

Efficacy and outcomes of rescue screws in unstable pelvic ring injuries - A retrospective matched cohort study.

The emergency treatment of unstable pelvic ring injuries is still a challenge and requires surgical and anesthesiological resuscitation. Emergency fixation of the unstable pelvic ring with percutaneous sacroiliac (SI) screws, also known as "Rescue Screws", is an established treatment method. The aim of our study was to compare the outcome and complication rates of "Rescue Screws" with elective SI-screw fixations. A 1:1 ratio nearest-neighbor matched, retrospective cohort study of trauma patients with acute pelvic ring injuries at a level one trauma center was performed. Patients ≥ 15 years, treated with SI-screw fixation were included. pathologic fractures, missing consent and navigated procedures. The primary outcome parameters was defined as SI-screw revision operations. Patients were stratified according to treatment strategy (RS: Rescue Screws; EL: elective SI-screws). From 392 patients identified between 11/2014 and 08/2021, 186 met the inclusion criteria with 41 in the RS Group and 145 in the EL group. After matching, 41 patients were included in each group with similar baseline characteristics except persistent hemodynamic shock (RS: n = 22 (53.37%) vs. EL: n = 1 (4.3%), p < 0.001). Surgical characteristics were comparable in terms of instrumentation levels and insertion-sites. No significant differences were observed in the outcome parameters (revisions, reoperations, implant-associated complications, LOS and mortality) between both groups. Treatment of unstable pelvic ring fractures with Rescue Screws appears as a feasible treatment option for emergency stabilization. Rescue Screws are not associated with elevated revision rates and increased complications rates. This minimally invasive technique enables safe emergency stabilization of the posterior pelvic ring. Prospective or randomized clinical trials are required to directly compare Rescue Screws with other competing emergency stabilization techniques.

Trend inflation and exchange rate dynamics: A new Keynesian approach

This study examines the exchange rate implications of trend inflation within a two-country New Keynesian (NK) model. An NK Phillips curve generalized by trend inflation makes the inflation differential smoother, more persistent, and less sensitive to the real exchange rate. A Bayesian analysis with post-Bretton Woods data for Canada and the U.S. shows that the model's equilibrium, which relies on Taylor rules with a persistent trend inflation shock and strong policy inertia, mimics empirical regularities in exchange rates that are difficult to reconcile within a standard NK model. Trend inflation helps explain the empirical puzzles of the exchange rate dynamics.

Political governance and urban systems: A persistent shock on population distribution from capital relocation in ancient China

This paper exploits a quasi-natural experiment with the exogenous shock of capital relocation in ancient China from Nanjing to Beijing in 1421 CE during the Ming Dynasty, to investigate the relationship between political governance and urban systems. We constructed a unique historical panel dataset that measures population distributions among Chinese counties spanning over centuries. Using a difference-in-differences identification strategy, our results reveal that after the capital relocation, the effect of localities' distance to Beijing, the newly established capital at that time, on local population size turns to be significantly negative. Moreover, these effects still persisted in the next dynasty and modern China. Furthermore, the results indicate that the impact of the capital relocation on population distribution occur through two major channels of political governance: delivery and national security. The causal relationship between capital relocation and population distribution is demonstrated to be robust using a variety of identification strategies and robustness checks.

Biomarker Assessment of a High-Risk, Data-Driven Pediatric Sepsis Phenotype Characterized by Persistent Hypoxemia, Encephalopathy, and Shock.

Identification of children with sepsis-associated multiple organ dysfunction syndrome (MODS) at risk for poor outcomes remains a challenge. We sought to the determine reproducibility of the data-driven "persistent hypoxemia, encephalopathy, and shock" (PHES) phenotype and determine its association with inflammatory and endothelial biomarkers, as well as biomarker-based pediatric risk strata. We retrained and validated a random forest classifier using organ dysfunction subscores in the 2012-2018 electronic health record (EHR) dataset used to derive the PHES phenotype. We used this classifier to assign phenotype membership in a test set consisting of prospectively (2003-2023) enrolled pediatric septic shock patients. We compared profiles of the PERSEVERE family of biomarkers among those with and without the PHES phenotype and determined the association with established biomarker-based mortality and MODS risk strata. Twenty-five PICUs across the United States. EHR data from 15,246 critically ill patients with sepsis-associated MODS split into derivation and validation sets and 1,270 pediatric septic shock patients in the test set of whom 615 had complete biomarker data. None. The area under the receiver operator characteristic curve of the modified classifier to predict PHES phenotype membership was 0.91 (95% CI, 0.90-0.92) in the EHR validation set. In the test set, PHES phenotype membership was associated with both increased adjusted odds of complicated course (adjusted odds ratio [aOR] 4.1; 95% CI, 3.2-5.4) and 28-day mortality (aOR of 4.8; 95% CI, 3.11-7.25) after controlling for age, severity of illness, and immunocompromised status. Patients belonging to the PHES phenotype were characterized by greater degree of systemic inflammation and endothelial activation, and were more likely to be stratified as high risk based on PERSEVERE biomarkers predictive of death and persistent MODS. The PHES trajectory-based phenotype is reproducible, independently associated with poor clinical outcomes, and overlapped with higher risk strata based on prospectively validated biomarker approaches.

Modes of Death in Patients with Cardiogenic Shock in the Cardiac Intensive Care Unit: A Report from the Critical Care Cardiology Trials Network

BackgroundThere are limited data on how patients with cardiogenic shock (CS) die. MethodsThe Critical Care Cardiology Trials Network is a research network of cardiac intensive care units coordinated by the Thrombolysis In Myocardial Infarction (TIMI) Study Group (Boston, MA). Using standardized definitions, site investigators classified direct modes of in-hospital death for CS admissions (October 2021 to September 2022). Mutually exclusive categories included 4 modes of cardiovascular death and 4 modes of noncardiovascular death. Subgroups defined by CS type, preceding cardiac arrest (CA), use of temporary mechanical circulatory support (tMCS), and transition to comfort measures were evaluated. ResultsAmong 1068 CS cases, 337 (31.6%) died during the index hospitalization. Overall, the mode of death was cardiovascular in 82.2%. Persistent CS was the dominant specific mode of death (66.5%), followed by arrhythmia (12.8%), anoxic brain injury (6.2%), and respiratory failure (4.5%). Patients with preceding CA were more likely to die from anoxic brain injury (17.1% vs 0.9%; P < .001) or arrhythmia (21.6% vs 8.4%; P < .001). Patients managed with tMCS were more likely to die from persistent shock (P < .01), both cardiogenic (73.5% vs 62.0%) and noncardiogenic (6.1% vs 2.9%). ConclusionsMost deaths in CS are related to direct cardiovascular causes, particularly persistent CS. However, there is important heterogeneity across subgroups defined by preceding CA and the use of tMCS.

Crystalloid Fluid Management of Non-Traumatic Hypotension by New South Wales Ambulance

Introduction Shock is circulatory insufficiency, inadequate oxygen delivery, and cellular hypoxia. Intravenous fluids are essential for shock management. Despite treatment, patients can face persistent shock with ongoing hypotension, contributing to higher mortality. This analysis aims to quantify hypotensive non-traumatic cases in an Australian ambulance service, determine persistent hypotension prevalence, and assess paramedic-administered intravascular fluids’ impact on blood pressure changes. Methods This study is a retrospective analysis of prehospital fluid resuscitation by New South Wales Ambulance paramedics during 2022. Hypotension is defined as a systolic blood pressure of ≤ 90 mmHg, and persistent hypotension is a systolic blood pressure consistently below 90 mmHg across all observations, with a final blood pressure below 90 mmHg. This study aimed to determine the volume of fluid resuscitation at which a plateau in population-level systolic blood pressure response is observed, by calculating the derivative of the fitted logistic regression model. Moreover, this analysis identified the relative contribution of factors influencing the probability of an attempt at intravenous or intraosseous access using machine learning. Results Among 796,865 attendances, 23,049 (2.9%) involved non-traumatic patients with hypotension. In total 7,388 (32.1%) of the hypotensive cases resulted in persistent hypotension, of which 3,235 (43.8%) received Hartmann’s solution and 1,745 (53.9%) received at least 500 ml of fluids but still had hypotension. The model showed that systolic blood pressure tends to stop increasing after 500–600 milliliters of fluid are given. This suggests that, on average, giving more fluid than this may not raise blood pressure further in a prehospital setting, though individual patient needs can differ. The top four factors from the machine learning shows that as initial respiratory rate goes up, the probability of intravascular access rises. Transport times less than 20 min are associated with a smaller chance of access and younger patients are less likely to receive an attempt. Finally, extremes of systolic blood pressure are more likely to receive access attempts. Conclusion This study found that three percent of non-traumatic attendances have at least one episode of hypotension, and that more than half of these have persistent hypotension. Only 44% of persistently hypotensive received fluids, and half of persistently hypotensive patients stayed hypotensive despite a reasonable volume of prehospital crystalloids.

Heterotopic pregnancy after a single embryo transfer with successful perinatal outcome: case report and literature review

A heterotopic pregnancy is a rare and serious pathological pregnancy. In this paper, we report a rare case of heterotopic pregnancy and perform a literature review. A 30-year-old patient with a history of left adnexectomy presented with persistent lower abdominal pain and hemorrhagic shock after single embryo transfer. Emergency laparoscopic exploration revealed a ruptured mass in the right isthmus of the fallopian tube, for which right salpingectomy was performed. After anti-inflammatory treatment and fetal preservation, the intrauterine pregnancy progressed smoothly, and a healthy baby was delivered at 39 weeks gestation. In this case, the patient’s heterotopic pregnancy was possibly due to a natural pregnancy caused by sexual intercourse during treatment, so we recommend that sexual intercourse be avoided during transfer cycles.

CAO Recovered in the General Intensive Care Unit: Epidemioclinical Characteristics and Mortality Factors in a Sub-Saharan African Country

Background: Cardiac arrest in the operating room (CAO) is a serious accident of often rare epidemiology.&#x0D; Methods: Retrospective, descriptive and analytical study from 2012 to 2021 in the multipurpose intensive care unit of the Cocody University Hospital in Abidjan, including all patients who presented a recovered CAO.&#x0D; Results: The prevalence was 1.5% (89 out of 5730 admissions). The mean age was 33.5 ± 26 years (13-81). The sex ratio was 0.1. The medical history was mostly hypertension (22.5%). Patients were classified ASA ≥ III (52.8%) for urgent surgery (52.8%) under spinal anesthesia (56.6%). CAO occurred mostly at anesthetic induction (44.3%). The causes were mainly persistent arterial hypotension (54.7%) and hemorrhagic shock (30.2%). Medical CPR was performed in 94.8% of cases in the operating room before transfer to the intensive care unit. The mean duration of LowFlow was 4.5±1.8 minutes (3-12). On admission, the mean Glasgow score was 6.3±4.4 (3-11). Treatment consisted of continued CPR. The mean stay was 3.1±2.9 minutes (1-12). The death rate was 60.4%. ASA class &gt;3, urgent procedure, general anesthesia, presence of NA alone, Gl score ≤ 7, and Low Flow duration&gt; 5 minutes were predictive of mortality (p &lt; 0.05).&#x0D; Conclusion: strengthening of material resources and continuous training in extreme emergency situations for anesthesia personnel could optimize the prognosis of CAO.

Impact of Intra-Operative Shock and Resuscitation on Surgical Site Infections After Trauma Laparotomy.

Background: Patients undergoing trauma laparotomy experience high rates of surgical site infection (SSI). Although intra-operative shock is a likely contributor to SSI risk, little is known about the relation between shock, intra-operative restoration of physiologic normalcy, and SSI development. Patients and Methods: A retrospective review of trauma patients who underwent emergent definitive laparotomy was performed. Using shock index and base excess at the beginning and end of laparotomy, patients were classified as normal, persistent shock, resuscitated, or new shock. Univariable and multivariable analyses were performed to identify predictors of organ/space SSI, superficial/deep SSI, and any SSI. Results: Of 1,191 included patients, 600 (50%) were categorized as no shock, 248 (21%) as resuscitated, 109 (9%) as new shock, and 236 (20%) as persistent shock, with incidence of any SSI as 51 (9%), 28 (11%), 26 (24%), and 32 (14%), respectively. These rates were similar in organ/space and superficial/deep SSIs. On multivariable analysis, resuscitated, new shock, and persistent shock were associated with increased odds of organ/space SSI (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.3-3.5; p < 0.001) and any SSI (OR, 2.0; 95% CI, 1.4-3.2; p < 0.001), but no increased risk of superficial/deep SSI (OR, 1.4; 95% CI, 0.8-2.6; p = 0.331). Conclusions: Although the trajectory of physiologic status influenced SSI, the presence of shock at any time during trauma laparotomy, regardless of restoration of physiologic normalcy, was associated with increased odds of SSI. Further investigation is warranted to determine the relation between peri-operative shock and SSI in trauma patients.

Observing mechanosensitive channels in action in living bacteria

Mechanosensitive (MS) channels act to protect the cytoplasmic membrane (CM) of living cells from environmental changes in osmolarity. In this report, we demonstrate the use of time-resolved second-harmonic light scattering (SHS) as a means of experimentally observing the relative state (open versus closed) of MS channels in living bacteria suspended in different buffer solutions. Specifically, the state of the MS channels was selectively controlled by changing the composition of the suspension medium, inducing either a transient or persistent osmotic shock. SHS was then used to monitor transport of the SHG-active cation, malachite green, across the bacterial CM. When MS channels were forced open, malachite green cations were able to cross the CM at a rate at least two orders of magnitude faster compared with when the MS channels were closed. These observations were corroborated using both numerical model simulations and complementary fluorescence experiments, in which the propensity for the CM impermeant cation, propidium, to stain cells was shown to be contingent upon the relative state of the MS channels (i.e., cells with open MS channels fluoresced red, cells with closed MS channels did not). Application of time-resolved SHS to experimentally distinguish MS channels opened via osmotic shock versus chemical activation, as well as a general comparison with the patch-clamp method is discussed.

Abstract 18094: Supersaturated Oxygen Therapy Benefits Late Presenters With Anterior ST-Segment Elevation Myocardial Infarction

Introduction: Patients with late-presentation ST-Segment Elevation Myocardial Infarction (STEMI) are at increased risk of mortality and development of heart failure and have limited therapeutic options besides percutaneous coronary intervention (PCI). Hypothesis: Intracoronary supersaturated oxygen therapy (SSO2) (Zoll / Therox) is approved as an adjunctive therapy to PCI in STEMI patients and may reduce infarct size in patients with less than 6 hours of ischemia. However, in pre-clinical studies, the delivery of SSO2 reduces infarct size even when delivered 24 hours following coronary occlusion. We hypothesized that late-presenting anterior STEMI patients may benefit from SSO2 therapy following PCI. Methods: We studied 12 patients (7M, 5F; 60 ± 9 years) with ongoing anterior STEMIs and prolonged ischemic times (12.2 ± 7.6 hrs). Ten of the 12 patients had an occluded LAD on presentation with TIMI 0 flow and 11 patients had anterior q-waves in at least 2 consecutive leads on the presenting EKG. All patients underwent successful PCI of the LAD with DES followed by 60 minutes of SSO2 therapy delivered through a catheter placed in the left main coronary artery. Cardiac MRI measurement of LV function and infarct size was performed in all patients 1 to 3 days later. Results: Mean infarct size was 32 ± 10 % of LV mass. Baseline left-ventricular ejection fraction (LVEF) measured within 24 hours of PCI was 37.8 ± 10.0 %. LVEF improved to 50.2 ± 11.2 % on follow-up imaging performed at a mean of 2 months following PCI (p &lt; 0.01). To date, all patients remain alive and no patients have been admitted for heart failure. One patient underwent LVAD placement during his baseline hospitalization for persistent cardiac shock and another patient underwent bypass surgery 7 months later after having developed in-stent restenosis and progressive CAD. Conclusions: SSO2 therapy can be safely performed in high-risk STEMI patients with prolonged ischemic times who undergo successful PCI and is associated with a significant recovery of LV function when measured several months later.

Abstract 15838: To Tear Again: Recurrent and Complicated Spontaneous Coronary Artery Dissection

Background: SCAD is as an infrequent cause of ACS with a predominance affecting a mean age of 42.6 years and 82% of patients being female. SCAD can be classified as primary or secondary, where primary dissections occur spontaneously, and secondary causes involve the aortic root and are a direct consequence of coronary interventions, surgery, or trauma. Case: 26-year-old female with no previous cardiac or significant family history presented with severe mid-sternal chest pain, radiating to both arms and back, and associated with nausea and cold sweats. Cardiovascular exam was unremarkable. Troponins were elevated at 0.18 and 0.59. Echo showed anteroseptal wall hypokinesis, consistent with Takotsubo cardiomyopathy. ECG showed anterolateral ST elevations. The patient went for cardiac catheterization and had spontaneous dissection of the left main into the LAD/diagonal with 100% occlusion of the LAD and 99% occlusion of the ramus/circumflex. Impella device was implanted due to persistent shock, V. fib., and cardiac arrest. Stents were placed in the proximal, mid, and distal LAD, ramus/circumflex, and LCA. The patient had an LVEF of 25%. Follow-up echo showed an LVEF of 30%, with subsequent Impella removal. Following week, LVEF increased to 45-50%. The patient began aspirin 81 mg, atorvastatin 10 mg, bisoprolol 5 mg, prasugrel 10 mg, and rivaroxaban 10 mg. Over the next few years, she had recurrent chest pain, syncope, palpitations, and a non-viable pregnancy at 12 weeks of gestation due to premature bleeding complications. 3 years after the initial SCAD, the patient presented with spiral dissection of the RCA, requiring three stents. LVEF was 30%. She is being managed with aspirin 81 mg, atorvastatin 20 mg, bisoprolol 10 mg, and prasugrel 10 mg. Discussion: The initial age of presentation of this patient makes this case unique. Risk of recurrent SCAD was present in 17% of patients at a median age of 2.8 years after the initial episode. Triggers for recurrent SCAD include extreme emotional/physical stress and pregnancy. Pregnancy it is not recommended in this patient population. Beta-blockade and adequate BP control are mainstay in medical management and reduce the reoccurrence of SCAD.

Diastolic blood pressure impact on pediatric refractory septic shock outcomes

Septic shock is the progression of sepsis, defined as cardiovascular dysfunction during systemic infection, and it has a mortality rate of 40%-80%. Loss of vascular tone is an important pathophysiological feature of septic shock. Diastolic blood pressure (DBP) was reported to be associated with vascular tone. This study aimed to identify the associations of several hemodynamic indices, especially DBP, with outcome in pediatric septic shock to allow for timely interventions. Children with persistent catecholamine-resistant shock had a pulse index continuous cardiac output (PiCCO®) system implanted for invasive hemodynamic monitoring and were enrolled in the current study. Serial cardiac index, systemic vascular resistance index (SVRI), systolic blood pressure (SBP), mean arterial pressure (MAP), and DBP were recorded during the first 24h following PiCCO® initiation. All hemodynamic parameters associated with 28-day mortality were further analyzed using receiver operating characteristic curve analysis. Thirty-three children with persistent catecholamine-resistant shock were enrolled. The median age was 12 years and the youngest children were 5 years old. Univariate analysis noted that SVRI, SBP, MAP, and DBP were significantly higher, and shock index was significant lower, in survivors compared with non-survivors (p<0.05). In the multivariate analysis, only SVRI and DBP remained independent predictors of 28-day mortality. DBP had the best correlation with SVRI (r=0.718, n=219, p<0.001). The area under the receiver operating characteristic curves of SVRI and DBP for predicting 28-day mortality during the first 24h of persistent catecholamine-resistant shock were >0.75, indicating a good prediction for mortality. DBP correlated well with SVRI and it can serve as a predictor for mortality in pediatric septic shock. Furthermore, DBP was a superior discriminator of mortality when compared with SBP and MAP. A lower DBP was an independent hemodynamic factor associated with 28-day mortality.

Evidence on monetary transmission and the role of imperfect information: Interest rate versus inflation target shocks

We present new empirical evidence on monetary transmission by incorporating two types of shocks – a standard temporary interest rate shock and a persistent inflation target shock. In an estimated DSGE model under imperfect information, where agents may be unable to distinguish these shocks, we find delayed Neo-Fisherian behavior in response to the persistent shock: interest rate and inflation increase, but with a lag. In an empirical VAR model that accounts for such uncertainty in identifying assumptions, we similarly find evidence for positive co-movement of interest rates and inflation in the short aftermath of the persistent shock, however, not on impact. This suggests that, when pursuing a higher inflation target, the central bank needs to engineer an expansionary monetary policy stance by lowering its real interest rate path and also initially lowering the nominal rate to stimulate inflation and inflation expectations.

Multisystem Inflammatory Syndrome in Children Associated with COVID-19 Infection: Clinical Presentation and Outcome

Abstract Objective In the midst of the COVID-19 pandemic, many children presenting with persistent fever, rashes, conjunctivitis, abdominal pain, respiratory distress, and shock were reported and diagnosed with multisystem inflammatory syndrome in children (MIS-C). The aim of the study was to observe the clinical presentation and outcome of MIS-C treated at a tertiary care hospital. Methods Eighteen children, aged 24 days to 18 years, with suspected MIS-C were admitted. Their clinical presentation, laboratory parameters, radiological investigations, management, and outcomes were recorded. Results Median age was 8 years (interquartile range [IQR]: 0.5, 14), and the male-to-female ratio was 1:1. Fever, tachycardia, respiratory distress, hypotension, and seizures with altered sensorium were present in 94.4, 88.8, 83.3, 44.4, and 44.4% of the cases, respectively. Median erythrocyte sedimentation rate, C-reactive protein, serum ferritin, and d-Dimer levels were 21 mm/h, 151 mg/L (1,14.2, 319), 1,091 µg/L (737.4, 1,456), and 3,094 ng/mL (990, 4,300), respectively. Methylprednisolone was given to all patients. Low molecular weight heparin and intravenous immunoglobulin (IVIG) were instituted in 83.3 and 38.8% cases, respectively. Seventeen patients (94.4%) required oxygen therapy and 44.4% needed mechanical ventilation. Fourteen patients (77.7%) recovered completely and four cases (22.2%) expired during the hospital stay. The need for ventilation and the presence of shock adversely affected the outcome. Conclusion Chief clinical presentations in the patients of MIS-C were fever, respiratory distress, hypotension, and altered sensorium. Among admitted patients, 87.8% cases were managed successfully by systemic corticosteroids with or without IVIG. Need for mechanical ventilation, shock, and central nervous system symptoms at admission appear to be important factors that can lead to mortality.

Use of norepinephrine in preterm neonates with dopamine-resistant shock: a retrospective single-centre cross-sectional study

BackgroundNorepinephrine (NE) is recommended for children and full-term neonates (born at >37 gestational weeks) with septic shock. Meanwhile, data on the effectiveness of NE in preterm neonates are still limited....

An Uncommon Presentation of Vasopressin-Induced Purpura Fulminans

Purpura fulminans (PF) is a rarely encountered rapidly evolving dermatological manifestation of ischemia, particularly in critically ill patients. Considered one of the very few dermatological emergencies, it has high mortality rate where patients often succumb to the illness. It can manifest in three forms: neonatal, idiopathic, and the more commonly infectious variety, which can be secondary to mostly bacterial and rarely viral etiology. It is also reported to be highly associated with disseminated intravascular coagulation (DIC), heparin-induced thrombocytopenia (HIT), and acute hepatic failure (AHF). Hereditary or acquired deficiency of protein C and dysregulation of the coagulation cascade, mainly protein C-thrombomodulin, has been implicated in the pathogenesis. We present a 55-year-old male admitted to the intensive care unit for diabetic ketoacidosis (DKA) and septic shock. Along with initiating management protocol for DKA and broad-spectrum antibiotics, he was initially started on norepinephrine for septic shock. Because of persistent refractory septic shock, he was subsequently initiated on phenylephrine and vasopressin to maintain adequate perfusion. The following day, he was found to have sharply demarcated blackish non-blanching discoloration on bilateral knees, lower limbs, and scrotum, sparing the acral regions. This cutaneous manifestation persisted throughout his hospital course, although it improved after discontinuation of vasopressin while continuing with other pressors. Vasopressin has been implicated in a few instances of skin necrosis; however, PF has rarely been documented and never within 1 day like ours. This case demonstrates a unique development of PF likely from vasopressin after ruling out the diagnoses of DIC, HIT, thrombotic thrombocytopenic purpura, and AHF.

(779) Persistent Cardiogenic Shock after Valve in Valve TAVR Rescued with Durable LVAD

(779) Persistent Cardiogenic Shock after Valve in Valve TAVR Rescued with Durable LVAD