Refractory Hypotension Research Articles

COMPARISON OF VASOPRESSIN AND PHENYLEPHRINE IN TREATMENT OF DOPAMINE RESISTANT SEPTIC SHOCK – A RANDOMISED CONTROL TRIAL

Objectives: Septic shock is associated with refractory hypotension and organ dysfunction and remains an important cause of mortality in intensive care units (ICUs). Vasopressors are the first-line treatment. The present study aims to compare vasopressin and phenylephrine in the management of dopamine-resistant septic shock in the ICU setting.
 Methods: The study is a prospective, open-labeled, and randomized study comparing the effects of vasopressin (Group I) and phenylephrine (Group II) in the management of dopamine resistant septic shock in intensive care set up. The parameters recorded from 0 to 6 h after persistent hypotension despite maximum dose of dopamine were: Heart rate (HR) (beats/min), systemic blood pressure (mmHg), cardiac output (L/min), cardiac index (CI) (L/min/m2), stroke volume (ml), systemic vascular resistance index (dynes/cm5/m2), oxygen delivery index (IDO) (ml O2/min/m2), urine output (ml), and serum lactate (mg/dl).
 Results: There was a significant difference in HR, systolic blood pressure, cardiac output, and CI in both groups from 1 h to 6 h. The IDO had a significant rise in Group II. The serum lactate level also decreased in Group II at 6 h.
 Conclusion: From our study, we concluded that as organ perfusion and oxygenation are more important for the treatment of septic shock and to keep the vital organs functioning rather than to increase the systemic vascular resistance and blood pressure, phenylephrine showed a better result than vasopressin in the treatment of septic shock.

Unexplained Acute Right Ventricular Dilatation and Dysfunction in COVID-19.

Sir, COVID-19 has a wide range of clinical presentations. The differential diagnosis of obstructive shock in patients with COVID-19 includes acute pulmonary embolism and acute cor pulmonale. A 39-year-old nonsmoker male with no known comorbidities was tested to be COVID positive by RT-PCR 5 days after a contact history. He had an uneventful course with no hypoxia till day 18, when he developed sudden-onset breathlessness and presented to the emergency department. Electrocardiography showed sinus tachycardia with S1Q3T3 pattern. Point-of-care ultrasound (POCUS) revealed gross dilatation of the right atrium and ventricle with D-shaped left ventricle and bilateral B-profile; deep venous thrombosis screening of bilateral lower limbs revealed no thrombus. Computed tomography pulmonary angiogram revealed no pulmonary embolus. He had refractory hypotension and succumbed to his illness on day 3 of admission. The various cardiovascular manifestations of COVID-19 can be broadly categorized into asymptomatic heart disease, myocardial injury, heart failure, cardiac arrhythmias, and vascular complications [Figure 1].[123]Figure 1: Cardiovascular manifestations of COVID-19The right ventricle (RV) has been called the forgotten chamber historically. However, the importance of RV is increasingly being recognized. The COVID pandemic has further highlighted the importance of RV. The two major life-threatening causes for acute RV dysfunction in COVID-19 are acute pulmonary embolism and acute cor pulmonale. Acute pulmonary embolism is well-recognized; however, acute cor pulmonale is not well-recognized and is poorly understood. The proposed mechanisms for acute right ventricular dilatation and dysfunction in COVID-19 include hypoxemic vasoconstriction from acute respiratory distress syndrome (ARDS), negative inotropic effects of cytokines, and direct effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on the right ventricle, through angiotensin-converting enzyme 2 (ACE2) mediated binding. In a study of 100 hospitalized patients, RV dilatation was the most common echocardiographic abnormality observed in COVID-19, and was the only echocardiographic finding significantly associated with mortality.[45] The diagnosis of acute cor pulmonale is based on bedside echocardiographic findings in such patients, implying the utility of point-of-care ultrasound (POCUS) performed by emergency physicians. Since the presence of acute cor pulmonale in COVID-19 patients has increased the risk of cardiac arrest and mortality, early recognition and its treatment may result in decreased mortality and improved patient outcomes. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Accidental systemic administration of 1 litre of cardioplegia solution during paediatric cardiac surgery

SummaryCardioplegia is used to induce cardiac arrest in order to facilitate cardiac surgery in patients supported by cardiopulmonary bypass. It is administered directly into the coronary vessels after the heart has been isolated from the systemic circulation. We describe the case of a 9‐year‐old boy who mistakenly received 1 l of high strength St Thomas’ Harefield cardioplegia solution delivered into the systemic circulation during cardiac surgery. Although the patient’s heart did not stop, the subsequent physiological derangements were severe. The presenting features were refractory hypotension and dilutional anaemia along with severe hyperkalaemia, hypermagnesaemia and hyperchloraemic metabolic acidosis. Local anaesthetic systemic toxicity from the procaine contained within the cardioplegia solution was also a concern. Treatment required vasopressor administration and an extended period of cardiopulmonary bypass while serum electrolyte concentrations were corrected by haemodiafiltration. The systemic administration of cardioplegia solution is a rare but important iatrogenic clinical emergency that anaesthetists working in cardiac centres should be aware of. This case demonstrates that full recovery is possible.

Venoarterial Extracorporeal Membrane Oxygenation as an Effective Therapeutic Support for Refractory Cardiac Arrest in the Setting of Spinal Anesthesia: A Case Report and Literature Review

Cardiac arrest is the most serious event among the complications associated with spinal anesthesia. Spinal anesthesia reduces the release of catecholamines and impairs neuroendocrine response following cardiac arrest, which contributes cardiopulmonary resuscitation (CPR) more difficult. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) may be a bridge to provide a more effective and durable mechanical solution under this extremely critical condition. This study reports a 50-year-old man who was scheduled to undergo surgical great saphenous vein varices under spinal anesthesia. A sudden cardiac arrest occurred after spinal anesthesia. Standard CPR was performed and large doses of vascular drugs are administered, but the effect of resuscitation was still poor. We fastly initiated VA-ECMO to provide cardiopulmonary support for this refractory cardiac arrest. Fortunately, the patient was successfully resuscitated with complete recovery. In summary, standard CPR might more difficult during spinal block anesthesia. Quick-started VA-ECMO is a potential option under this situation, which protects the patient from further harm from repeated prolonged CPR, refractory hypotension and deteriorated desaturation, and therefore benefit for patient in this critical condition.

Use of CytoSorb hemoadsorption in a patient with sepsis and acute kidney injury: A case report

Introduction. Continuous renal replacement therapy is one of the methods that proved to be successful in the treatment of sepsis and its complications such as acute kidney injury. One of the adsorbers tested is CytoSorb, which contains polystyrene-divinylbenzene pores with a biocompatible polyvinylpyrrolidone coating and that is also a highly adsorptive and biocompatible filter that facilitates selective removal of medium molecular weight molecules (10 - 15 kDa). Case Report. A 51-year-old male patient was hospitalized at the Department of Anesthesia, Resuscitation and Intensive Care due to multiple traumas caused by a fall from the third floor. After admission, laboratory and diagnostic methods were performed, the injuries were surgically treated and the patient received infusion, antibiotic and preventive anti-ulcer therapy along with measures of intensive treatment and monitoring of vital parameters. Progression of the pulmonary lesions, prolonged refractory hypotension unresponsive to therapeutic protocols, predisposed the onset of acute renal impairment and continuous venovenous hemodialysis with CytoSorb was applied. The procedure lasted 21 hours and 39 minutes, during which the urine output increased, and the need for vasoactive support was significantly reduced, while the lactate levels declined. Upon completion of the procedure, hemodynamic stability was achieved, with gradual improvement of consciousness, regression of pulmonary changes and reduction of inflammatory parameters and parameters of renal function. Conclusion. We can say that control of the patient?s hyperinflammatory response was the key factor in achieving stabilization of the patient, as well as organ recovery and survival. Future research should provide additional information on the contribution of CytoSorb in the treatment of patients with sepsis.

Terlipressin in norepinephrine-resistant hyperdynamic shock after cardiac surgery

Background Various vasoconstrictors have shown promising results in the management of vasoplegic shock. However, there are very few studies on the effect of terlipressin regarding the management of refractory hypotension after cardiac surgery. In this study, we evaluate and compare the efficacy of terlipressin and noradrenaline in the treatment of this type of shock. This study was done to assess the effectiveness of each group in elevating the mean arterial blood pressure (BP) with serial measurements to evaluate serum lactate, systemic vascular resistance, pulmonary artery pressure, and cardiac output. Patients and methods Persistent hypotensive patients after cardiac surgery receiving noradrenaline (150 ng/kg/min) infusion were divided into two groups, with group N receiving noradrenaline (dose started 150 ng/kg/min up to 300 ng/kg/min) and group T receiving terlipressin 1 mg intravenous bolus injection/4 h with noradrenaline (150 ng/kg/min). Results This study showed that group T was more effective regarding improvement of mean arterial BP. There was significant BP improvement in group T [19 of 20 patients (95% of shocked patient in group T) compared with only 25% of patient in N group]. There was significant decrease in the length of ICU stay in group T compared with group N (12±3 days in N group and 6±2 days Mortality is 70% in group N and 40% in group T). However, mortality rate was 40% in group T compared with 70% in group T, with no statistical significance. Conclusion In patients with vasoplegic shock unresponsive to norepinephrine after cardiac surgery, exogenous administration of terlipressin raises BP by increasing vascular tone more. By reducing the requirement for catecholamines, it decreases the stimulation of arrhythmogenic myocardial β1-receptors and associated myocardial oxygen demand.

Elevated liver enzymes in association with vasopressin use in a neonate

Vasopressin has been used in neonates for refractory hypotension. Elevation in liver enzymes due to mesenteric mucosal hypoperfusion has been associated with the use of vasopressin in adults. We present a case of a neonate that develop elevated liver enzymes in association with vasopressin use and migration of umbilical venous catheter.

Case Report: Refractory Hypotension of GABA B Receptor Autoimmune Encephalitis

Introduction: With the development of antibody detection technology, Gamma-Aminobutyric Acid (GABA) B receptor encephalitis is a known autoimmune disease. This paper describes a patient with refractory hypotension who suffered GABA B receptor autoimmune encephalitis.Case Report: We describe a 63-year-old man with GABA B receptor autoimmune encephalitis who had hypotension on day 17 of the disease onset. Despite two rounds of immunoglobulin administration, high-dose intravenous steroid injections and immunosuppressive therapy on day 35 of hospitalization, psychiatric symptoms and seizures were significantly improved; however, the patient's blood pressure remained low.Conclusion: This case study and literature review investigated the impairment of autonomic nerve function and its subsequent management in patients with GABA B receptor autoimmune encephalitis.

Interleukin 8 may predict surgical necrotizing enterocolitis in infants born less than 1500 g

Necrotizing enterocolitis (NEC) often leads to gastrointestinal emergency resulting high mortality in very low birth weight infants (VLBWIs) requiring surgery. To date, few studies have explored the role of serum cytokines in the development of feeding intolerance (FI) or NEC outcomes in VLBWIs. Infants born weighing <1500 g or of 32 weeks of gestational age were prospectively enrolled from May 2018 to Dec 2019. We measured several cytokines routinely within 72 h of life, even before NEC-like symptoms developed. NEC or FI group comprised 17 (27.4%) infants, and 6 (9.7%) infants had surgical NEC. The gestational age and birth weight were significantly lower in the NEC or FI group with more prematurity-related complications. The surgical NEC group also demonstrated significantly lower gestational age and birth weight along with more infants experiencing refractory hypotension within a 1 week of life, pulmonary hypertension, and patent ductus arteriosus. IL-10 levels were significantly higher in the NEC or FI group, whereas IL-8 levels were significantly higher in the infants with surgical NEC. Our findings indicated to IL-8 can predict surgical NEC while increased IL-10 can predict NEC development in VLBWIs.

Treatment variables associated with outcome in emergency department patients with suspected sepsis

BackgroundEarly treatment is advocated in the management of patients with suspected sepsis in the emergency department (ED). We sought to understand the association between the ED treatments and outcome in patients admitted with suspected sepsis. The treatments studied were: (i) the time to antibiotics, where time zero is the time the patient was booked in which is also the triage time; (ii) the volume of intravenous fluid (IVF); (iii) mean arterial pressure (MAP) after 2000 ml of IVF and (iv) the final MAP in the ED.MethodsWe performed a retrospective analysis of the ED database of patients aged ≥ 18 year who met two SIRS criteria or one red flag sepsis criteria on arrival, received intravenous antibiotics for a suspected infection and admitted between 8th February 2016 and 31st August 2017. The primary outcome measure was all-cause in-hospital mortality. The four treatments stated above were controlled for severity of illness and subject to multivariate logistic regression and Cox proportional-hazard regression to identify independent predictors of mortality.ResultsOf the 2,066 patients studied 272 (13.2%) died in hospital. The median time to antibiotics was 48 (interquartile range 30–82) minutes. The time to antibiotics was an independent predictor of mortality only in those who developed refractory hypotension (RH); antibiotics administered more than 55 mins after arrival was associated with an odds ratio (OR) for mortality of 2.75 [95% confidence interval (CI) 1.22–6.14]. The number-needed-to-treat was 4. IVF > 2000 ml (95% CI > 500– > 2100), except in RH, and a MAP ≤ 66 mmHg after 2000 ml of IVF were also independent predictors of mortality. The OR for mortality of IVF > 2,000 ml in non-RH was 1.80 (95% CI 1.15–2.82); Number-needed-to-harm was 14. The OR for morality for a MAP ≤ 66 mmHg after 2000 ml of IVF was 3.42 (95% CI 2.10–5.57). A final MAP < 75 mmHg in the ED was associated with, but not an independent predictor of mortality. An initial systolic blood pressure of < 100 mmHg has a sensitivity of 63.3% and specificity of 88.4% for the development of RH.ConclusionIn this study, antibiotics were found to be time-critical in RH. Intravenous fluids > 2000 ml (except in RH) and a MAP ≤ 66 mmHg after 2000 ml of IVF were also independent predictors of mortality.

Endocrine and Metabolic Manifestations of Snakebite Envenoming.

Snakebite envenoming is a neglected, public health problem in tropical and subtropical regions. Local tissue necrosis, neurotoxic, and hemo-vasculotoxic effects are well-recognized features, whereas the endocrine and metabolic derangements are not as well known. In addition to contributing to morbidity, some of these manifestations can be potentially life-threatening if not recognized early. The most prominent endocrine manifestation is hypopituitarism (HP), which can manifest acutely or remain asymptomatic and present years later. Unexplained recurrent hypoglycemia and refractory hypotension are early clinical clues to suspect corticotroph axis involvement in acute settings. Chronic pituitary failure may present, like Sheehan's syndrome, several years after the bite. The occurrence of acute kidney injury, capillary leak syndrome, and disseminated intravascular coagulation are predictors of HP. Adrenal hemorrhages are documented in autopsy series; however, primary adrenal insufficiency is very rare and confounded by the presence of HP. Hyponatremia, hypokalemia or hyperkalemia, and dysglycemia can occur, but the mechanisms involved are only partially understood. Awareness, a high index of suspicion, correct interpretation of hormonal parameters, and timely treatment of these abnormalities can be lifesaving.

The effect of emergency manuals on team performance during two different simulated perioperative crises: A prospective, randomized controlled trial

Study objectiveWhether having an emergency manual (EM) available for use during perioperative crises enhances or detracts from team performance, especially for multi-factorial diagnostic situations that do not explicitly match a chapter of the EM. DesignA simulation-based, prospective randomized trial based upon two perioperative crises, one involving a patient with a transfusion reaction for which the EM contains a specific chapter, and the other involving a patient with refractory hypotension progressing into septic shock for which the EM does not have a specific chapter. Setting52 regularly scheduled 6-h courses at the Center for Medical Simulation in Boston, Massachusetts, USA. Study group304 US-trained practicing anesthesiologists. InterventionsThe absence or presence of the EM during the simulation case. MeasurementsTeams were rated in the following categories: primary underlying diagnosis, fluid resuscitation, treatment of primary diagnosis, cardiac arrest management, overall crisis management, and (if applicable) EM usage. Also, raters recorded free-text ‘field notes’ about the usage-patterns and perceived utility of the EM. Using these ‘field notes’ and a two-stage, inductively revised procedure, two independent reviewers examined a subset of case videos for action analysis. Main resultsPerformance ratings for a total of 51 teams and 95 simulations were included in the final analysis. No effect on performance was demonstrated with providing the EM in either the refractory hypotension/septic shock case or the transfusion reaction case, with the exception of the PEA arrest category. In the subset of simulations in which resuscitation from PEA arrest performance could be evaluated, EM availability was associated with an adjusted mean 1.3 point (99% confidence interval [CI]: 0.2, 2.4) improvement in performance in the transfusion reaction case (p = 0.004), but only an adjusted mean 0.2 point (99% CI, −0.7, 1.1) improvement in the refractory hypotension/septic shock case (p = 0.530) (p for interaction = 0.069). Analysis of actions found that when available, the EM was usually used, but often not until after cardiac arrest had occurred. In some cases, teams persisted with incorrect diagnoses and treatments irrespective of the presence or absence of an EM. ConclusionsProviding an EM did not affect team performance in areas like diagnosis, treatment, fluid resuscitation, communication, and teamwork in management of perioperative crises such as transfusion reaction where an explicit chapter in the EM exists and refractory hypotension / septic shock where an explicit chapter does not exist. A suggestion of improved cardiac arrest resuscitation with the availability of an EM was found, but should be interpreted with caution given a limited sample size. Observed actions using the EM demonstrated that only about half of the teams used the EM to any substantive degree and most used it relatively late in the crisis. By observation, the EM appeared to be helpful in about half of the cases and did not, by itself, deter from appropriate management.

Fatal primary dengue-induced Haemophagocytic Lymphohistiocytosis (HLH) in a returning traveller from India treated with anakinra for the first time

Abstract Background Dengue fever is an arthropod-borne flavivirus infection that is highly prevalent in the tropics. A proportion of clinical cases develop severe dengue, defined by life-threatening complications including haemorrhage, capillary leak and multi-organ failure. Recently there has been increasing recognition that some cases of severe dengue may be a consequence of HLH. To our knowledge, this is the first report of treatment with Anakinra for dengue-induced HLH. Case report We report a case of Dengue fever triggering HLH in an eighteen-year-old female returning traveller from India, diagnosed with systemic lupus erythematosus (SLE) two months prior to presentation. The patient initially presented to a district general hospital emergency department (ED) with a three-day history of flu-like symptoms, fever, erythematous rash, widespread joint pain, nausea and chills. Acute Dengue virus infection was confirmed with serum polymerase chain reaction (PCR) testing. On day two, she was admitted to intensive care for multi-organ support necessitated by refractory hypotension, oligo-anuric severe acute kidney injury (AKI), acute liver failure with lactataemia and type one respiratory failure. The possibility of Dengue-induced HLH was considered early with multiple criteria for diagnosis met including hyperferritinaemia, pancytopenia, lipaemia and a marked transaminitis. HLH-directed therapy was commenced with intravenous immunoglobulins (IVIG), intravenous methylprednisolone (IVMP) and Anakinra. Subsequent bone marrow biopsy analysis demonstrated clear evidence of HLH, in the context of a persistent and marked Dengue viraemia. We observed resolution of HLH markers as well as reducing requirements for multi-organ support after initiation of Anakinra therapy. During her recovery, the patient unexpectedly developed focal neurology; intracranial imaging demonstrated widespread, discreet parenchymal lesions thought to be haemorrhagic in nature, which were deemed too severe an insult to recover from. On day 19, the difficult decision of withdrawing care after deep discussion with the family was reached, soon after which the patient passed away. A post-mortem examination was not arranged.

Journal-related Activities and Other Special Activities at the 2020 American Society of Anesthesiologists Meeting.

Journal-related Activities and Other Special Activities at the 2020 American Society of Anesthesiologists Meeting.

CYCLOBENZAPRINE OVERDOSE PRESENTING WITH RHABDOMYOLYSIS, DISTRIBUTIVE SHOCK, AND MULTIORGAN FAILURE

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Few cases of cyclobenzaprine (CBZ) overdose exist in the literature, and the range of toxicity is not well-defined. We report a case of CBZ overdose with life-threatening shock and multiorgan failure. CASE PRESENTATION: A 51-year-old woman with type 2 diabetes, hypertension, chronic back pain, and depression presented to the emergency department after being found unresponsive near an empty bottle of CBZ. She was hypotensive and mildly tachycardic with a Glasgow coma score of 8. She was intubated and admitted to the intensive care unit. She had multiorgan failure with acute kidney injury (blood urea nitrogen: 57 mg/dL, creatinine: 7.1 mg/dL), elevated liver enzymes, anion gap metabolic acidosis (arterial blood gas pH 7.1, pCO2: 34, pO2: 80, HCO3: 10), creatine kinase level of 39K IU/L, and myoglobin >3000 ng/mL. Her urine drug screen was positive for TCA; her serum qualitative screen was positive for CBZ. Her electrocardiogram (ECG) showed widened QRS with no acute ST changes. Given her hypotension refractory to intravenous (IV) fluid resuscitations, she received 2 inotropic agents for 2 days, maintenance IV fluids, and NaHCO3 infusion. Her QRS interval normalized after 6 hours. She was extubated on day 3 with subsequent normalization of both her kidney and liver functions (Graph 1, 2). Later she reported ingesting the CBZ as a suicide attempt. DISCUSSION: Cyclobenzaprine is a centrally acting muscle relaxant, that is structurally similar to amitriptyline (TCA), differing by only one double bond. CBZ and TCA cause reserpine antagonism, norepinephrine potentiation, potent peripheral and central anticholinergic effects, and sedation. Toxic effects can be mild (e.g., confusion, visual hallucination, agitation, drowsiness, dry mouth, dizziness) or severe (e.g., cardiac arrhythmias, hypotension, convulsions, stupor, coma). Spiller et al.'s analysis of 402 cases of CBZ toxicity found respiratory failure requiring mechanical ventilation in 12 cases (3%). Only 2 cases had refractory hypotension requiring inotropic support. Rhabdomyolysis is an uncommon complication, reported only in 2 independent case reports. The management of a CBZ overdose is like that of any TCA. Gastrointestinal decontamination by lavage and activated charcoal is time sensitive. QRS widening or intraventricular conduction abnormalities should be treated with NaHCO3. CONCLUSIONS: To our knowledge, this is the first case report of life-threatening shock resulting in concurrent multiorgan failure, including acute renal insufficiency, hepatic injury, rhabdomyolysis, metabolic encephalopathy, and respiratory failure from CBZ overdose. Health care professionals should realize that CBZ overdose can present as a spectrum of toxicities, including life-threatening complications. Early recognition and appropriate intervention can help reverse this otherwise possible fatal condition Reference #1: Spiller HA, Winter ML, Mann KV, Borys DJ, Muir S, Krenzelok EP. Five-year multicenter retrospective review of cyclobenzaprine toxicity. J Emerg Med. 1995;13(6):781–785. doi:10.1016/0736-4679(95)02019-5 Reference #2: Chabria SB. Rhabdomyolysis: a manifestation of cyclobenzaprine toxicity. J Occup Med Toxicol. 2006;1:16. doi:10.1186/1745-6673-1-16 DISCLOSURES: No relevant relationships by Meily Arevalo, source=Web Response No relevant relationships by Mohamed Elmassry, source=Web Response No relevant relationships by John Makram, source=Web Response No relevant relationships by Haneen Mallah, source=Web Response No relevant relationships by Arunee Motes, source=Web Response No relevant relationships by Kenneth Nugent, source=Web Response No relevant relationships by Pablo Paz, source=Web Response

UNCOMMON AMONGST COMMON: ANGIOTENSIN II-INDUCED PERIPHERAL ISCHEMIA IN REFRACTORY SEPTIC SHOCK

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Angiotensin (AT) II, a naturally occurring hormone, modulates blood pressure through direct vasoconstriction of the circulatory system and through stimulation of various catecholamines and vasopressin. Derived from the hydrolysis of AT I via the AT-converting enzyme (ACE) in the pulmonary & renal endothelium, AT II has been studied for cases of vasodilatory shock since the 1930’. Most recently, the ATHOS-3 trial demonstrated AT II’s utility as a rescue vasopressor agent, highlighting its catecholamine-sparing effects. CASE PRESENTATION: 34-year-old African American male presented with 3-day history of dyspnea, productive cough and an episode of hemoptysis. Upon presentation, he was febrile, tachycardic, hypotensive and hypoxic prompting endotracheal intubation and vasopressor support. Laboratory studies were significant for leukocytosis with bandemia, lactic acidosis, acute kidney injury, transaminitis & positive for influenza A. Despite aggressive critical care management with maximum ventilator requirements, broad-spectrum antibiotics, renal replacement therapy & proning, his overall condition continued to worsen. AT II was initiated on Day 2 of ICU admission for refractory hypotension secondary to septic shock. Approximately 48-72 hours after the initiation of AT II, he developed skin discoloration and blistering in all extremities secondary to both arterial and venous thromboemboli despite prophylaxis. The lesions ultimately progressed leading to gangrenous necrosis extending proximally to the torso. Unfortunately, on day 7 of ICU admission, patient suffered a cardiac arrest and expired despite ACLS efforts. DISCUSSION: In our patient, we exhibited similar results to those described in the ATHOS-3 trials. Administration of the AT II resulted in an overall improvement in the patient’s mean arterial pressure, systemic vascular resistance and reduced norepinephrine requirements. We also observed a concomitant improvement in serum lactate, indicating improvement in overall organ perfusion. There are no absolute contraindications to AT II administration, but ATHOS-3 did report an increased incidence of both venous and arterial thromboembolic events in patients who received AT II. Although AT II has been FDA approved for the management of refractory septic shock, more studies are necessary to define those populations most at risk of the adverse effects. CONCLUSIONS: AT II is an important vasopressor agent used in refractory shock; however, more studies are needed to understand the adverse effects in populations most at risk. Reference #1: National Center for Biotechnology Information. PubChem Database. Angiotensin II, CID=172198, https://pubchem.ncbi.nlm.nih.gov/compound/Angiotensin-II (accessed on Mar. 26, 2020) DISCLOSURES: No relevant relationships by Krupa Gandhi, source=Web Response No relevant relationships by Mohit Mody, source=Web Response

Use of Droxidopa to Treat Orthostatic Hypotension in a Patient With Hfref

Background Orthostatic hypotension in patients with a low ejection fraction has been associated with a very high morbidity and mortality. Some of this is due to co-morbidity and some is due to the inability to use conventional medications such as ACE inhibitors, ARBs, sacubitril/valsartan and beta blockers because of worsening hypotension. Midodrine and Florinef can raise blood pressure, but are limited in their ability to do so and have theoretical disadvantages due to increase in systemic resistance and increase in volume overload, respectively. Droxidopa, a new treatment for orthostatic hypotension due to autonomic failure, is metabolized into norepinephrine and could potentially provide a new treatment modality for these very difficult patients. Case report We treated a 71 -year-old, Caucasian male with chronic atrial fibrillation and non-ischemic cardiomyopathy. Even with a biventricular defibrillator, severe orthostatic hypotension continued resulting in falls and head trauma. He was unable to tolerate any of the conventional medications to try to raise his ejection fraction due to worsening hypotension. Droxidopa was initiated and progressively up titrated, finally reaching a dose of 300 mg t.i.d. At this dose, his blood pressure stabilized and he was able to tolerate the following medications: Sacubitril/valsartan 24/26 b.i.d., metoprolol succinate 25 mg daily. On this medicine combination his blood pressure ranged from 101/58 to 110/65 and his New York Heart Association class improved from class IV to class II. LV ejection fraction was 30% initially and increased to 50% after 4 months of treatment with Droxidopa. He became ambulatory and had a much improved quality of life. Renal function and other laboratory parameters remained stable on the droxidopa. His ICD interrogation showed no evidence of any proarrhythmia affects of droxidopa. Conclusion Droxidopa provides potentially a new treatment modality for patients with low ejection fraction and refractory orthostatic hypotension. Longer term follow up will be needed to confirm efficacy and safety. Rhythm follow up of over 9 months has shown no evidence of proarrhythmia. Additional patients and longer term follow up results are in preparation, but have had similar benefits to date.

Intravenous calcium as a pressor in a swine model of hypoxic pseudo-pulseless electrical mechanical activity\u2014a preliminary report

BackgroundPseudo-pulseless electrical activity (pseudo-PEA) is a lifeless form of profound cardiac shock characterized by measurable cardiac mechanical activity without clinically detectable pulses. Pseudo-PEA may constitute up to 40% of reported cases of cardiac arrest. Resuscitation from pseudo-PEA is often associated with hypotension refractory to catecholamine pressors. We hypothesized that this post-resuscitation state may be associated with hypocalcemic hypotension responsive to intravenous calcium.MethodsUsing pre-existing data from our hypoxic swine pseudo-PEA model, we measured blood pressure, hemodynamics, and electrolytes. Physiological data were analyzed on a heartbeat by heartbeat basis. The midpoint of the calcium response was defined using change of curvature feature detection. Hemodynamic parameters were shifted such that the value at the midpoint was equal to zero.ResultsIn 9 animals with refractory hypotension, we administered 37 boluses of intravenous calcium in the dosage range of 5-20 mg. Comparisons were made between the average values in the time period 40-37 s before the midpoint and 35-40 s after the midpoint. Of the 37 administered boluses, 34 manifested a change in the blood pressure, with mean aortic pressure, systolic and diastolic pressures all increasing post bolus administration.ConclusionsAdministration of intravenous calcium may be associated with a pressor-like response in refractory hypotension after resuscitation from pseudo-PEA. Relative ionized hypocalcemia may cause hypotension after resuscitation from pseudo-PEA. Therapy with intravenous calcium should be further investigated in this setting.

LONG-TERM OUTCOMES OF RENAL TRANSPLANTATION FROM UNCONTROLLED AND CONTROLLED DONATIONS AFTER CIRCULATORY ARREST AT A TERTIARY CARE HOSPITAL IN INDIA

Introduction: Donation after circulatory death (DCD) has never been attempted in India because of legal constraints and lack of guidelines for the withdrawal of life support in end-of-life situations. Renal transplantation from DCD donors was started in 2011 at our centre. The present report describes the outcomes of these transplants from Maastricht category IV and V donors at a tertiary care hospital in India. Methods: Between 2011 and 2019, 394 deceased donor transplants were performed at our centre. During this period, 14 donors had kidneys retrieved after circulatory arrest. These patients were declared dead after waiting for 5 min with no electrocardiographic signal on monitor following failed cardiopulmonary resuscitation (CPR), which was restarted in eight patients till organ retrieval. All donors received heparin and underwent rapid cannulation of aorta, infusion of preservative cold solution, and immediate surface cooling of organs during retrieval surgery. 25/28(89.2%) kidneys were utilized. Two kidneys were explanted due to refractory hypotension in a patient undergoing dual kidney transplant. Mean follow up duration was 40.2 + 20 months (Range 5.3 - 74 months) Results: Mean donor age was 32.8 ± 13.6 years, M:F 9:5 and mean age of recipients was 42.5 ± 11.3 years, M:F 14:10. 21/25 patients had delayed graft function and required dialysis in the postoperative period. Mean serum creatinine of 1.49 ± 0.38 mg/dl was achieved at the time of discharge at a mean duration of 32.2 ± 19.9 days. Kidneys from donors where CPR was continued after the declaration of death had earlier recovery of renal function (time to reach baseline creatinine 21.2 ± 7.2 vs. 34.3 ± 23.7 days). One kidney from the first uncontrolled DCD donor never functioned. For the remaining cohort of 23 patients, the mean creatinine at the last follow up was 1.26 ± 0.57 mg/dl. Patient survival was 100% and graft survival 95.8% at 1 year and 91.6% at the last follow up. Conclusion: Kidneys from DCD donors can provide good outcomes in the long term and serve as a useful adjunct in deceased donor program. Continuing CPR after the declaration of death hastens recovery of kidney function.

Arterial Stiffness Predicts General Anesthesia–Induced Vasopressor-Resistant Hypotension in Patients Taking Angiotensin-Converting Enzyme Inhibitors

Patients chronically treated with angiotensin-converting enzyme inhibitors (ACEIs) may develop hypotension after induction of general anesthesia. A fraction of these patients are resistant to therapeutic doses of vasopressors, which poses serious concerns for hemodynamic management. The authors hypothesized that the patients who develop refractory hypotension, compared with those who do not, show lower central arterial stiffness due to the profound effect of ACEIs. Prospective observational study. Single tertiary center. Fifty surgical patients chronically treated with ACEIs were enrolled. Prior to surgery, all the patients had central arterial stiffness assessment measured by carotid-femoral pulse-wave velocity. Patients were categorized into 2 groups according to the systolic blood pressure response during the first 10 minutes after induction of general anesthesia: a vasopressor-resistant hypotension group requiring more than 200 µg phenylephrine, or a control group requiring no more than 200 µg of phenylephrine to maintain systolic blood pressure above 90 mmHg during the study period. Carotid-femoral pulse-wave velocity was significantly lower in the vasopressor-resistant hypotension group compared to the control group (7.6 [7.2-8.3] m/s v 9.9 [8.7-12.0] m/s, p = 0.001 [Hodges-Lehman median difference 2.2, 95% confidence interval = 1.1-4.4]). These findings suggested that preoperative measurement of carotid-femoral pulse-wave velocity in patients chronically treated with ACEIs could help identify patients at increased risk of developing hypotension refractory to vasopressors after induction of general anesthesia.