Refractory Shock Research Articles

Additional Bicarbonate Infusion Complements WHO Rehydration Therapy in Children with Acute Diarrhea and Severe Dehydration Presenting with Severe Non-anion Gap Metabolic Acidemia: An Open Label Randomized Trial.

To assess the efficacy and safety of bicarbonate infusion in children with Acute Diarrhea and Severe Dehydration (ADSD) having severe Non-Anion Gap Metabolic Acidemia (sNAGMA). Children (aged 1-144 mo) with ADSD and sNAGMA (pH ≤7.2 and/or serum bicarbonate ≤15mEq/L) were enrolled in an open-label randomized design. Controls (n = 25) received WHO-recommended rehydration therapy with Ringer Lactate, while intervention group (n = 25) received additional bicarbonate deficit correction. Primary outcome was time taken to resolve metabolic acidemia (pH >7.30 and/or bicarbonate >15mEq/L). Secondary outcome measures were adverse outcome [composite of pediatric intensive care unit (PICU) transfer and deaths], acute care area free days in 5 d (ACAFD5), hospital stay, and adverse effects. Time taken to resolve metabolic acidemia was significantly lesser with intervention [median (IQR); 8h (4, 12) vs. 12h (8, 24); p = 0.0067]. Intervention led to acidemia resolution in significantly more children by 8h and 16h (17/25 vs. 9/25, p = 0.035 and 23/25 vs. 17/24, p = 0.018, respectively). Patients with fluid refractory shock needed lesser inotropes in intervention group [median Vasoactive Inotrope Score (VIS), 10.5 vs. 34]. Intervention led to significantly lesser adverse outcome (0/25 vs. 5/25, p = 0.049), and noticeably more ACAFD5 [median (IQR); 2 (1, 2) vs. 1 (1, 2); p = 0.12]. Two patients died in the control group while none in the intervention group. No adverse effect was documented. Additional calculated dose of bicarbonate infusion led to significantly early resolution of metabolic acidemia, lesser utilization of critical care facilities, and lesser adverse outcome in children with ADSD and sNAGMA, compared to standard therapy, with no adverse effect.

Severe Refractory Vasoplegic Shock Syndrome after OPCABG Successfully Treated with Hydroxycobalamin: A Case Report and Review of the Literature.

Vasoplegic shock syndrome (VSS) after an off-pump coronary artery bypass graft (OPCABG) is an extremely rare condition. Inotropic support is usually the first-line therapy, though it can precipitate several complications or be ineffective. We report the first case of severe refractory VSS after OPCABG successfully treated with hydroxycobalamin. A 77-year-old gentleman underwent OPCABG for three vessels coronary artery disease. Preoperative LV ejection fraction was 28%, and the patient before surgery started sacubitril/valsartan titrated, then, at the highest dose. Surgery was uneventful and, by the end of the procedure, TEE showed improved biventricular contractility. The patient was transferred to the ICU without inotropic support, but soon developed hypotension. TEE ruled out pericardial tamponade and confirmed fair contractility. Norepinephrine was titrated to a medium-high dose, vasopressin was started and a Swan-Ganz catheter was placed. SVR was 480 dyn·s·cm-5. Despite aggressive pharmacologic treatment (including methylprednisolone and methylene blue), no improvements were noticed. Ten grams of hydroxycobalamin were administered. One hour later, hemodynamic status re-assessment showed SVR > 800 dyn·s·cm-5. Afterward, vasopressors were gradually reduced. Our case demonstrated the importance of adequate early treatment in VSS after OPCABG. This case report shows, for the first time, that hydroxycobalamin was effectively used to restore homeostasis.

SCAI Staging Application for Acute Myocardial Infarction-Related Cardiogenic Shock at a Single-Center Russian Registry.

To access the features of the course of myocardial infarction (MI) in patients with different stages of MI complicated by cardiogenic shock (MI CS) according to the SCAI scale. We retrospectively described the portrait of CS MI (n = 117) at different stages of SCAI from the hospital MI registry (n = 1253). Hospital mortality increased from stage to stage (p ≤ 0.001). Significant differences in biochemical parameters were found both for indicators characterizing intensive care measures, such as the presence of mechanical lung ventilation or an intra-aortic balloon pump, and for indicators of organ hypoperfusion such as lactate level, pHv (7.39 (7.36; 7.44) at stage A-B; 7.14 (7.06; 7.18) at stage E), creatinine, and glomerular filtration rate. Parameters related to MI characteristics, such as instrumental and laboratory data, anamnesis of ischemia, and performed treatment, did not differ between groups. Polynomial logistic regression showed that lactate level, mechanical ventilation, and monocyte count upon admission (1.15 (0.96; 1.23) at stage A-B; 0.78 (0.49; 0.94) at stage E, p = 0.005) correlated with CS severity. The characteristics of MI at different stages of SCAI do not have differences and do not determine the severity of shock. We revealed a high discriminatory potential of the pH level in predicting refractory shock. The value of monocytes at admission may be a promising predictor of the severity of MI CS. The question of the causes of heterogeneity of MI CS, taking into account the homogeneity of MI characteristics, remains open and promising.

Angiotensin II treatment is associated with improved oxygenation in ARDS patients with refractory vasodilatory shock

BackgroundThe physiological effects of renin-angiotensin system modulation in acute respiratory distress syndrome (ARDS) remain controversial and have not been investigated in randomized trials. We sought to determine whether angiotensin-II treatment is associated with improved oxygenation in shock-associated ARDS.MethodsPost-hoc subgroup analysis of the Angiotensin Therapy for High Output Shock (ATHOS-3) trial. We studied patients who met modified Berlin ARDS criteria at enrollment. The primary outcome was PaO2/FiO2-ratio (P:F) at 48-h adjusted for baseline P:F. Secondary outcomes included oxygenation index, ventilatory ratio, PEEP, minute-ventilation, hemodynamic measures, patients alive and ventilator-free by day-7, and mortality.ResultsOf 81 ARDS patients, 34 (42%) and 47 (58%) were randomized to angiotensin-II or placebo, respectively. In angiotensin-II patients, mean P:F increased from 155 mmHg (SD: 69) at baseline to 265 mmHg (SD: 160) at hour-48 compared with no change with placebo (148 mmHg (SD: 63) at baseline versus 164 mmHg (SD: 74) at hour-48)(baseline-adjusted difference: + 98.4 mmHg [95%CI 35.2–161.5], p = 0.0028). Similarly, oxygenation index decreased by − 6.0 cmH2O/mmHg at hour-48 with angiotensin-II versus − 0.4 cmH2O/mmHg with placebo (baseline-adjusted difference: -4.8 cmH2O/mmHg, [95%CI − 8.6 to − 1.1], p = 0.0273). There was no difference in PEEP, minute ventilation, or ventilatory ratio. Twenty-two (64.7%) angiotensin-II patients had sustained hemodynamic response to treatment at hour-3 versus 17 (36.2%) placebo patients (absolute risk-difference: 28.5% [95%CI 6.5–47.0%], p = 0.0120). At day-7, 7/34 (20.6%) angiotensin-II patients were alive and ventilator-free versus 5/47(10.6%) placebo patients. Day-28 mortality was 55.9% in the angiotensin-II group versus 68.1% in the placebo group.ConclusionsIn post-hoc analysis of the ATHOS-3 trial, angiotensin-II was associated with improved oxygenation versus placebo among patients with ARDS and catecholamine-refractory vasodilatory shock. These findings provide a physiologic rationale for trials of angiotensin-II as treatment for ARDS with vasodilatory shock.Trial Registration: ClinicalTrials.Gov Identifier: NCT02338843 (Registered January 14th 2015).

Effects of enhanced adsorption haemofiltration versus haemoadsorption in severe, refractory septic shock with high levels of endotoxemia: the ENDoX bicentric, randomized, controlled trial

BackgroundEndotoxin adsorption is a promising but controversial therapy in severe, refractory septic shock and conflicting results exist on the effective capacity of available devices to reduce circulating endotoxin and inflammatory cytokine levels.MethodsMultiarm, randomized, controlled trial in two Swiss intensive care units, with a 1:1:1 randomization of patients suffering severe, refractory septic shock with high levels of endotoxemia, defined as an endotoxin activity ≥ 0.6, a vasopressor dependency index ≥ 3, volume resuscitation of at least 30 ml/kg/24 h and at least single organ failure, to a haemoadsorption (Toraymyxin), an enhanced adsorption haemofiltration (oXiris) or a control intervention. Primary endpoint was the difference in endotoxin activity at 72-h post-intervention to baseline. In addition, inflammatory cytokine, vasopressor dependency index and SOFA-Score dynamics over the initial 72 h were assessed inter alia.ResultsIn the 30, out of 437 screened, randomized patients (10 Standard of care, 10 oXiris, 10 Toraymyxin), endotoxin reduction at 72-h post-intervention-start did not differ among interventions (Standard of Care: 12 [1–42]%, oXiris: 21 [10–51]%, Toraymyxin: 23 [10–36]%, p = 0.82). Furthermore, no difference between groups could be observed neither for reduction of inflammatory cytokine levels (p = 0.58), nor for vasopressor weaning (p = 0.95) or reversal of organ injury (p = 0.22).ConclusionsIn a highly endotoxemic, severe, refractory septic shock population neither the Toraymyxin adsorber nor the oXiris membrane could show a reduction in circulating endotoxin or cytokine levels over standard of care.Trial registration ClinicalTrials.gov. NCT01948778. Registered August 30, 2013. https://clinicaltrials.gov/study/NCT01948778

Extracorporeal membrane oxygenation in diabetic ketoacidosis-related cardiac and respiratory failure.

Diabetic ketoacidosis (DKA) is a common clinical problem. When patients develop severe shock and/or respiratory failure, extracorporeal membrane oxygenation (ECMO) may be considered. This case series describes the clinical presentation and outcomes of patients with DKA supported with ECMO. We conducted a retrospective and anonymized review of 15 patients with DKA who required ECMO at our institution. Demographic and ECMO-specific data were collected. Additional variables include ICU length of stay (LOS), acute kidney injury and use of continuous renal replacement therapy, disposition, and mortality. All ECMO cannulations were performed by an intensivist using peripheral vascular access. The majority of patients were female (73%) with a median age of 27 (IQR = 21.5-45) years. A diagnosis of diabetes mellitus (DM) prior to ECMO was present in 11 (73%) patients. Venoarterial ECMO was the initial mode used in 11 (73%) patients. The median duration of ECMO support was 7 (IQR = 6-14) days. The median ICU LOS was 12 (IQR = 8.5-20.5) days, and the median hospital LOS was 21 (IQR = 11-36.5) days. Eight patients had cardiac arrest and underwent extracorporeal cardiopulmonary resuscitation (ECPR) of which 4 (50%) patients survived to discharge. Overall, 10 (66.7%) patients were successfully weaned from ECMO and survived to discharge. This is the largest case series regarding the use of ECMO for patients with refractory shock, cardiac arrest, or respiratory failure related to DKA. The findings suggest that ECMO is a viable support option for managing these patients and has excellent outcomes, including patients with cardiac arrest.

Central ECMO cannulation for severe dihydropyridine calcium channel blocker overdose

Calcium channel blocker (CCB) toxicity carries a high mortality and is the sixth most fatal drug class reported to US poison centers. Amlodipine overdose is characterized by a life-threatening arterial vasodilation that compromises organ perfusion. The management of CCB intoxication is focused on maintaining adequate organ perfusion. In cases refractory to medical therapies, hemodynamic support with extracorporeal membrane oxygenation (ECMO) is warranted necessitating higher flows than usual to compensate for the vasodilation and requiring central cannulation. We present a case of a 12-year-old with severe dihydropyridine CCB ingestion, refractory to medical management and successfully treated with central ECMO cannulation. The patient was discharged home with no significant disability. Central ECMO cannulation may be helpful to facilitate adequate flows in vasodilatory shock such as CCB overdose.

Peri-operative extracorporeal membrane oxygenation in adult and pediatric living donor liver transplantation: a single-center experience.

Extracorporeal membrane oxygenation (ECMO) is a potential rescue therapy for patients with acute cardiopulmonary dysfunction refractory to conventional treatment. In this study, we described the clinical profiles and outcomes of adult and pediatric living donor liver transplantation (LDLT) patients who received ECMO support during the peri-operative period. From June 1994 to December 2020, eleven out of the 1,812 LDLTs performed at Kaohsiung Chang Gung Memorial Hospital required ECMO support: six for respiratory failure, three for cardiogenic shock, and two for refractory septic shock. Comparison between the survivor and non-survivor groups was made. The survival rate for liver transplantation (LT) patients on ECMO support is 36.4%-40% in adults and 33.3% in pediatrics, while the survival rate per indication is as follows: acute respiratory distress syndrome (ARDS) (50%), cardiogenic shock (33.3%), and sepsis (0%). Shorter durations of LT-to-ECMO and pre-ECMO mechanical ventilation were observed in the survivor group. On the other hand, we observed persistently elevated total bilirubin levels in non-survivors, while none of the survivors had aspartate aminotransferase (AST)/alanine aminotransferase (ALT) levels >1,000 U/L. A higher proportion of non-survivors were on concurrent continuous renal replacement therapy (CRRT). Our experience has proven ECMO's utility during the peri-operative period for both adult and pediatric LDLT patients, more specifically for indications other than septic shock. Further studies are needed to better understand the factors leading to poor outcomes in order to identify patients who will more likely benefit from ECMO.

Treatment of refractory shock with vitamin B12 : A narrative review.

High-dose vitamin B12 is a potential treatment for patients with vasodilatory shock that is refractory to other therapies. Vasodilatory shock is characterized by low blood pressure and low systemic vascular resistance. Nitric oxide and hydrogen sulfide, two potential targets of high-dose vitamin B12 given as hydroxocobalamin, facilitate this syndrome. This review explores the relationship between high-dose vitamin B12 and hemodynamic outcomes in adults with vasodilatory shock and provides an update on the literature since a 2019 review on this topic. A literature search of studies published in the past 5 years was conducted in the CINAHL, PubMed, Cochrane, and EMBASE databases in May 2023. After assessing for eligibility, eight studies met this review's inclusion criteria. Seven of the eight studies reported decreased vasopressor requirements for part or all of the study samples after receiving a hydroxocobalamin infusion. However, not all patients responded to hydroxocobalamin. These findings are limited by patient selection and differences in the timing of vasopressor requirement and blood pressure outcome assessments. The current evidence is promising as to whether vitamin B12 , given as a hydroxocobalamin infusion, may improve hemodynamic outcomes in vasodilatory shock, but the evidence is of low quality. The use of hydroxocobalamin to treat refractory, vasodilatory shock remains investigative. Larger randomized controlled trials are required to elucidate the role of vitamin B12 in treating refractory, vasodilatory shock, including in conjunction with other alternative therapies such as methylene blue and corticosteroids.

Central Extracorporeal Membrane Oxygenation Support Following Calcium Channel Blocker Overdose in Children.

Refractory vasodilatory shock (RVS) following massive calcium channel blocker (CCB) overdose remains a challenging clinical entity. Peripheral venoarterial extracorporeal membrane oxygenation (ECMO) has proven useful in several cases of CCB intoxication, however, its use in the pediatric population poses unique challenges given the generally small size of pediatric peripheral vasculature in comparison to the high flow rates necessary for adequate mechanical circulatory support. As a result of these challenges, our group has adopted a "primary" central ECMO cannulation approach to the treatment of children and adolescents admitted to our center with profound RVS after CCB ingestion. We present four cases within the last year using this approach. All patients were successfully discharged from the hospital with no late morbidity at most recent follow-up. Central ECMO support in cases of massive vasodilatory shock following CCB overdose is safe and effective and should be considered early in the clinical course of these critically ill patients.

Predictors on admission associated with successful weaning and in - hospital mortality in patients with refractory shock undergoing veno - arterial extracorporeal membrane oxygenation

Abstract Introduction In assessment of prognosis of patients undergoing veno-arterial extracorporeal membrane oxygenation (VA-ECMO), considerable data have been focused on predictors just before or after VA-ECMO initiation. The aim of this study is to determine the prognostic factors on admission in patients with refractory shock undergoing VA-ECMO. Methods A total of 307 patients (median age 57; interquartile rate [IQR]: 48-68, male 220 (72%)) who underwent VA-ECMO due to refractory shock from 2015 to 2021 were retrospectively analyzed. Successful weaning was defined as successful removal of VA-ECMO without mechanical support over the following 30 days. In-hospital mortality (IHM) was defined as death occurred during the hospital stay. Results Median duration of weaning and hospital stay was 10 days (IQR: 7-14) and 24 days (IQR: 9-43), respectively. Of all patients, 115 patients (37%) were successfully weaned from VA-ECMO and 191 (62%) died before discharge. Patients with successful weaning and survived before discharge had lower prevalence of sepsis, higher cystatin C based estimated glomerular filtration rate (cyc-eGFR) and total cholesterol, and lower blood urea nitrogen, C-reactive protein and INR on admission than those with failed weaning and those who had died. In multivariate regression analyses, sepsis, cyc-eGFR and INR on admission were independently associated with successful weaning and only cyc-eGFR on admission was remained as independent predictor of IHM. In an incremental model, the addition of cyc-eGFR significantly increased the χ² of the clinical and laboratory data model including creatinine based eGFR (Cr-eGFR), from 22.3 to 33.7 (p<0.001) for prediction of successful weaning and from 22.2 to 33.6 (p<0.001) for prediction of IHM, respectively. Conclusion Cyc-eGFR on admission showed an incremental prognostic value beyond Cr-eGFR on admission for prediction of successful weaning and IHM in patients with refractory shock undergoing VA-ECMO.

Outcome of patients with cardiogenic shock in acute myocardial infarction treated with Impella CP and a standardized protocol

Abstract Background Recent registry data indicate improved outcome of patients with cardiogenic shock in acute myocardial infarction (AMICS) if treated with Impella CP according to a standardized protocol. Purpose To evaluate in-hospital and 6-months survival of patients with AMICS after implementation of a standardized protocol with early use of Impella CP. Methods The study compared a contemporary cohort of consecutive patients treated in our centre for AMICS with Impella CP according to an established protocol with a historical cohort of consecutive patients treated with IABP without a protocol (admissions during 5/2019 - 5/2022 vs. 1/2007 - 12/2012). The criteria for implantation of Impella included: 1.) ischemia duration of <24 hours, 2.) age <75 years and absence of life-limiting comorbidities, 3.) impaired left ventricular contractility with enddiastolic pressure (LVEDP) of >18 mmHg, and 4.) successful percutaneous coronary intervention (PCI), urgent coronary artery bypass grafting (CABG), or potential candidacy for long-term left ventricular assist device (LVAD) in case of unattainable coronary revascularization. Excluded were patients with out-of-hospital cardiac arrest of >5 minutes, mechanical complications of myocardial infarction, and patients with small diameter of access arteries. The protocol contained recommendations for early identification of AMICS, complex intensive care, pharmacotherapy, and escalation of the mechanical circulatory support. The patients in the historical cohort were retrospectively matched with the contemporary cohort by the same idication criteria except for LVEDP, which was not measured routinely. In-hospital and 6-months survival status were evaluated from collected medical records. Results In total, 21 patients were treated with Impella CP according to the protocol and 23 patients were treated with IABP without a protocol (age: 65 ± 10 vs. 64 ± 10 years; males: 19 [90%] vs. 20 [87%], LVEF: 27 ± 7% vs. 24 ± 6%, median [IQR] lactate: 3.7 [2.1 - 5.7] vs. 4.2 [2.2 – 9.2] mmol/l, all p-values >0.2). Revascularisation was successful in 90% and 91% of the patients, respectively (PCI/CABG: 17/2 vs. 17/4). In 5 (24%) of the patients treated with Impella, the device was implanted before PCI. Subsequent addition of ECMO for refractory shock was needed in 4 (19%) of the patients in the contemporary cohort and 3 (13%) of the patients in the historical cohort. Long-term LVAD was implanted in 3 (14%) patients and 1 patient (4%), respectively. In-hospital survival was 15 (71%) in the contemporary cohort vs. 14 (61%) in the historical cohort, and 6-months survival was 15 (71%) vs. 11 (48%), respectively (p = 0.008 by log-rank test). Conclusions Patients with AMICS who were treated according to a standardized protocol with early implantation of Impella CP had a relatively favourable 6-months survival that was better compared to a historical cohort.

Sugammadex-Induced Anaphylactic Shock Reversed With Short-Term Continuous Veno-Venous Hemodiafiltration: A Case Report

Anaphylaxis is a life-threatening, systemic, hypersensitivity reaction, manifested by urticaria, hypotension, and respiratory symptoms. Antigens that are cleared renally may have protracted exposure in patients with impaired renal function, resulting in prolonged and refractory anaphylactic shock. After administration of sugammadex, a 47-year-old man developed prolonged, refractory anaphylactic shock, with anuria due to acute kidney injury. The patient was treated with continuous, short-term, veno-venous hemodiafiltration. Initiating this therapy in patients with refractory anaphylactic shock and anuria due to an antigen that is excreted renally can expedite recovery.

Abstract 12495: Modes of In-Hospital Death in Patients With Cardiogenic Shock (CS): An Analysis From the Critical Care Cardiology Trials Network (CCCTN)

Introduction: Mortality from cardiogenic shock (CS), a syndrome of multi-organ system dysfunction, remains high. However, data regarding how patients with CS expire are limited and may have implications for designing clinical trials, identifying therapeutic strategies, and improving outcomes. Aim: We sought to describe primary modes of in-hospital death among patients admitted with CS to cardiac intensive care units (CICUs). Methods: CCCTN is a multi-national research network of advanced CICUs coordinated by the TIMI Study Group (Boston, MA). Using standardized definitions, site investigators classified the direct mode of in-hospital death for patients with CS. Categories included 8 possible modes of cardiovascular (CV) and non-CV death ( Fig ). Subgroups defined by cardiac arrest prior to CICU admission and use of mechanical circulatory support (MCS) were explored. Results: Among 1098 CS cases captured from 10/2021-09/2022, 358 (32.6%) died during the index hospitalization with a median time to death of 4.3 (Q1-Q3, 1.1-10.9) days from CICU admission. Among the deaths, 50%, 41%, and 9% occurred in the context of HF-CS, AMI-CS, and secondary CS, respectively. Overall, mode of death was CV in 82% of cases ( Fig A ). Refractory CS was the dominant mode of death (66%), followed by arrhythmia (13%), anoxic brain injury (6%), and respiratory failure (5%; Fig A ). Compared to patients without preceding cardiac arrest, those with cardiac arrest prior to CICU admission were more likely to die from anoxic brain injury (10% vs. 1%; p<0.01; Fig B ). Compared to patients managed without MCS, those with MCS were more likely to die from refractory shock (p<0.01), either cardiogenic (74% vs. 61%) or non-cardiogenic (6% vs. 3%; Fig C ). Conclusions: Most in-hospital deaths in patients with CS are related to direct CV causes, particularly refractory CS. However, there is potentially important heterogeneity in mode of death across subgroups defined by preceding cardiac arrest and use of MCS.

Abstract 16396: A Tale of Two Maladies: An Interplay of Mendelian Principles

A 22-year-old male with no medical history presented in acute decompensated heart failure and cardiogenic shock. Physical exam showed a thin body habitus, reduced muscle bulk, bilateral ptosis, limited extraocular motion, and upper extremity weakness. An echocardiogram revealed severe biventricular dilation and systolic dysfunction. Invasive hemodynamics revealed elevated cardiac filling pressures and low cardiac output. Coronary angiography excluded coronary artery disease and anatomical variants. He was initiated on dobutamine and eventually milrinone given persistently low index and elevated lactate. An evaluation for the etiology of his cardiomyopathy focused on nutritional deficiencies (e.g., Wet Beriberi), myocarditis, genetic mutations, infiltrative cardiomyopathy (e.g., Friedrich’s ataxia), and mitochondrial and myopathy-related cardiomyopathy. CMR had globally elevated T1 and normal T2 values ruling out acute myocarditis or infiltrative processes. Serum thiamine, TSH and B12 were within normal range. Muscle biopsy and mitochondrial genetic testing revealed a pathogenic deletion (m.7416_14556) and 70% heteroplasmy. Physical exam, biopsy and mitochondrial genetics were diagnostic of Kearns-Sayre Syndrome (KSS). Notably KSS does not typically cause severe cardiomyopathy suggesting an alternative cause. A genetic cardiomyopathy panel was sent revealing a pathologic mutation in the plakophilin 2 gene which was the suspected cause of his cardiomyopathy. A heart transplant evaluation was initiated as he developed refractory shock requiring mechanical support via an Impella 5.5, placed via the right innominate artery due to his small body and vessel size. He underwent an uncomplicated heart transplantation and is doing well. This case underscores the significance of a broad differential diagnosis, multidisciplinary collaboration, and a detailed physical examination in diagnosing and managing complex cardiac conditions.

Abstract 16273: Contemporary Risk Prediction Model for In-Hospital or 30-day Mortality After Percutaneous Coronary Interventions: An NCDR CathPCI Registry Model

Introduction: While the ACC NCDR CathPCI registry has long provided risk-adjusted benchmarking of in-hospital mortality after percutaneous coronary intervention (PCI), extending follow-up to 30 days in those who are discharged can provide a more comprehensive assessment of post-PCI outcomes. Aims: We sought to develop a new model for predicting in-hospital or 30-day mortality after PCI with excellent discrimination to be used for quality improvement efforts. Methods: Data from 472,594 PCIs performed in 2019 at 1,369 sites from the CathPCI registry linked to National Death Index data were used to identify pre-procedural and angiographic predictors of mortality and develop a predictive model of in-hospital or 30-day mortality. A thousand bootstrapped samples of the development cohort were created, and stepwise logistic regression was performed on each sample. The final model included variables that were selected in at least 70% of the bootstrapped samples. Results: The overall in-hospital or 30-day mortality rate after PCI in the entire cohort was 2.8%. In those undergoing elective PCI without shock or clinical instability, mortality was 0.5%, while in those undergoing salvage PCI or for refractory shock it was 60.3% . Cardiovascular instability, level of consciousness after cardiac arrest, frailty, and chronic kidney disease stage were the factors most predictive of mortality (Table 1). The full model performed well with good discrimination in the overall population (C-index= 0.907), and in the cohorts of patients with STEMI (c-index=0.899), and cardiac arrest or shock (c-index=0.828), as well as across the spectrum of procedural risk. Conclusions: This risk model can accurately predict in-hospital or 30-day mortality in those undergoing PCI by incorporating variables that capture cardiovascular instability and clinical status. Extending the mortality follow-up period should enable for a more standardized evaluation of outcomes across hospitals.

Abstract 15265: Rilonacept for Refractory Pericarditis Following Immune Checkpoint Inhibitor Therapy: A Case Report

Background: Immune checkpoint inhibitor (ICI)-mediated cardiotoxicities are rare but potentially fatal. Myocarditis, with clinical presentations ranging from asymptomatic to cardiogenic shock, and pericarditis, have been reported in clinical trials and as post-marketing experience with immunotherapy. It is estimated to occur in less than 1% of individuals receiving single immune checkpoint inhibitor therapy, with a median time to onset of 30 days. Herein, we report a case of late-onset ICI-mediated myopericarditis presenting with cardiogenic shock, followed by recurrent pericarditis refractory to steroid taper. Case Presentation: A 44-year-old woman with triple-negative breast cancer underwent chemotherapy, immune checkpoint inhibitor therapy with Pembrolizumab, lumpectomy, and radiation therapy. After the treatment, the patient developed symptoms consistent with myopericarditis, complicated by pericardial effusion with tamponade and cardiogenic shock. The patient underwent emergent pericardiocentesis and, due to refractory shock, was initiated on high-dose steroid therapy with complete resolution. However, during the tapering of steroids, the patient experienced a recurrence of pericarditis, characterized by chest pain, recurrent pericardial effusion, and elevated inflammatory markers. NSAIDs and colchicine were initiated early in the management but failed to achieve symptom control. Given the refractory nature of the recurrent pericarditis, the decision was made to reintroduce prednisone therapy, which led to substantial symptomatic improvement. To avoid further flares with steroid taper, the patient was started on rilonacept. It led to sustained pain control, and steroids were successfully tapered. Conclusion: Pericarditis is a rare complication of pembrolizumab. There are no specific guidelines on the management of ICI-related recurrent pericarditis. Rilonacept was added due to the refractory nature of her symptoms with steroid taper. It led to sustained improvement in pain, and steroids were successfully tapered.

Comparison of efficacy of dopamine versus epinephrine infusion in fluid refractory septic shock in a tertiary care pediatric ICU.

Objective: To compare the effectiveness of dopamine versus epinephrine as 1st line vasoactive therapy among children aged 6 months to 12 years and presenting with fluid-refractory septic shock in pediatric intensive care unit (PICU). Study Design: Randomized Controlled Trial. Setting: Department of Medicine, The Children’s Hospital, Multan, Pakistan. Period: August 2022 to January 2023. Material & Methods: A total of 156 children aged between 6 months to 12 year presenting to PICU with fluid refractory shock. Children were randomized to either Group-A (epinephrine) or Group-B (dopamine) till end points of resolution of shock was achieved. When the maximum recommended dose of the study drugs was reached, open-label vasoactive was initiated. Frequency of resolution of shock within 1st hour of resuscitation was noted. Results: In a total of 156 children, there were 85 (54.5%) children between 7 to 12 years of age. There were 90 (57.7%) males and 66 (42.3%) females. The efficacy was observed in 41 (52.6%) children in Group-A (epinephrine) versus 18 (23.1%) in Group-B (dopamine), p=0.0001. Conclusion: The epinephrine was more effective than dopamine as first-line vasoactive therapy in fluid-refractory septic shock in children aged 6 months to 12 years presenting in PICU.

Angiotensin II in liver transplantation (AngLT-1): protocol of a randomised, double-blind, placebo-controlled trial

IntroductionCatecholamine vasopressors such as norepinephrine are the standard drugs used to maintain mean arterial pressure during liver transplantation. At high doses, catecholamines may impair organ perfusion. Angiotensin II is a...

Exploring the norepinephrine to angiotensin II conversion ratio in patients with vasodilatory hypotension: A post-hoc analysis of the ARAMIS trial

PurposeAngiotensin II is approved for catecholamine-refractory vasodilatory shock but the conversion dose ratio from norepinephrine to angiotensin II remains unclear. MethodsWe conducted a post-hoc analysis of the Acute Renal effects of Angiotensin II Management in Shock (ARAMIS) trial involving patients with vasodilatory hypotension. We determined the norepinephrine equivalent dose immediately prior to angiotensin II initiation and calculated the conversion dose ratio between norepinephrine and angiotensin II. We performed subgroup analyses based on recent exposure to angiotensin receptor blockers (ARBs) and renin levels at baseline. ResultsIn 37 patients, the median conversion dose ratio between norepinephrine equivalent and angiotensin II was to 10:1 for norepinephrine bitartrate (5:1 for norepinephrine base). The conversion ratio was not affected by the baseline renin, with a median ratio of 10 (7–21) in the high renin group versus 12 (5–22) in the low renin group. Finally, exposure to ARBs prior admission appeared to diminish the conversion ratio with a median ratio of 7 (4–13) in ARB patients vs. 12 (7–22) in non-ARB patients. ConclusionsThe norepinephrine to angiotensin II conversion dose ratio is 10:1 in a vasodilatory hypotension population. These findings can guide clinicians and researchers in the use, dosing, and study of angiotensin II in critical care.