Resistant Hypotension Research Articles

Our Treatment Experience in Poisoning With Calcium Channel Blockers: A Series of Twelve Cases

Background: Intoxications with cardiovascular system drugs constitute a small percentage of all poisoning cases. Calcium Channel Blockers (CCBs) are the most common drug poisoning in this group. Objectives: We aimed to evaluate the effectiveness of treatments for CCB poisoning and add to the current body of literature by outlining the clinical treatments we employ for bradyarrhythmia, hypotension, and resistant vasodilation resulting from CCB poisoning, as well as sharing our clinical insights in this field. Methods: Twelve patients, ranging in age from 1 month to 18 years, were admitted to the Tertiary Paediatric Intensive Care Unit (PICU) for treatment of medication poisoning related to the CCB group. Patients who ingested several drugs that caused CCB were not allowed to participate in the trial. Results: Twelve patients were followed up in the PICU due to poisoning with CCB group drugs. Of the patients, 7 were male and 5 were female. Five of the patients had taken CCB medication with the purpose of committing suicide, and 7 of them accidentally. All of the patients who received CCB to commit suicide had taken verapamil. Five patients whose hypotension and bradycardia continued were administered inotropes. In addition to PI, calcium gluconate, intravenous lipid, glucagon, insulin, bicarbonate, and methylene blue were given as therapy to our symptomatic patients. Plasmapheresis was applied to a patient who was hospitalized in the PICU due to a sudden loss of consciousness. Conclusions: In the management of patients with CCB poisoning, the use of hyperinsulinemia euglycemia, intravenous lipid emulsion treatment, glucagon treatments, and treatments including methylene blue and extracorporeal life support should be considered in cases of resistant hypotension, bradycardia, and coma in the early period.

Acute suppression of the hypothalamo-pituitary-adrenal axis from a large singular dose of dexamethasone: A case report on a hypothesis for resistant intraoperative hypotension.

Acute suppression of the hypothalamo-pituitary-adrenal axis from a large singular dose of dexamethasone: A case report on a hypothesis for resistant intraoperative hypotension.

Vasoplegic Syndrome and Anaesthesia: A Narrative Review.

Vasoplegic syndrome (VS) is defined as low systemic vascular resistance, normal or high cardiac output, and resistant hypotension unresponsive to vasopressor agents and intravenous volume. VS is a frequently encountered complication in cardiovascular and transplantation surgery, burns, trauma, pancreatitis, and sepsis. The basis of the pathophysiology is associated with an imbalance of vasodilator and vasoconstrictive structure in vascular smooth muscle cells and is highly complex. The pathogenesis of VS has several mechanisms, including overproduction of iNO, stimulation of ATP-dependent K+ channels and NF-κB, and vasopressin receptor 1A (V1A-receptor) down-regulation. Available treatments involve volume and inotropes administration, vasopressin, methylene blue, hydroxocobalamin, Ca++, vitamin C, and thiamine, and should also restore vascular tone and improve vasoplegia. Other treatments could include angiotensin II, corticosteroids, NF-κB inhibitor, ATP-dependent K+ channel blocker, indigo carmine, and hyperbaric oxygen therapy. Despite modern advances in treatment, the mortality rate is still 30-50%. It is challenging for an anaesthesiologist to consider this syndrome's diagnosis and manage its treatment. Our review aims to review the diagnosis, predisposing factors, pathophysiology, treatment, and anaesthesia approach of VS during anaesthesia and to suggest a treatment algorithm.

More than meets the eye: a scoping review on the non-medical uses of THZ eye drops

Tetrahydrozoline is an alpha agonist imidazole derivative found in over-the-counter decongestive eye and nasal drops. The drug was patented in 1954 and was available for medical use in 1959. This drug recently gained the attention of law enforcement as it has been utilized in criminal activity such as homicide and drug-facilitated sexual assault. The aim of this scoping review is to scope the literature for all mentions of tetrahydrozoline eye/nasal drops use in a non-medical context to delineate areas of future research and development. We used Google Scholar and PUBMED/Medline databases to search for non-medicinal and criminal uses of THZ. The search word used was “tetrahydrozoline.” A total of 15 articles matched our criteria. Among the case reports, two (11.1%) cases reported on drug-facilitated sexual assault, and two (11.1%) cases used THZ eyedrops to attempt suicide. Incidental ingestion of THZ eyedrops was reported in eight (44.4%) cases, three (16.7%) cases of attempted murder were reported, two (11.1%) cases of intentional ingestion were reported, and one (5.5%) case was a combination of drug-facilitated sexual assault and attempted murder. The most common clinical presentation was unexplained and resistant bradycardia and hypotension. THZ eye drops can be used to produce false negative results on drug tests. This study recognizes that THZ can be used in non-medicinal and criminal uses. There is room for future research and development. More studies should be conducted to better understand the mechanism of action, therapeutic window, and toxicity levels among various age groups at different methods of intake and to find an effective treatment in case of overdose. Eyedrop and nasal decongestant bottles should be designed with child proofing to prevent incidental ingestion and should contain warning labels. A fast and alternative test to GC/MS can be developed to ease the diagnosis of THZ toxicity. Purchases of this medication may need to be monitored.

Rapid Death from Aluminum Phosphide Poisoning

Abstract
 Aluminum phosphite is a chemical used as an insecticide and pesticide to improve the storage conditions of agricultural products. Combined with the humidity in the air or after being taken orally as a tablet, it reacts with the acidic environment of the stomach and turns into phosphine gas and can cause poisoning. Suicidal use is also common. When poisoning develops, deep metabolic acidosis, hypotensive shock, acute respiratory failure, multi-organ failure, cardiac arrest and death may occur. Resistant hypotension and deep metabolic acidosis are the most important indicators of poor prognosis. In this case, an 18 year old male patient was brought to the emergency room after taking 3 tablets of aluminum phosphide. The patient was unconscious and had hypotensive shock. Despite gastric lavage, massive fluid replacement, positive inotropes, sodium bicarbonate, intravenous N acetyl cysteine loading, and hemodialysis, the patient died 6 hours after admission to the emergency department.

Primary adrenal insufficiency and myocarditis in COVID-19 disease: a case report

BackgroundCOVID-19 has different manifestations from respiratory to GI problems, and some of them are more common, but some are rare. Reporting rare cases can significantly advance our understanding of the disease.Case presentationIn this case, we report an 18-year-old teenage boy with chest pain and resistant hypotension following COVID-19 infection, finally diagnosed as primary adrenal insufficiency and COVID-19 myocarditis.ConclusionAdrenal insufficiency can be life-threatening due to its adverse effects on hemodynamic and electrolyte equilibrium. In addition, COVID-19 induced myocarditis can make the situation more complicated.

ODP472 Creation of the Anaplastic Care Team (ACT) protocol: Establishing a Benchmark for Timely Access to Care for Anaplastic Thyroid Cancer Patients

Abstract Introduction Novel Coronavirus 19 (COVID19) has been shown to involve multiple organs. Its reported effects on the endocrine system have been via subacute thyroiditis, functional hypopituitarism, and triggering type 1 diabetes with ketosis. We describe a case of COVID19 infection presenting as adrenal insufficiency. Case A 35-year-old female with a history of developmental delay, anxiety, and hypothyroidism presented to the emergency department (ED) from her group home with complaints of abdominal pain and 2-3 episodes of nausea and vomiting per day for one week. She denied any changes in bowel habits, chest pain, shortness of breath. On physical examination, there was mild diffuse abdominal tenderness without any skin hyperpigmentation. In the ED, her vitals showed blood pressure 99/56, heart rate 94, respiratory rate 23, saturating at 100% on room air. Laboratory tests were remarkable for hyponatremia (sodium 123), hypokalemia (potassium 1.9), hypochloremia (chloride 88), hypophosphatemia (phosphorus 2), metabolic acidosis with bicarbonate of 14. Her COVID19 test was positive. She was admitted to the intensive care unit as her blood pressure continued to drop to as low as 76/37. Potassium, phosphorus was replaced, and normal saline infusion was started at 75ml/hr with minimal improvement in blood pressure to 94/53 and sodium to 126 in 24 hours. Urine electrolytes showed sodium <15, making SIADH less likely. On day 3, we suspected adrenal insufficiency due to persistent hypotension. Results showed am cortisol of 1 and ACTH of 10. ACTH stimulation test was unable to be done. She was started on hydrocortisone which improved her blood pressure as well as electrolytes. CT abdomen showed no adrenal abnormality. She was able to be tapered off the steroids in 2 weeks. Conclusion COVID19 associated hypocortisolism presents both as primary and transient secondary adrenal insufficiency (via suppression of the hypothalamic-pituitary-adrenal axis, like in our case). Similar reversible hypocortisolism post-SARS infection was observed in 24 of 61 patients (39.3%) during the 2005 outbreak. Autopsy studies on patients with COVID19 showed adrenal necroptosis of the adrenal cortex. Although critical illness-related cortical insufficiency is not a new concept, the cortisol levels in COVID19 critically ill patients have been shown to be lower than non-COVID19 critically ill patients. Prompt addition of stress dose steroids can be lifesaving in critically ill COVID patients, especially when associated with resistant hypotension. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

A Term Neonate with Multiorgan Dysfunction, Severe Metabolic Acidosis, and Hyperkalemia.

A Term Neonate with Multiorgan Dysfunction, Severe Metabolic Acidosis, and Hyperkalemia.

Midodrine Is an Effective Therapy for Resistant Intradialytic Hypotension: CON.

This is an Early Access article. Please select the PDF button, above, to view it. Be sure to also read the PRO: 10.34067/KID.0007432021 and the COMMENTARY: 10.34067/KID.0007442021

Midodrine Is an Effective Therapy for Resistant Intradialytic Hypotension: COMMENTARY.

This is an Early Access article. Please select the PDF button, above, to view it. Be sure to also read the PRO: 10.34067/KID.0007432021 and the CON: 10.34067/KID.0007422021

Midodrine Is an Effective Therapy for Resistant Intradialytic Hypotension: PRO.

This is an Early Access article. Please select the PDF button, above, to view it. Be sure to also read the CON: 10.34067/KID.0007422021 and the COMMENTARY: 10.34067/KID.0007442021

Impact of Vasoplegic Syndrome on Early Clinical Outcome After Orthotopic Heart Transplantation

<h3>Purpose</h3> Vasoplegic syndrome (VS) is a possible complication after cardiac surgery using cardiopulmonary bypass (CPB) and is mainly characterized by a loss of systemic resistance leading to refractory hypotension and inadequate peripheral tissue perfusion. The objective of this retrospective study is to determine the impact of VS on short- and long-term morbidity and mortality after heart transplantation (OHT). <h3>Methods</h3> We retrospectively reviewed data of 156 consecutive adult patients who underwent OHT at our center between 2010 and 2021. VS was defined as persistent low systemic vascular resistance (<800 dynes/s/cm⁵) with preserved cardiac index (>2.5 L/min/m²) and catecholamine resistant hypotension despite intravenous vasopressors at a high dose (>0.2μg/kg/min norepinephrine) within the first 6-24 hours after surgery. Patients were divided into two groups classified by the presence or absence of vasoplegia. <h3>Results</h3> The incidence of VS was 11.5% (18 patients) with comparable donor and recipient characteristics in both groups. The mean age of vasoplegic patients was 51±10 (vs. 50±12) years and 88.9 % (vs.71.0%) were male. 61.6% (vs. 48.1%) had a history of prior cardiac surgery of which 44.4 % (vs. 28.1%) were implantations of left ventricular assist devices. Vasoplegic patients showed increased lactate levels at the end of CPB (9.0±5.3 vs. 4.9±3.1 mmol/L, p<.001) and higher rate of reoperation for bleeding (55,6% vs. 15.2% p<.001). Of the 18 vasoplegic patients, five patients (27.8%) received immediate mechanical circulatory support (MCS) at the end of CPB for a mean of 5±2.7 days, six patients (33.3%) received delayed MCS after a mean of 7.8±5.7 hours postoperatively for 6.1±4.6 days and seven patients (38.9%) were treated without MCS. 30-day survival rates were 100 % in patients receiving immediate MCS, 50% in patients with delayed MCS and 71.4% in patients without MCS, respectively. Overall 30-day survival rate was lower in vasoplegic patients (72.2% vs 94.9%, p<.001). If patients survived the first 30 days there was no significant difference in 1-year survival (92.3 % vs 90.2%). <h3>Conclusion</h3> Vasoplegic syndrome following heart transplantation was associated with increased perioperative 30-day mortality. Early MCS implantation seemed to be beneficial for short-term survival. Vasoplegic patients surviving the first 30 days had a comparable and good long-term outcome.

Use of Remdesivir in the treatment of Coronavirus Disease 2019 (COVID-19) infection among Sudanese patients: a case series

Introduction: The coronavirus disease 2019 (COVID-19) pandemic is affecting populations worldwide. Remdesivir is an anti-retroviral agent, with a broad spectrum of usage. Remdesivir usage against COVID-19 had been studied both in vitro and in vivo but is still considered a new treatment for COVID-19 and is not available in all countries. The aim of our study was to report several cases of the use of Remdesivir in Sudanese patients and report the adverse events related to the course of treatment. Methods: A case series study was conducted in Imperial Hospital, Khartoum, Sudan reporting two cases who received Remdesivir for treating COVID-19 besides other treatments such as steroids and supportive therapy in December 2020. Cases were males aged over 65 years. Cases presentation: Both patients were severe cases of COVID-19 admitted to the intensive care unit (ICU), who received Remdesivir for treating COVID-19 infection. Several side effects were reported: the first case had increased liver enzymes and then unexpectedly died from severe resistant hypotension; and hypoalbuminemia was noticed in the second case. Conclusions: Remdesivir use among patients in Sudan must be studied extensively in order to determine the unexpected fatal event and assess the association of this event to Remdesivir use, as well as to report the frequency of the side effects.

Treatment via oral midodrine in a patient with prolonged hypotension following carotid artery stenting: a case report

BackgroundHypotension and bradycardia are common hemodynamic complications following carotid artery stenting in patients with carotid artery stenosis. Intravenous fluid resuscitation and inotropes such as dopamine are conventional treatments for post-carotid artery stenting hypotension. However, in case of resistant hypotension, there is no clear treatment method. In this report, while intravenous fluid and inotropes did not resolve the patient’s hypotension, oral midodrine treated post-carotid artery stenting hypotension.Case presentationIn this report, we present an 82-year-old Caucasian man complaining of a single episode of unilateral visual loss. The patient had left internal carotid artery stenosis and underwent carotid artery stenting. After the procedure, he developed prolonged post-carotid artery stenting hypotension, which was resistant to intravenous fluids and inotropes but immediately showed a promising response to oral midodrine.ConclusionOral midodrine can be considered in treatment of post-carotid artery stenting hemodynamic complications.

Novel Treatments Targeting the Dysregulated Cell Signaling Pathway during Sepsis

Previously characterized as a purely immune mediated disease, sepsis is now recognized as a dysregulated multisystem response against a pathogen. Recognition of the infectious agent by pathogen recognition receptors (PRRs) can initiate activation of the NF-κB signaling pathway and promote the secretion of proinflammatory cytokines. During sepsis, the activation of NF-κB is dysregulated and results in cytokine storm, or the pathologic release of cytokines. Current treatments for sepsis rely on broad spectrum antimicrobial medications and fluid replacement therapy, to neutralize the inciting pathogen and maintain adequate blood pressure. The addition of vasopressor therapy is also utilized when sepsis progresses to septic shock, which is defined by treatment resistant hypotension. Even though modern treatment guidelines have improved clinical outcomes, the mortality rate of sepsis and septic shock is still 15-20% and 20-50%, respectively. To reduce mortality, recent sepsis treatment research has focused on investigating novel therapeutics that can attenuate the dysregulated NF-κB signaling pathway. Antioxidants, such as Retinoic acid and Oxytocin, can reduce activation of the NF-κB pathway by neutralizing stimulatory reactive oxygen species (ROS). Likewise, anti-inflammatory agents can also affect the NF-κB pathway by decreasing the secretion of proinflammatory cytokines, such as TNFα and IL-6. Novel anti-inflammatory cytokines, such as IL-37 and IL-38, have recently been characterized and shown to reduce inflammation in mice with bacterial sepsis. Separately, antioxidants and anti-inflammatory cytokines show promise as potential therapies for sepsis, however, a combined therapy including both agents may prove more beneficial in further improving clinical outcomes.

Life-Threatening Amlodipine Over Dose Requiring ECMO Support Treated by High-Cut-Off Dialysis and Cytosorb

Calcium Channel Blockers (CCBs) may cause profound vasopressor resistant hypotension in case of intoxication. Recently, the EXTRIP workgroup recommended against the use of Extra Corporeal Treatment Modalities (ECTM) for the elimination of amlodipine. Anecdotal evidence suggests that Veno-Arterial Extra Corporeal Membrane Oxygenation (VA-ECMO) may be beneficial in patients with severe shock due to amlodipine intoxication. We report a case of severe amlodipine poisoning (total amlodipine intake 625 mg), in which we used awake-VA- ECMO support for hemodynamic stabilization. A combination of a HCO dialyzer and the Cytosorb® adsorber was used to eliminate amlodipine in two consecutive treatment sessions. Amlodipine dialyzer clearance and Cytosorb® adsorber clearance were 13.8 (-2,3–20.4) mL/min and 17.5 (9.6–25.6) mL/min, respectively. Clearance levels varied depending on drug plasma levels. During this treatment, initial amlodipine levels fell by 48% and 15% with a total eliminated amount of 242 and 352 μg of amlodipine, respectively, in the dialysate. EXTRIP criteria for dialyzability could not be met by the investigated modalities. ECMO therapy was discontinued after three days and the patient fully recovered. In conclusion, VA-ECMO support can be used for hemodynamic stabilization of patients with severe amlodipine poisoning, while the extracorporeal elimination techniques used in this setting were unable to remove a meaningful amount of drug.

Varis ve Tanı Konulmamış Beyin Tümörü Olan Hastanın Anestezi Yönetimi

Intraoperative hemodynamic perturbations are common due to the effects of anesthetic medications and techniques, surgical manipulations, and the patient's medical comorbidities. But Intraoperative intractable hypotension is very rare and serious in young healthy patients. The case of a 36 year old American Society of Anesthesiologists (ASA) risk class I patient who developed intractable hypotension during varicose vein operation was presented and discussed in association with the relevant literature. The adverse effects of transient foam embolism and / or due to the contribution of anesthesia to autonomic disorders secondary to the brain tumor may result in resistant hypotension in the patient. The magnitude of preoperative evaluation in anesthesia practice is indisputable, fine details during anamnesis should be taken into consideration.

The Need for a Physiological Classification of Hemorrhagic Shock.

Classifications mean to conceptualize in a cluster and rapidly summarize the assessment and management of a clinical scenario. In the specific case of a hemorrhagic shock (HS), a classification should serve the purpose of allowing a rapid clinical assessment of the shock level and the earliest or right timing of source control, possibly also on whether to apply damage control surgery (DCS) strategy or not. ATLS® classification of HS is not sensitive and specific enough to help decision-making in reference to the timing of management, based only on the amount of blood loss that may be or may not rightly estimated, for example, blood loss on the floor in penetrating injuries before theatre. Moreover, it focuses also on other parameters, which are taken singularly, instead of the individual generalized physiological response to hemorrhage, which is the core by definition of the derangement we call “shock.” It is unhelpful, difficult, and impractical to apply as well. A new classification, which may well be called as the “physiological HS classification” or “therapeutic HS classification,” was proposed since 2010, following the new developments on microcirculation and an already going-on sensible praxis among some trauma surgeons. It bases on some physiological considerations such as the significance of fluid-blood resistant hypotension, body natural hemostatic mechanisms, the right definition of shock, and the relevance that hemorrhage-triggered ischemia-reperfusion toxemia and systemic inflammatory response have in critical illness scenarios as secondary insults from ischemia, which is what we mean to prevented with DCS. The key factor remains the persistence of hypotension, following fluid challenge.

Is Bilateral Facial Paralysis an Indicator of Respiratory Outcome in Guillain-Barré Syndrome?

Background and objectives: Bilateral facial paralysis is a rare and specific clinical manifestation of various neurological disorders. Bilateral facial paralysis has been reported as an essential feature of Guillain–Barré syndrome (GBS) for many years. We aim to describe the incidence of bilateral facial paralysis and prognosis in our GBS patients. Materials and Methods: A retrospective chart review of all patients with GBS and bilateral facial paralysis who were treated at the Inönü University Medical Faculty was performed. Results: A total of 45 cases of GBS were reviewed. Four out of 45 patients (8.8%) had associated bilateral facial paralysis. Only one of the patients also had acute multiple cranial neuropathies. All patients experienced sudden deterioration and respiratory distress. In one of our patients who had multiple cranial neuropathies, serum antiganglioside antibody assay was performed, and anti-GQ1b IgG antibody positivity was observed. The cerebrospinal fluid had albuminocytological dissociation in all patients, and axonal involvement was present in nerve conduction studies (NCS). Three patients improved with immunotherapy; one patient died due to cardiac arrest after resistant hypotension. Conclusion: Bilateral facial paralysis is a rare condition in children. We wanted to emphasize bilateral facial involvement and poor prognosis in our GBS patients.

Aluminum Phosphide Poisoning: A Rare Presentation

Aluminum phosphide (ALP) is extremely lethal and invariably suicidal in nature.1 It is a major cause of suicidal poisoning in many countries.2, 3 Toxicity by ALP is caused by the liberation of phosphine gas, which causes cell hypoxia due to inhibition of oxidative phosphorylation leading to circulatory failure.3 Treatment of ALP toxicity is mainly supportive as there is no specific antidote. Mortality with ALP poisoning is very high, ranging from 37% to 100%.4, 5 A 40-year-old female was admitted to R.L Jalappa hospital kolar with complaints of nausea, vomiting and epigastric pain h/o after ingestion of 7 to 8 tablets of unknown composition and 20 tablets of cetrizine. She had a history of bronchial asthma. On arrival, she was alert and hemodynamic status with pulse rate of 130 beats/min and blood pressure 110/70 mm/hg. There was not any abdominal tenderness or guarding, no cyanosis, jaundice or edema of feet. Gastric lavage initiated, but after 2 hour her condition deteriorated with cardio toxicity, resistant hypotension, tachycardia, epigastric pain, generalized tonic-clonic seizure (GTCS), Arterial blood gas (ABG) showed severe metabolic acidosis. Electrocardiogram (ECG) showed extensive inferolateral ST elevation myocardial infarction (STEMI). After few hours of admission, rhythm became ventricular fibrillation (VF) and cardiopulmonary resuscitation (CPR) began but it was unsuccessful. As aluminum phosphide poisoning leads to fatal condition, early diagnosis and proper management is warranted, this can be reduce the morbidity and mortality. But sometimes early diagnosis may not save the victim as in our case. We present a case wherein the victim succumbed to death due to acute respiratory failure and bleeding diathesis following consumption of aluminum phosphide.