Refractory Shock Research Articles

BETA BLOCKER AND CALCIUM CHANNEL BLOCKER OVERDOSE COMPLICATED BY COVID-19 PNEUMONIA AND RENAL FAILURE IN A PATIENT WITH SEVERE OBESITY

BETA BLOCKER AND CALCIUM CHANNEL BLOCKER OVERDOSE COMPLICATED BY COVID-19 PNEUMONIA AND RENAL FAILURE IN A PATIENT WITH SEVERE OBESITY

SEVERE COVID-19 COMPLICATED WITH HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS: A CASE REPORT

SEVERE COVID-19 COMPLICATED WITH HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS: A CASE REPORT

WHEN TREATING ACNE GOES WRONG: A CASE OF BACTRIM-INDUCED ARDS IN A HEALTHY YOUNG WOMAN

WHEN TREATING ACNE GOES WRONG: A CASE OF BACTRIM-INDUCED ARDS IN A HEALTHY YOUNG WOMAN

POST-TRANSPLANT BRONCHIAL STENOSIS: A SINGLE CENTER RETROSPECTIVE STUDY

POST-TRANSPLANT BRONCHIAL STENOSIS: A SINGLE CENTER RETROSPECTIVE STUDY

VACCINE-INDUCED ANTIBODY DEPENDENT ENHANCEMENT IN COVID-19

VACCINE-INDUCED ANTIBODY DEPENDENT ENHANCEMENT IN COVID-19

HIDING IN PLAIN SIGHT: DISSEMINATED PULMONARY TB

HIDING IN PLAIN SIGHT: DISSEMINATED PULMONARY TB

SHOCK FROM NADOLOL OVERDOSE: THE FIRST REPORTED CASE OF SUCCESSFULLY TREATED WITH CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT)

SHOCK FROM NADOLOL OVERDOSE: THE FIRST REPORTED CASE OF SUCCESSFULLY TREATED WITH CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT)

A fatal outcome following complications of multiple blind attempts of removal of a displaced intrauterine device: A case report

Background: Intrauterine devices (IUDs) are long-acting reversible contraceptives that are widely used due to their effectiveness and safety profile. Complications associated with IUD insertion or removal are rare but can be fatal. Case presentation: A 36-year-old para 3+0 presented to the accident and emergency department with per vaginal bleeding and signs of an acute abdomen following three failed attempts to remove an IUD inserted two weeks prior. Ultrasound imaging revealed marked hemoperitoneum, and an IUD embedded in the left ovary. An exploratory laparotomy revealed that the IUD was embedded on the left ovary with multiple perforations on the uterus and ileum. The IUD was removed, and the perforations were repaired. Her condition deteriorated and she succumbed to refractory septic shock two days later. Conclusion: The presented patient succumbed to complications resulting from injuries caused by an IUD. Blind procedures to remove displaced IUDs should be avoided especially where previous attempts have failed.

Extracorporeal Membrane Oxygenation for COVID-19: Collaborative Experience From the Texas Medical Center in Houston With 2 Years Follow-Up.

Patients with severe refractory hypoxemic respiratory failure may benefit from extracorporeal membrane oxygenation (ECMO) for salvage therapy. The Coronavirus disease 2019 (COVID-19) pandemic offered three high-volume independent ECMO programs at a large medical center the chance to collaborate to optimize ECMO care at the beginning of the pandemic in Spring 2020. Between March 15, 2020, and May 30, 2020, 3,615 inpatients with COVID-19 were treated at the Texas Medical Center. During this time, 35 COVID-19 patients were cannulated for ECMO, all but one in a veno-venous configuration. At hospital discharge, 23 (66%) of the 35 patients were alive. Twelve patients died of vasodilatory shock (n = 9), intracranial hemorrhage (n = 2), and cannulation-related bleeding and multiorgan dysfunction (n = 1). The average duration of ECMO was 13.6 days in survivors and 25.0 days in nonsurvivors ( p < 0.04). At 1 year follow-up, all 23 discharged patients were still alive, making the 1 year survival rate 66% (23/35). At 2 years follow-up, the overall rate of survival was 63% (22/35). Of those patients who survived 2 years, all were at home and alive and well at follow-up.

P294 A descriptive study of Trichosporon fungemia cases from tertiary care center from north India

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PMObjectiveIncidence of fungaemia with Trichosporon spp is increasing especially in immunocompromised patients. High mortality of 60% is associated with T. fungemia. Trichosporon species are intrinsically resistant to echinocandins, exhibit high MICs to amphotericin B, and have a propensity to form biofilm necessitating accurate and timely diagnosis. Cases of Trichosporon fungemia are often misdiagnosed and under-reported owing to the difficulties in diagnosis. Here, we report the clinical presentation and outcome of Trichosporon fungemia cases at the tertiary care center from north India.MethodsThis is a descriptive study conducted at the Department of Medical Microbiology, PGIMER, Chandigarh, India. A total of 8 patients who had fungemia due to Trichosporon spp. were included in the study. Trichosporon spp. was identified by matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) with an updated database. Antifungal susceptibility was done using microbroth dilution method recommended by the Clinical and Laboratory Standards Institute (CLSI). Beta-D-glucan (BDG) assay was performed as per the manufacturer's recommendation. Demographic and clinical data along with treatment outcomes of all the patients were noted from medical records.ResultsThe average age of presentation of patients diagnosed with Trichosporon fungemia was 44 years and the male to female ratio was 5:3. The underlying conditions included necrotizing pancreatitis (n = 2), infective endocarditis (n = 2) and renal transplant (n = 1) The other risk factors included the use of broad-spectrum antibiotics (n = 7), a central venous catheter (n = 4), and prior surgical procedures (n = 3) BDG was tested in 5 patients and 4 patients had a positive value of >80 pg/ml. A total of 5/8 patients received antifungal treatment. Six patients clinically improved and were discharged while two patients died of refractory shock despite treatment with amphotericin B. Minimum inhibitory concentration of Trichosporon isolates was (range): amphotericin B 0.5-16 μg/ml, fluconazole 0.12-32 μg/ml, voriconazole 0.03-1 μg/ml, itraconazole 0.03-1 μg/ml, and posaconazole 0.03-0.5 μg/ml.Conclusion Trichosporon spp. is an opportunistic pathogen causing fungemia in immunocompromised patients. Most of the patients in our study were immunocompetent except for one post-transplant patient. BDG helps in the diagnosis of this infection. This study highlights the need to accurately diagnose Trichosporon infections and perform antifungal susceptibility testing for guiding appropriate management and reducing mortality.

Refractory Anaphylactic Shock Requiring Emergent Venoarterial Extracorporeal Membrane Oxygenation in the Emergency Department: A Case Report

Venoarterial extracorporeal membrane oxygenation is a viable salvage intervention for patients who experience cardiopulmonary arrest or profound shock from any cause. Acute anaphylactic shock is a rare cause of cardiac arrest. We present a case of a 35-year-old male who experienced cardiac arrest owing to anaphylactic shock while receiving general anesthesia for a routine outpatient surgical procedure. Traditional advanced cardiac life support therapies were provided by paramedics en route to the emergency department of a suburban, community-based hospital. Maximal medical management including endotracheal intubation, intravenous steroids, intravenous crystalloid fluid administration, intravenous vasoactive medications, and high-quality cardiopulmonary resuscitation was provided. Although return of spontaneous circulation was achieved, profound cardiogenic shock persisted. Venoarterial extracorporeal membrane oxygenation was initiated by the emergency department provider and nursing team. The patient survived, was neurologically intact, had full recovery, and was discharged home several days later. We have extensive experience with venoarterial extracorporeal membrane oxygenation, and this case exemplifies the value of an established emergency department extracorporeal membrane oxygenation program in managing all causes of cardiac arrest or refractory shock.

Effect of Hemadsorption Therapy in Critically Ill Patients with COVID-19 (CYTOCOV-19): A Prospective Randomized Controlled Pilot Trial

Introduction: Immunomodulatory therapies have shown beneficial effects in patients with severe COVID-19. Patients with hypercytokinemia might benefit from the removal of inflammatory mediators via hemadsorption. Methods: Single-center prospective randomized trial at the University Medical Center Hamburg-Eppendorf (Germany). Patients with confirmed COVID-19, refractory shock (norepinephrine ≥0.2 µg/kg/min to maintain a mean arterial pressure ≥65 mm Hg), interleukin-6 (IL-6) ≥500 ng/L, and an indication for renal replacement therapy or extracorporeal membrane oxygenation were included. Patients received either hemadsorption therapy (HT) or standard medical therapy (SMT). For HT, a CytoSorb® adsorber was used for up to 5 days and was replaced every 18–24 h. The primary endpoint was sustained hemodynamic improvement (norepinephrine ≤0.05 µg/kg/min ≥24 h). Results: Of 242 screened patients, 24 were randomized and assigned to either HT (N = 12) or SMT (N = 12). Both groups had similar severity as assessed by SAPS II (median 75 points HT group vs. 79 SMT group, p = 0.590) and SOFA (17 vs. 16, p = 0.551). Median IL-6 levels were 2,269 (IQR 948–3,679) and 3,747 (1,301–5,415) ng/L in the HT and SMT groups at baseline, respectively (p = 0.378). Shock resolution (primary endpoint) was reached in 33% (4/12) versus 17% (2/12) in the HT and SMT groups, respectively (p = 0.640). Twenty-eight-day mortality was 58% (7/12) in the HT compared to 67% (8/12) in the SMT group (p = 1.0). During the treatment period of 5 days, 6/12 (50%) of the SMT patients died, in contrast to 1/12 (8%) in the HT group. Conclusion: HT was associated with a non-significant trend toward clinical improvement within the intervention period. In selected patients, HT might be an option for stabilization before transfer and further therapeutic decisions. This finding warrants further investigation in larger trials.

Iatrogenic Bowel Traversal during Percutaneous Drainage Catheter Placement: A Single-Center Retrospective Review of 3,507 Procedures

AbstractImage-guided drainage catheter placement is a commonly performed procedure. While the complication rate is low, one potential complication is iatrogenic bowel traversal (IBT). Prior literature reported up to a 3.0% incidence of IBT events. This retrospective review examined image-guided percutaneous abscess catheter placements over 82 months to characterize the incidence, risk factors, and outcomes of IBT. Of 3,507 catheters placed, there were 13 IBT events, conferring a 0.4% incidence. Rates of IBT were similar whether ultrasound and fluoroscopy or computed tomography was utilized for placement. Of these 13 IBT events, 2 were transgastric, 1 was transcolonic, and 10 were through small bowel. Of these events, one patient died of vasopressor refractory septic shock, four underwent operative repair of the enterotomy, and eight were managed with catheter placement and gradual downsizing. The Society of Interventional Radiology Adverse Event Severity Scale was utilized to further categorize IBT events with observed severity ranging from moderate to life threatening. Although overall incidence has decreased since 35 years ago, IBT events are potentially life-threatening adverse events and further study to identify and minimize risk factors is essential.

High-Dose Hydroxocobalamin for Refractory Vasoplegia Post Cardiac Surgery.

Administration of high-dose hydroxocobalamin, or vitamin B12, is an emerging, targeted rescue therapy for the treatment of refractory vasoplegic shock. This is an uncommon but potentially life-threatening complication following cardiac surgery and carries a poor prognosis, particularly when patients fail to respond to first-line therapy with catecholamine vasopressors. This study describes our experience in treating refractory vasodilatory shock following cardiac surgery with high-dose hydroxocobalamin. Administration of hydroxocobalamin in seven patients was associated with an improvement in mean arterial blood pressure or reduction in vasopressor requirements, which were both immediate and sustained throughout our observational period. No deaths or adverse effects attributable to hydroxocobalamin administration occurred in our cohort. Our observations show that high-dose hydroxocobalamin is a safe and effective rescue therapy in refractory vasoplegic shock post cardiopulmonary bypass (CPB).

Effect of milrinone versus placebo on hemodynamic in patients with septic shock: A randomize control trial

Background: Sepsis is one of the most serious healthcare problems worldwide, which is associated with high mortality and financial burdens. The common causes of death are refractory shock and multi-organ failure. Myocardial dysfunction, a relatively common complication of septic shock, causes a significantly decrease in stroke volume and cardiac output. This results in insufficient blood supply to the organs, creates multi-organ failure and finally, leading to death. The Surviving Sepsis Campaign Guidelines 2016 also recommended using dobutamine in septic shock patients who had been resuscitated until achieving normal blood pressure target of mean arterial pressure 65 mmHg or more, but still had evidence of inadequate tissue perfusion. Milrinone action via an alternative pathway from the sympathetic inotropic agents, makes the milrinone to be used as an option for improve cardiac function among sepsis patients. However, there are few studies of milrinone in patients with septic shock. Methods: We plan to conduct a double blind randomized controlled trial, enrolling patients at Siriraj hospital and Hat-Yai hospital. The adults with the diagnosis of septic shock according to definition of SEPSIS III will be screened. Patients who receive fluid resuscitation at least 30 mL/kg, mean arterial pressure (MAP) ≥ 65 mmHg, with a clinical sign of poor tissue perfusion, or evidence of impaired left ventricular systolic function (left ventricular ejection fraction (LVEF) &lt; 40%) will be enrolled. The patients were randomly assigned in a 1:1 ratio by their sequential number to receive either milrinone (intervention group) or placebo (control group). The physician performs an echocardiogram for assessing cardiac function, before the starting of the study drug and after the 6 and 24 hours. The monitoring of vital signs, urine output, and lactate at 6 and 24 hours after milrinone or placebo commencement is recorded. Conclusion: This study will evaluate the efficacy of milrinone in improving cardiac output among adult patients with septic shock who is resuscitated to achieve target blood pressure but still have signs of poor tissue perfusion.

Dexmedetomidine to reduce vasopressor resistance in refractory septic shock: Protocol for a double-blind randomized controlled pilot trial (ADRESS Pilot study).

IntroductionRefractory septic shock (RSS) is characterized by high vasopressor requirements, as a consequence of vasopressor resistance, which may be caused or enhanced by sympathetic hyperactivation. Experimental models and clinical trials show a reduction in vasopressor requirements and improved microcirculation compared to conventional sedation. Dexmedetomidine did not reduce mortality in clinical trials, but few septic shock patients were enrolled. This pilot trial aims to evaluate vasopressor re-sensitization with dexmedetomidine and assess the effect size, in order to design a larger trial.MethodsThis is an investigator-initiated, multicenter, randomized, double-blind, placebo-controlled trial, comparing dexmedetomidine versus placebo in RSS patients with norepinephrine dose ≥0.5μg/kg/min. The primary outcome is blood pressure response to phenylephrine challenge, 6 hours after completion of a first challenge, after study treatment initiation. Secondary outcomes include feasibility and safety outcomes (bradycardia), mortality, vasopressor requirements, heart rate variability, plasma and urine catecholamines levels. The sample size is estimated at 32 patients to show a 20% improvement in blood pressure response to phenylephrine. Randomization (1:1) will be stratified by center, sedation type and presence of liver cirrhosis. Blood pressure and ECG will be continuously recorded for the first 24 h, enabling high-quality data collection for the primary and secondary endpoints. The study was approved by the ethics committee “Sud-Est VI” (2019-000726-22) and patients will be included after informed consent.DiscussionThe present study will be the first randomized trial to specifically address the hemodynamic effects of dexmedetomidine in patients with septic shock. We implement a high-quality process for data acquisition and recording in the first 24 h, ensuring maximal quality for the evaluation of both efficacy and safety outcomes, as well as transparency of results. The results of the study will be used to elaborate a full-scale randomized controlled trial with mortality as primary outcome in RSS patients.Trial registrationRegistered with ClinicalTrials.gov (NCT03953677). Registered 16 May 2019, https://clinicaltrials.gov/ct2/show/NCT03953677.

The pharmacotherapeutic options in patients with catecholamine-resistant vasodilatory shock

Introduction Septic and vasoplegic shock are common types of vasodilatory shock (VS) with high mortality. After fluid resuscitation and the use of catecholamine-mediated vasopressors (CMV), vasopressin, angiotensin II, methylene blue (MB) and hydroxocobalamin can be added to maintain blood pressure. Areas covered VS treatment utilizes a phased approach with secondary vasopressors added to vasopressor agents to maintain an acceptable mean arterial pressure (MAP). This review covers additional vasopressors and adjunctive therapies used when fluid and catecholamine-mediated vasopressors fail to maintain target MAP. Expert opinion Evidence supporting additional vasopressor agents in catecholamine resistant VS is limited to case reports, series, and a few randomized control trials (RCTs) to guide recommendations. Vasopressin is the most common agent added next when MAPs are not adequately supported with CMV. VS patients failing fluids and vasopressors with cardiomyopathy may have cardiotonic agents such as dobutamine or milrinone added before or after vasopressin. Angiotensin II, another class of vasopressor is used in VS to maintain adequate MAP. MB and/or hydoxocobalamin, vitamin C, thiamine and corticosteroids are adjunctive therapies used in refractory VS. More RCTs are needed to confirm the utility of these drugs, at what doses, which combinations and in what order they should be given.

Pseudoshock: A Challenging Presentation of Bilateral Subclavian Artery Stenosis.

IntroductionSubclavian artery stenosis (SAS) is a manifestation of peripheral artery disease (PAD). Presentation varies, ranging from arm claudication and muscle fatigue to symptoms which reflect vertebrobasilar hypoperfusion, among which are syncope, ataxia and dysphagia. Although rare, severe bilateral SAS can exist and present as refractory hypotension. We describe a case of bilateral SAS masquerading as circulatory shock, or rather ‘pseudoshock’.Case DescriptionA 59-year-old female patient presented to the emergency department with complaints of dark stools. She was anaemic and hypotensive and therefore suspected to have an acute gastrointestinal bleed (GIB) with resultant haemorrhagic shock. Her hypotension was unresponsive to fluid resuscitation and blood transfusions. Bilateral upper extremity radial artery catheters confirmed low blood pressures. After her blood pressure failed to improve despite the addition of several vasopressors, a femoral artery catheter (FAC) was placed, which revealed significant hypertension discordant with the hypotension measured by the radial artery catheters. Review of CT angiography of the upper extremities revealed the presence of bilateral SAS which was deemed to be the aetiology of the falsely low blood pressure.DiscussionSAS should be suspected in patients with lower extremity PAD or a blood pressure (BP) differential of 15 mmHg or more between arms. When bilateral subclavian arteries are stenosed, this difference in BP may be concealed, making lower extremity BP measurements, as seen in non-invasive tests such as ankle brachial index (ABI) tests or through more invasive procedures such as FAC placement, critically important.ConclusionBilateral SAS may present as pseudo-hypotension. In cases of refractory shock of unclear aetiology, especially in patients with known PAD, a high index of suspicion is warranted for ‘pseudoshock’ secondary to severe vascular stenosis. Comparison of upper and lower extremity BP via invasive arterial catheters or non-invasive ABI tests can aid in the diagnosis of bilateral SAS.LEARNING POINTSBilateral subclavian artery stenosis (SAS) may present as pseudo-hypotension and shock of unclear aetiology.In patients with underlying peripheral arterial disease, pseudoshock should be considered in the differential diagnosis.Comparison of upper and lower extremity blood pressure via invasive arterial catheters or the non-invasive ankle brachial index (ABI) test has diagnostic value for bilateral SAS.Pseudoshock is managed via secondary prevention with antiplatelets and statins for asymptomatic patients, and revascularization for symptomatic patients.

Evaluation of vasopressin use in the management of refractory shock in patients admitted to the intensive care unit

Refractory shock is characterized by hemodynamic instability unresponsive to norepinephrine with a high mortality rate. As there are still doubts regarding the pharmacological benefit of the vasopressin addition, this retrospective study aimed to assess the profile of vasopressin use in the intensive care unit of a university hospital in Paraná, Brazil. The information collected was obtained through the analysis of electronic medical records. 73 patients with refractory shock, mainly of septic etiology (61.6%), were included. The dose (μg/Kg/minute) and duration of norepinephrine, upon finding refractoriness, was 35.6% infusion &lt; 1, 34, 3% of 1-1.9, 30.1% &gt; 2 and mean time of 1.5 days. High mortality (80.8%) was observed, with a mean hospital stay of 8.2 days. Median survival after vasopressin infusion was 4.5 days until the unfavorable outcome. Still, 80.5% of patients used other adjuvant therapy, 71.2% being corticotherapy and 9.6% dobutamine. Due to the great variability, it was not possible to define a pattern of use. There were limitations in the analysis due to the lack of clinical and prognostic information. However, the need for deepening scientific discussions and continuous updating of protocols that guide management is highlighted.

Use of vasopressors for treatment of vasodilatory hypotension in dogs and cats by Diplomates of the American College of Veterinary Emergency and Critical Care.

To identify the most common practices of Diplomates of the American College of Veterinary Emergency and Critical Care (DACVECCs) as they relate to the recognition and treatment of hypotension in dogs and cats, particularly concerning the use of vasopressors in vasodilatory shock states. A survey regarding vasopressor use was sent to all active DACVECCs using the Veterinary Information Network. Questions focused on respondent characteristics, method of recognition of hypotension, triggers for initiation of vasopressor therapy, first- and second-line vasopressor choice, and methods of determining response to therapy. A total of 734 DACVECCs were invited to participate, and 203 Diplomates (27.7%) completed the survey. For both dogs and cats, the most common first-line vasopressor was norepinephrine (87.9% in dogs and 83.1% in cats). The most common second-choice vasopressor was vasopressin (44.2% in dogs and 39.0% in cats). Cutoff values for initiating vasopressor therapy varied between species and modality used for blood pressure measurement. In general, most DACVECCs chose to initiate vasopressor therapy at a Doppler blood pressure <90mmHg or a mean arterial pressure of <60 or <65mmHg when using oscillometric or direct arterial blood pressure measurements in dogs and cats. Most DACVECCs adhere to published human guidelines when choosing a first-line vasopressor. However, there is significant variability in blood pressure measurement technique, cutoffs for initiation of vasopressor use, and choice of second-line vasopressors.