Refractory Shock Research Articles

Augmented-Medication CardioPulmonary Resuscitation Trials in out-of-hospital cardiac arrest: a pilot randomized controlled trial

BackgroundPreviously conducted physician-centered trials on the usefulness of vasopressin have yielded negative results; thus, patient-oriented trials have been warranted. We hypothesize that Augmented-Medication CardioPulmonary Resuscitation could be helpful for selected patients with out-of-hospital cardiac arrest (OHCA).MethodsThis is a double-blind, single-center, randomized, placebo-controlled trial conducted in the emergency department in a tertiary, university-affiliated hospital in Seoul, Korea. A total of 148 adults with non-traumatic OHCA who had initial diastolic blood pressure (DBP) < 20 mm Hg via invasive arterial monitoring during the early cardiac compression period were randomly assigned to two groups. Patients received a dose of 40 IU of vasopressin or placebo with initial epinephrine. The primary endpoint was a sustained return of spontaneous circulation. Secondary endpoints were survival discharge, and neurologic outcomes at discharge.ResultsOf the 180 included patients, 32 were excluded, and 148 were enrolled in the trial. A sustained return of spontaneous circulation was achieved by 27 patients (36.5%) in the vasopressin group and 24 patients (32.4%) in the control group (risk difference, 4.1%; P = .60). Survival discharge and good neurologic outcomes did not differ between groups. The trial group had significantly higher median DBPs during resuscitation than the control group (16.0 vs. 14.5 mm Hg, P < 0.01). There was no difference in end-tidal carbon dioxide, acidosis, and lactate levels at baseline, 10 min, and end-time.ConclusionAmong patients with refractory vasodilatory shock in OHCA, administration of vasopressin, compared with placebo, did not significantly increase the likelihood of return of spontaneous circulation.

Advanced Cardiovascular Support in Refractory Shock

“Shock” is a term that is used to signify inadequate tissue perfusion and cellular oxygenation. The basic principle of treating shock is restoring tissue perfusion and adequate cellular oxygenation. Resuscitation from shock is achieved using a combination of fluid therapy, inotropes, and vasopressors. Refractory shock has been defined as requirement of noradrenaline infusion of >0.5 μg/kg/min despite adequate volume resuscitation. Inability to use oxygen damages the cellular machinery and if not restored in time, shock can become irreversible. Mortality in these patients is very high, and the assessment and management of these patients requires a much more aggressive approach for survival. This article will focus on the management of refractory shock.

Vitamin C and thiamine for the treatment of refractory septic shock in surgical critically ill patients: a retrospective before-and-after study.

This study aimed to evaluate whether early vitamin C and thiamine administration was associated with a lower 28-day and in-hospital mortality in surgical critically ill patients with refractory septic shock. We performed a retrospective before-and-after study on patients with refractory septic shock. According to local protocol, hydrocortisone is initiated in case of refractory septic shock. In January 2017, the protocol was changed and vitamin C and thiamine were included. Patients who were admitted in 2015-2016 and 2017-2018 were included in the control and treatment groups, respectively. The primary end point was 28-day and in-hospital mortality. Secondary end points were ICU mortality, ICU and hospital length of stay, duration of vasopressors and mechanical ventilation, use of renal replacement therapy (RRT), and the modification in serum procalcitonin and SOFA score during the first 72 h. A total of 120 patients were included (58 in the treatment group and 62 in the control group). Log-rank test in Kaplan-Meier curves showed lower 28-day and in-hospital mortality over time in the treatment group (p=0.021 and p=0.035, respectively) but it not reached statistical significance in ICU mortality over time (p=0.100). The need of RRT was less frequent in treatment group (17.2% vs. 37.1%, p=0.024). There were no differences in other secondary outcomes. Intravenous vitamin C and thiamine administration in surgical patients with refractory septic shock may be associated with a lower 28-day and in-hospital mortality. Further prospective studies are needed in refractory septic shock.

Outcomes of Pediatric Patients with Sepsis Managed on Extracorporeal Membrane Oxygenation: An Analysis of the Extracorporeal Life Support Organization Registry

AbstractExtracorporeal membrane oxygenation (ECMO) support is increasingly used for refractory septic shock. There is a lack of data on the outcomes of children requiring ECMO support for refractory septic shock. Our study objective was to describe the variables associated with survival, risk factors for mortality, and outcomes of children requiring ECMO support for refractory shock. This was retrospective registry study of 340 international centers contributing data to the ELSO Registry, analyzing children &lt;18 years who received ECMO with septic shock, severe sepsis, sepsis, systemic inflammatory response syndrome, toxic shock syndrome, shock associated with infection, and septicemia from any organism from 1990 to 2015. Outcomes were analyzed by categorizing the data into survivors and nonsurvivors. Logistic regression models were used to describe the association of dependent variable and multiple independent variables. A total of 1,928 patients were identified who met the inclusion criteria. In total, 744 (38.5%) of the cohort survived. Survivors in this cohort tend to have a longer duration of ECMO (230 vs. 201 hours, p = 0.005) and shorter time from intubation to ECMO cannulation (87 vs. 116 hours, p = 0.0033) when compared to nonsurvivors. Survivors were also noted to have higher pH, higher serum bicarbonate, higher saturations, and higher systolic, diastolic, and mean arterial pressures compared to nonsurvivors. These results suggest that early initiation of ECMO therapy for refractory sepsis is associated with better patient outcomes. ECMO is unlikely to recover patients once circulatory and metabolic collapse has developed.

Value of functional echocardiographic parameters in predicting refractory septic shock in neonates

To study the value of functional echocardiographic parameters in predicting refractory septic shock in neonates. A total of 72 neonates with septic shock were enrolled. According to the highest value of septic shock score, they were divided into two groups: refractory (n=30) and non-refractory (n=42). The two groups were compared in terms of clinical data, laboratory findings, and functional echocardiographic parameters. The receiver operating characteristic (ROC) curve was used to evaluate the performance of functional echocardiographic parameters in predicting refractory septic shock. Compared with the non-refractory group, the refractory group had significantly lower cardiac output and cardiac index (CI) and a significantly higher mean arterial pressure (MAP)/CI ratio (P<0.05). CI had a cut-off value of 2.6 L/(min·m2), a sensitivity of 79%, a specificity of 83%, and an area under the ROC curve (AUC) of 0.841 in predicting septic shock-related death (P<0.05), and MAP/CI ratio had a cut-off value of 11.4, a sensitivity of 83%, a specificity of 73%, and an AUC of 0.769 (P<0.05). CI had a cut-off value of 2.9 L/(min·m2), a sensitivity of 69%, a specificity of 69%, and an AUC of 0.717 in predicting all-cause death within 28 days (P<0.05). CI and MAP/CI ratio can be useful for early prediction of septic shock-related death in neonates.

Is venoarterial extracorporeal membrane oxygenation an option for managing septic shock.

To describe sepsis-induced cardiomyopathy. Discuss indications and current evidence of using venoarterial extracorporeal membrane oxygenation (VA-ECMO) in setting of sepsis-induced cardiomyopathy. Recent data suggests a survival benefit with the use of VA-ECMO in patients with septic shock complicated by septic-induced cardiomyopathy with severe left ventricular systolic dysfunction. VA-ECMO was associated with poor outcomes in adults with septic shock without severe systolic dysfunction. The evidence is generated from retrospective and meta-analysis of observational studies. Sepsis-induced cardiomyopathy is an increasingly recognized entity characterized by reversible ventricular dysfunction in the setting of sepsis. When hypotension persists despite standard management of septic shock (e.g. adequate fluid resuscitation, vasopressors, inotropes) and there is evidence of severe cardiac systolic dysfunction and end-organ hypoperfusion, VA-ECMO should be considered as a bridge therapy to recovery. VA-ECMO should not be used for isolated vasodilatory septic shock without significant myocardial dysfunction.

A new machine learning algorithm to predict veno-arterial ECMO implantation after post-cardiotomy low cardiac output syndrome

BackgroundPost-cardiotomy low cardiac output syndrome (PC-LCOS) is a life-threatening complication after cardiac surgery involving a cardiopulmonary bypass (CPB). Mechanical circulatory support with veno-arterial membrane oxygenation (VA-ECMO) may be necessary in the case of refractory shock. The objective of the study was to develop a machine-learning algorithm to predict the need for VA-ECMO implantation in patients with PC-LCOS. Patients and methodsPatients were included in the study with moderate to severe PC-LCOS (defined by a vasoactive inotropic score (VIS) > 10 with clinical or biological markers of impaired organ perfusion or need for mechanical circulatory support after cardiac surgery) from two university hospitals in Paris, France. The Deep Super Learner, an ensemble machine learning algorithm, was trained to predict VA-ECMO implantation using features readily available at the end of a CPB. Feature importance was estimated using Shapley values. ResultsBetween January 2016 and December 2019, 285 patients were included in the development dataset and 190 patients in the external validation dataset. The primary outcome, the need for VA-ECMO implantation, occurred respectively, in 16% (n = 46) and 10% (n = 19) in the development and the external validation datasets. The Deep Super Learner algorithm achieved a 0.863 (0.793−0.928) ROC AUC to predict the primary outcome in the external validation dataset. The most important features were the first postoperative arterial lactate value, intraoperative VIS, the absence of angiotensin-converting enzyme treatment, body mass index, and EuroSCORE II. ConclusionsWe developed an explainable ensemble machine learning algorithm that could help clinicians predict the risk of deterioration and the need for VA-ECMO implantation in moderate to severe PC-LCOS patients.

Sudden Cardiac Death due to Giant Cell Myocarditis in a 37-Year-Old Female: Case Report

Abstract Introduction/Objective Giant cell myocarditis (GCM) is a rare and aggressive inflammatory process that targets the myocardium and is often rapidly fatal. Most cases have been reported in young to middle aged adults with a slight male predominance. The etiology of this disease is largely unknown, however there is an association with multiple autoimmune disorders. Most patients present with rapidly progressive or fulminant heart failure, arrhythmias, heart block or sudden cardiac death. The incidence of GCM ranges from 0.007% to 0.051% and most cases are confirmed on autopsy examination. Here we present a case of GCM in a young female diagnosed on autopsy. Methods/Case Report A 37-year-old female presented with shortness of breath and chest pain for a 5-day duration. She had no past medical history and was otherwise well before the onset of symptoms. On admission, she was noted to have clinical findings consistent with heart failure and progressed to cardiogenic shock with ventricular arrhythmias within hours. Despite high dose corticosteroids and other supportive therapy, the patient remained in refractory, vasodilatory shock, in cardiac standstill and eventually died. Findings on autopsy included mild ventricular hypertrophy, petechial hemorrhages through out the atria and ventricles, as well as pulmonary edema and congestion. Microscopic examination showed a diffuse infiltrating pattern of inflammation within the heart, that was composed predominantly of lymphocytes, giant cells, scattered neutrophils, and eosinophils. The lymphocytes were CD3, CD4, CD8 positive and CD20 negative, consistent with a T-cell infiltrate. Gram and GMS stains were negative for bacterial and fungal microorganisms. Focal areas of necrosis without granuloma formation are also noted ruling out sarcoidosis. Results (if a Case Study enter NA) NA. Conclusion This case demonstrates a rapid manifestation of GCM in a previously healthy individual. GCM must be considered in the differential diagnosis when a young patient presents with cardiac symptoms. Early diagnosis and initiation of targeted therapy is critical for GCM patients' survival.

Abstract 13900: Combined Use of Venoarterial Extracorporeal Menbrane Oxygenation and Impella Improves the Outcome in Patients With Cardiogenic Shock

Introduction: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides benefit to patients in refractory cardiac arrest and cardiogenic shock. However, VA-ECMO elevates LV afterload and causes pulmonary edema and LV distension. Additional IABP support has been recommended in Japan to reduce LV afterload. Alternatively, transcatheter left ventricular assist device, Impella has been recently introduced. However, it remains to be evaluated if there is clinical benefit of concomitant use of VA-ECMO and Impella (ECPELLA). Methods: Aim of this single-site cohort study is to assess the effects of ECPELLA as compared with ECMO with IABP in patients who were managed with VA-ECMO due to refractory cardiogenic shock including cardiac arrest. Results: We retrospectively reviewed 253 consecutive patients, who received VA-ECMO from January 2012 to May 2022 in our institute. Among them, 67 patients who were managed with VA-ECMO alone were excluded. Patients were divided into two groups, ECEPLLA (n=68) and ECMO with IABP (n=118). We applied propensity score analysis with 1:1 score matching using dependent variables of age, the rate of sex, acute coronary syndrome, out-of-hospital and in-hospital cardiac arrest, and extracorporeal cardio-pulmonary resuscitation. We assessed 30-day survival rate, hemodynamic data, and safety profiles including acute kidney injury, blood transfusion and embolic cerebral infarction. Results: Following propensity score matching, 60 ECPELLA and 60 ECMO with IABP patients were included for analysis. The 30-day survival was significantly higher with ECPELLA group compared with ECMO with IABP group (ECPELLA: 48% vs. ECMO with IABP: 28%, p= 0.01, log-rank test). There were no statistical differences in ECMO weaning rate and safety profiles between treatment groups. Conclusions: ECPELLA may be associated with improved 30-day survival in patients with refractory cardiac shock including cardiac arrest.

Abstract 15164: Refractory Shock Following Ingestion of Gamma Hydroxy Butyrate Laced With Xylazine

Case: A 35 year old male with a complex psychiatric history including previous suicide attempts was brought to the emergency department after being found on a sidewalk with bradycardia and bradypnea by emergency medical services (EMS). He responded to naloxone administered by EMS and admitted to using heroin, gamma hydroxyl butyrate (GHB), and rohypnyol prior to becoming unconscious. On arrival, his vitals showed a sinus heart rate at 60, decreased respiratory rate with normal oxygenation, hypotension with systolic blood pressures in the 50’s, and hypothermia with a temperature of 95 degrees Fahrenheit. On physical exam his heart rate and rhythm were regular, lungs were clear to auscultation, he had pinpoint pupils, and was perfusing his extremities well with normal capillary refill without diaphoresis. A bedside echocardiogram showed normal left ventricular ejection fraction without signs of cardiogenic shock. He was subsequently started on two pressors but continued to clinically worsen requiring overmaxed doses of five pressors including Angiotensin II. He continued to clinically decline with worsening renal failure requiring CRRT therapy and remains ventilator dependent. Discussion: This patient was admitted to the intensive care unit for profound vasoplegic shock. The etiology of his shock was due to a veterinary drug called xylazine. Xylazine is a horse tranquilizer which is commonly laced in drugs of abuse including GHB. It’s an alpha 2 agonist which causes decreased sympathetic outflow and decreased norepinephrine release leading to a clinical presentation including profound hypotension, bradycardia, CNS depression, and miosis. While it can mimic opioid toxicity patients tend to have preserved respiratory status and transiently respond to painful stimulation. Patients who don’t concomitantly use opioids, do not typically respond to naloxone. It is critical to consider this in the differential in patients with an opioid toxidrome who don’t respond to naloxone. The treatment for xylazine overdose is supportive care of their hemodynamics. The half-life of the drug is around 48 hours but can persist for several days. While xylazine overdose generally carries a good prognosis, it can still lead to devastating consequences.

Abstract 10735: Brash Syndrome: Frequently Under-Recognized and Often Confused With Simple Hyperkalemia

Introduction: BRASH syndrome is a relatively newly recognized and under-reported clinical entity characterized by bradycardia, renal dysfunction, atrioventricular node blockade (AVNB), shock, and hyperkalemia. We report a case of BRASH syndrome that was refractory to medical therapy alone, requiring transvenous pacing, hemodialysis, and vasopressor support. Case presentation: An 82-year-old female with hypertension, diabetes, and paroxysmal atrial fibrillation (on metoprolol and verapamil) was found unresponsive at a nursing home. She had refractory shock (99/34 mmHg) and symptomatic bradycardia with heart rate (HR) of 33 BPM. EKG showed atrial fibrillation rhythm with ventricular rate of 31 BMP and peaked T-waves. Labs revealed creatinine of 1.98 mg/dL, potassium of 6.8 mmol/L, and TSH of 2.90 ulU/ml. She had no signs of infection and echocardiogram showed normal left ventricular systolic function. She was intubated for airway protection. AVNB agents were immediately held. Potassium-lowering agents and vasoactive drugs were administered. Temporary transvenous pacemaker was placed due to persistent bradycardia with hemodynamic instability even after transcutaneous pacing. Temporary hemodialysis was started for worsening renal failure and refractory hyperkalemia. She was weaned off vasopressor support, mechanical ventilation, hemodialysis and temporary pacing over the next few days. Renal function improved and HR stabilized at 70 BPM. Discussion: In our case, AVNB agent overdose caused bradycardia which in turn led to decreased cardiac output and renal hypoperfusion. Resultant acute kidney injury led to decreased clearance of renally excreted metoprolol and verapamil and worsening hyperkalemia, which locked the patient in a vicious cycle of BRASH syndrome leading to hemodynamic compromise. Therefore, rapid diagnosis and correct management with transvenous pacemaker and renal replacement therapy are crucial to reduce mortality.

Abstract 10437: Venoarterial Extracorporeal Membrane Oxygenation Rescue Therapy in Vasoplegic Shock Due to Calcium Channel Blocker Overdose: 5 Year Single Center Experience

Introduction: Over 15,000 incidences of Calcium Channel Blocker (CCB) overdose were reported by the American Association of Position Control Centers (AAPCC) in 2020, resulting in 45 deaths from pure CCB overdose and 176 deaths from multidrug overdose involving CCBs. We present a single-center experience on the use of VA ECMO in the management of refractory hypotension due to CCB toxicity. Hypothesis: VA ECMO is effective and can be life-saving in vasoplegic shock from drug overdose Methods: We retrospectively reviewed our ECMO registry in the last 5 years to identify patients who were started on ECMO support for refractory hypotension due to drug overdose. Results: We found 5 patients who were started on VA-ECMO for drug overdose, all involving CCBs. Mean age was 60. They had persistent lactic acidosis and hypotension after fluid resuscitation, requiring escalating doses of vasopressors until they were on or near the maximum. All patients were started on hyperinsulinemia euglycemic protocol and 3 patients received methylene blue. The mean time to intubation was 11.2 ± 4.14 hours. An echocardiogram demonstrated intact systolic function in all patients. VA-ECMO was started within 11.2 ± 4.5 hours of admission. Pressor requirements quickly improved on ECMO support. Average time on ECMO was 69 ± 48.6 hours. 4 of 5 patients improved quickly and were extubated within 10 days (mean: 4.88 ± 2.95). In these 4 patients, the length of ICU stay was 8.5 ± 3.87 days, and hospital stay was 11.75 ± 2.06 days. One patient had a protracted course due to renal failure, pneumonia, and concern for North-South Syndrome. Cannulation was switched to subclavian/axillary approach, but that was complicated by left arm ischemia and switch to VV-ECMO after 44 hours of VA-ECMO. She was discharged after a 46-day hospital stay. Conclusions: VA-ECMO support is effective and lifesaving in patients with refractory shock from CCB toxicity. Early referral to ECMO capable center should be considered in these patients.

PSUN32 Critical Illness-Related Corticosteroid Insufficiency (CIRCI) Among Patients with COVID-19 at a Tertiary Hospital: Clinical Characteristics and Outcomes

Abstract Introduction A significant number of patients afflicted with COVID-19, a viral illness caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), present with refractory shock, hemodynamic instability, acute respiratory distress syndrome and other severe manifestations of infection, warranting intensive care. Among critically ill patients, there is usually impairment of the hypothalamic-pituitary- adrenal axis, leading to a condition known as critical illness-related corticosteroid insufficiency (CIRCI). Currently, the incidence of CIRCI among critically ill patients with COVID-19 is unknown. There is also a paucity of data on how CIRCI is likely a significant risk factor for poor clinical outcomes in COVID-19 infected patients. Addressing this knowledge gap will shape decision-making in the intensive care setting because CIRCI is a treatable condition, and intervention for CIRCI in the form of glucocorticoids, when utilized in the appropriate context, is potentially lifesaving. Objectives The aims of this investigation were to determine the occurrence of CIRCI among patients with COVID-19 as well as to analyze the clinical characteristics and outcomes of these critically ill patients. Methodology This was a single-center, retrospective, cohort study that investigated the occurrence of CIRCI among critically ill patients infected with COVID-19. A chart review among admitted patients was done. Results In this cohort, there were 145 COVID-19 patients included. The median age of the patients was at 63 years old and the study population comprised of 57.24% males. Septic shock was the top etiology of shock at 72.22% of the population. The median Sequential Organ Failure Assessment (SOFA) score was 13 which suggests that most of the patients included in the study had a very high mortality rate, 40-50% risk of death. There was a high rate of organ dysfunction. For COVID-19 patients in refractory shock, there was a high rate of utilization of steroids at 70.83%. After corticosteroids were initiated, blood pressure improved in 70.45% of the patients. Patients who were given corticosteroids were found to have statistically significant longer median days on ventilator (p= 0.001). However, those on the corticosteroid arm were at higher risk of morbidity and mortality as signified by statistically significant higher APACHE II scores (p = 0.0233), MPM scores (p = 0.006), and a greater proportion of patients with acute kidney injury (p= 0.028), oliguria, (p= 0.020) and CNS dysfunction (p = 0.019). Significant predictors of mortality in CIRCI are higher MPM and APACHE II scores and longer time to initiation of steroids. Conclusion There is a substantially high incidence of CIRCI among critically ill patients infected with COVID-19. CIRCI has a unique presentation among COVID-19 patients because of the presence of a high level of inflammation in this life-threatening infection. It is a harbinger of markedly increased risk of mortality in these patients. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

SYSTEMIC MASTOCYTOSIS PRESENTING WITH KOUNIS SYNDROME AND REFRACTORY SHOCK

<h3>Introduction</h3> Systemic mastocytosis (SM) can rarely present in the setting of refractory shock and/or coronary artery vasospasm triggered by mast cell activation, also known as Kounis Syndrome. <h3>Case Description</h3> A 30-year-old male with a history of urticaria pigmentosa (lost to follow up as an adolescent) and unexplained syncopal episodes was found unconscious at home. Upon EMS arrival, he was hypotensive and severely hypoxemic prompting intubation. The patient required epinephrine, norepinephrine, and vasopression to maintain normotension. Skin exam was notable for diffusely distributed small monomorphic brown macules sparing the face, palms, and soles. In the ED, initial EKGs showed ST segment elevations in leads II, III, aVF and reciprocal ST segment depressions in V4-V6. He underwent emergent left heart catheterization which lacked evidence of coronary artery disease. Unexpectedly, troponins were negative and abnormal EKG findings resolved without intervention. Extensive infectious workup was also negative. Allergy was then consulted given suspicion for undiagnosed SM. Workup revealed an elevated serum tryptase of 77.6 ng/mL, positive KIT D816V mutation, and a bone marrow biopsy demonstrating atypical aggregates of mast cells (≥15 mast cells). He was diagnosed with aggressive SM; undifferentiated shock resolved following treatment with cladribine followed by midostaurin. <h3>Discussion</h3> This case describes a patient who presented with an excessive burden of mast cell degranulation leading to persistent shock and a rare phenomenon known as Kounis Syndrome. Undiagnosed aggressive SM can masquerade as sepsis or cardiogenic shock as the initial presentation potentially leading to increased morbidity and mortality.

Extended stability of vasopressin 0.2 unit/mL in PVC containers.

Vasopressin is used to maintain blood pressure in vasodilatory shock. Vasopressin is diluted from concentrated vials prior to administration as a continuous infusion. This study evaluates the physical and chemical stability changes of vasopressin diluted to 0.2 units/mL with 0.9% sodium chloride injection in polyvinyl chloride (PVC) bags stored under refrigeration. Vasopressin Injection, USP, 20 unit/mL solution was diluted to 0.2 unit/mL with 0.9% sodium chloride injection, and stability changes were evaluated over 10 days via mass spectrometry on days 0, 7, and 10. Solutions of vasopressin 0.2 unit/mL in 0.9% sodium chloride injection in PVC bags were physically stable and showed less than 10% degradation over 10 days of refrigerated storage. Vasopressin 0.2 unit/mL may be given a beyond-use date (BUD) of 10 days based on United States Pharmacopeia BUD recommendations, with this study showing less than 10% degradation over 10 days of refrigerated storage.

A case of refractory hypoxia and shock due to drug overdose successfully managed with ECMO first time ever in Bangladesh

A 36 -year-old female developed refractory cardiac and respiratory failure after self-declared ingestion of unknown amount of propranolol, benzodiazepine and few other unknown drugs in unknown dose. She also had vomiting followed by aspiration pneumonia. Despite giving adequate I/V fluid, antibiotics, activated charcoal, lipid emulsion, intravenous sodium bicarbonate and inotropic support, she became hypotensive and developed acute heart failure with pulmonary edema. This patient was managed with extracorporeal membrane oxygenation (ECMO) for 72 h, she survived without any deficit. This records country’s first ever use of extracorporeal membrane oxygenation in any patient. In this particular case when traditional antidotes were insufficient to prevent collapse, ECMO was introduced in the form of extracorporeal life support (ECLS) to maintain perfusion, reduce vasopressor requirements, and maintain oxygenation and carbon dioxide removal from blood. With increasing expertise and availability, extracorporeal membrane oxygenation should be considered in patients who develop cardiac or respiratory failure due to any cause, refractory to conventional therapy. Bangladesh Crit Care J September 2022; 10(2): 142-145

68 The confounder in time of confusion: a case report on Multisystem Inflammatory Syndrome in Children (MIS-C)

68 The confounder in time of confusion: a case report on Multisystem Inflammatory Syndrome in Children (MIS-C)

VASOPRESSOR-RESISTANT HYPOTENSION, COMBINATION VASOPRESSOR THERAPY, AND SHOCK PHENOTYPES IN CRITICALLY ILL ADULTS WITH VASODILATORY SHOCK.

ABSTRACTObjective: To examine the risk factors, resource utilization, and 1-year mortality associated with vasopressor-resistant hypotension (VRH) compared with vasopressor-sensitive hypotension (VSH) among critically ill adults with vasodilatory shock. We also examined whether combination vasopressor therapy and patient phenotype were associated with mortality. Design: Retrospective cohort study. Setting: Eight medical-surgical intensive care units at the University of Pittsburgh Medical Center, Pittsburgh, PA. Patients: Critically ill patients with vasodilatory shock admitted between July 2000 and October 2008. Interventions: None. Measurements and Main Results: Vasopressor-resistant hypotension was defined as those requiring greater than 0.2 μg/kg per minute of norepinephrine equivalent dose of vasopressor consecutively for more than 6 h, and VSH was defined as patients requiring ≤0.2 μg/kg per minute to maintain MAP between 55 and 70 mm Hg after adequate fluid resuscitation. Of 5,313 patients with vasodilatory shock, 1,291 patients (24.3%) developed VRH. Compared with VSH, VRH was associated with increased risk of acute kidney injury (72.7% vs. 65.0%; P < 0.001), use of kidney replacement therapy (26.0% vs. 11.0%; P < 0.001), longer median (interquartile range [IQR]) intensive care unit length of stay (10 [IQR, 4.0–20.0] vs. 6 [IQR, 3.0–13.0] days; P < 0.001), and increased 1-year mortality (64.7% vs. 34.8%; P < 0.001). Vasopressor-resistant hypotension was associated with increased odds of risk-adjusted mortality (adjusted odds ratio [aOR], 2.93; 95% confidence interval [CI], 2.52–3.40; P < 0.001). When compared with monotherapy, combination vasopressor therapy with two (aOR, 0.91; 95% CI, 0.78–1.06) and three or more vasopressors was not associated with lower mortality (aOR, 0.93; 95% CI, 0.68–1.27). Using a finite mixture model, we identified four unique phenotypes of patient clusters that differed with respect to demographics, severity of illness, processes of care, vasopressor use, and outcomes. Conclusions: Among critically ill patients with vasodilatory shock, VRH compared with VSH is associated with increased resource utilization and long-term risk of death. However, combination vasopressor therapy was not associated with lower risk of death. We identified four unique phenotypes of patient clusters that require further validation.

SECONDARY HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS IN A PATIENT WITH COVID-19 AND HERPES SIMPLEX VIRUS (HSV): A CASE REPORT

SECONDARY HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS IN A PATIENT WITH COVID-19 AND HERPES SIMPLEX VIRUS (HSV): A CASE REPORT

Pediatric Sepsis: The Importance of Understanding Criteria for Diagnosis.

Pediatric sepsis is a very significant issue for the pediatric population. Sepsis can be defined in relation to systemic inflammatory response syndrome. It can be further characterized based on the severity, including severe sepsis, septic shock, multiorgan failure, and refractory septic shock, in the setting of proven infection or suspected infection. In the pediatric population, sepsis is a complicated and dangerous event with no one specific criteria or definition in the systemic inflammatory response syndrome criteria applicable to every child who is suffering from the condition. The goal of this paper is to enhance awareness of the various forms and severities of sepsis in the pediatric population so that swift diagnosis can be made and treatment can be initiated. An electronic literature review search was performed, and relevant data were collected from peer-reviewed articles from January 2005 to May 2020. The nonspecific nature of this condition can manifest as cardiovascular dysfunction, and hematologic abnormalities to neurologic symptoms, resulting in a late diagnosis, which ultimately leads to an increase in mortality and morbidity. The implications of sepsis in the pediatric population needs to be addressed. It is imperative for all medical professionals, including medical students, to understand the criteria and to raise a high level of suspicion when presented with a child exhibiting symptoms that may indicate sepsis. By increasing awareness of pediatric sepsis, complications, including death, that arise as a result of late diagnosis and treatment would be substantially decreased. [Pediatr Ann. 2022;51(10):e405-e408.].