Vasoplegic Shock Research Articles

Is increased perfusion pressure really necessary during cardiopulmonary bypass?

We read with great interest the work by Siepe et al .[ 1] investigating the effect of increased systemic perfusion pressure during cardiopulmonary bypass on cognitive dysfunction and delirium. In this revolutionary study questioning cerebral autoregulation, they found that maintaining mean perfusion pressure during normothermic cardiopulmonary bypass (CPB) at 80–90 mmHg is associated with less early cognitive dysfunction and delirium after coronary artery bypass grafting (CABG), and elevated perfusion pressure is not associated with increased morbidity and mortality. This finding may lead to severe changes in the routine practice of cardiac surgeons and anaesthesiologists including us. However, we believe that there are some issues that need to be addressed. This study lacks a power and sample analysis and seems to have been conducted in a very small group of patients. For this reason, postoperative complications such as atrial fibrillation (19 vs 36%), bleeding requiring reoperation (2 vs 7%), use of blood products (50 vs 70), cessation of catecholamine support (26 vs 14 h), superficial wound infection (4 vs 7%) and pleural effusion (33 vs 48%) which may be statistically significant in a larger group of patients appears to be insignificant. As the low perfusion group needed longer catecholamine support, it is easy to assume that they were in either low cardiac output (LCO) or vasoplegic state. The incidence of preoperative left ventricular dysfunction, which is a predictor of LCO, is not reported and should be included in the statistical analysis. Furthermore, it is well known that preoperative medication by inhibitors of angiotensin-converting enzyme in coronary artery patients is associated with vasoplegic shock early after CABG. This issue also needs to be addressed. If low perfusion pressure during CPB is to be blamed, then the postoperative period should be comparable in both groups. However, as the LP group suffered from LCO postoperatively, measurement of neurochemical markers (S-100 beta and neuronspecific enolase) immediately after CPB might be appropriate. It is clear that patients with delirium had longer CPB, ventilation and intensive care unit (ICU) stay times, and were still in LCO (probably still in ICU and under major depression) at the time of Mini-Mental-State examination. All of these factors have been shown to be associated with postoperative delirium [2, 3]. Cerebral circulation during CPB may be affected by partial arterial oxygen (hyperoxaemia by impairing red cell rheology and microcirculation) and carbon dioxide pressure (by changing cerebral arteriolar reactivity) [4]. Thus, they should be monitored closely (more frequently than every 20 min) and kept similar in both groups. Spot measurements of transcutaneous cerebral oxygen saturation as measured by near-infrared spectroscopy seem to be similar in both groups. However, it is reported that rSo2 desaturation score, which is calculated by multiplying rSo2 below 50% by time (s), is a more sensitive method of predicting early postoperative cognitive decline than spot measurements [5]. Nitric oxide (NO) formed via endothelial NO synthase and neuronal NO synthase plays crucial roles in the regulation of blood flow through vasodilatation and decreased vascular resistance. Endothelial and autonomic nitrergic nerve functions are impaired in patients with diabetes mellitus, resulting in regional blood flow decrease [6]. As the duration of the diabetes mellitus and insulin dependence may change from patient to patient, it seems necessary to exclude these patients or at least compensate for the severity of their disease.

P31 Predictors of fluid responsiveness in patients with acute liver failure

IntroductionProfound haemodynamic changes are invariably seen in ALF and resemble those found in later stages of septic shock. Vasopressor support is frequently required and in discriminatory fluid resuscitation can worsen...

Association between Preoperative C-Reactive Protein Levels with Postoperative Complications of Cardiovascular Surgery

Background Systemic inflammatory response syndrome is a frequent postoperative complication of cardiovascular surgery that can develop vasoplegic shock and organ or multiorgan dysfunction in the most severe cases. Preoperative and postoperative predictors associated with this complication have been described; however, a subclinical preoperative inflammatory state, not detected by routine tests, might be related to the postoperative inflammatory response. Elevated C-reactive protein (CRP) levels, a parameter of inflammation in different clinical scenarios that is associated with the prognosis of diverse cardiovascular diseases, might predict the syndrome. Objective To evaluate the value of elevated C-reactive protein to predict systemic inflammatory response syndrome and its postoperative complications after cardiovascular surgery. Material and Methods A total of 169 consecutive patients (77.3% were men, age 61.1±15.9, Euroscore 9.46 [SD 12.7]) undergoing cardiovascular surgery were prospectively included between April 2007 and December 2008. CRP levels were determined in all patients. The combined endpoint included the incidence of systemic inflammatory response syndrome and its association with atrial fibrillation, kidney failure, shock or death. Results Eighty seven patients (54%) developed systemic inflammatory response syndrome and 50 patients (31%) presented the combined endpoint. In-hospital mortality was 5.6% (9 patients). The preoperative levels of CRP ≥2 mg/dl adjusted for preoperative and postoperative variables were independently associated with the combined endpoint (OR 2.95, 95% CI 1.20-7.23; p<0.018), with the development of systemic inflammatory response syndrome (SIRS) (OR 2.46, 95% CI 1.17-5.15; p<0.000), and with the combination of SIRS and kidney failure (OR 5.10, 95% CI 1.48-17.58; p<0.010), SIRS and shock (OR 6.50, 95% CI 1.59-27.34; p<0.005), and SIRS kidney failure (OR 2.91, 95% CI 1.19-7.12; p<0.019) and shock (OR 4.13, 95% CI 1.25-13.60; p < 0.020). Conclusions Preoperative levels of CRP ≥2.0 mg/dl may predict the systemic inflammatory response syndrome and the systemic inflammatory response syndrome with kidney failure, atrial fibrillation, shock and death in the postoperative period of cardiovascular surgery.

Clinical Experience With Berlin Heart Excor in Pediatric Patients in Argentina: 1373 days of Cardiac Support

The objective of this study was to describe our experience (1373 days of support) with the Berlin Heart Excor (BH) ventricular-assist device (VAD) as bridging to cardiac transplantation in pediatric patients with end-stage cardiomyopathy. This study involved a retrospective observational cohort. Records of patients supported with the BH VAD were reviewed. Data regarding age, sex, weight, diagnosis, preoperative condition, single versus biventricular support, morbidity, and mortality were collected. Criteria for single versus biventricular support and intensive care unit management were registered. The procedure was approved by our Institutional Ethics Committee, and informed consent was obtained. Between March 2006 and March 2010, 12 patients with diagnosis of dilated (n = 10) and restrictive (n = 2) cardiomyopathy were supported. Median age was 56.6 months (range 20.1-165.9); mean weight was 18.3 kg (range 8.5-45); and nine patients were female. Every patient presented with severe heart failure refractory to pharmacological therapy. Biventricular support was necessary in four patients. Nine patients underwent heart transplantation. No child was weaned off the BH VAD because of myocardial recovery. Mean length of support was 73 days (range 3-331), and the total number of days of support was 1373. Three patients had fatal complications: 2 had thrombo-hemorrhagic stroke leading to brain death, and one had refractory vasoplegic shock. The BH VAD is a useful and reasonable safe device for cardiac transplantation bridging in children with end-stage heart failure. Team experience resulted in less morbidity and mortality, and time for implantation, surgical procedure, anticoagulation monitoring, and patient care improved.

Adjuvant Therapy with Methylene Blue in the Treatment of Right Ventricular Failure after Pulmonary Embolectomy

Severe pulmonary embolism often leads to right ventricular failure after surgical embolectomy secondary to ischaemia reperfusion injury and acute lung injury (ALI). Acute right ventricular dysfunction is traditionally treated with inotropes and vasopressors to maintain cardiac output and coronary perfusion as well as selective pulmonary vasodilators to provide right ventricular afterload reduction. We report the first case of utilisation of methylene (MB) in a patient with acute right ventricular failure and vasoplegic shock after surgical pulmonary embolectomy.

Perioperative infusion of low- dose of vasopressin for prevention and management of vasodilatory vasoplegic syndrome in patients undergoing coronary artery bypass grafting-A double-blind randomized study

Preoperative medication by inhibitors of angiotensin-converting enzyme (ACE) in coronary artery patients predisposes to vasoplegic shock early after coronary artery bypass grafting. Although in the majority of the cases this shock is mild, in some of them it appears as a situation, "intractable" to high-catecholamine dose medication. In this study we examined the possible role of prophylactic infusion of low-dose vasopressin, during and for the four hours post-bypass after cardiopulmonary bypass, in an effort to prevent this syndrome. In addition, we studied the influence of infused vasopressin on the hemodynamics of the patients, as well as on the postoperative urine-output and blood-loss. In our study 50 patients undergoing coronary artery bypass grafting were included in a blind-randomized basis. Two main criteria were used for the eligibility of patients for coronary artery bypass grafting: ejection fraction between 30-40%, and patients receiving ACE inhibitors, at least for four weeks preoperatively. The patients were randomly divided in two groups, the group A who were infused with 0.03 IU/min vasopressin and the group B who were infused with normal saline intraoperativelly and for the 4 postoperative hours. Measurements of mean artery pressure (MAP), central venous pressure (CVP), systemic vascular resistance (SVR), ejection fracture (EF), heart rate (HR), mean pulmonary artery pressure (MPAP), cardiac index (CI) and pulmonary vascular resistance (PVR) were performed before, during, and after the operation. The requirements of catecholamine support, the urine-output, the blood-loss, and the requirements in blood, plasma and platelets for the first 24 hours were included in the data collected. The incidence of vasodilatory shock was significantly lower (8% vs 20%) in group A and B respectively (p = 0,042). Generally, the mortality was 12%, exclusively deriving from group B. Postoperatively, significant higher values of MAP, CVP, SVR and EF were recorded in the patients of group A, compared to those of group B. In group A norepinephrine was necessary in fewer patients (p = 0.002) and with a lower mean dose (p = 0.0001), additive infusion of epinephrine was needed in fewer patients (p = 0.001), while both were infused for a significant shorter infusion-period (p = 0.0001). Vasopressin administration (for group A) was associated with a higher 24 hour diuresis) (0.0001).In conclusion, low-dose of infused vasopressin during cardiopulmonary bypass and for the next 4 hours is beneficial for its postoperative hemodynamic profile, reduces the doses of requirements of catecholamines and contributes to prevention of the postcardiotomy vasoplegic shock in the patient with low ejection fraction who is receiving ACE preoperatively.

Vasopressin versus norepinephrine infusion in patients with vasoplegic shock after cardiac surgery

Vasopressin is commonly used as an adjunct to catecholamines to support blood pressure in refractory septic shock. Its effect on vasoplegic shock after cardiac surgery is unknown. We hypothesized that low-dose vasopressin as compared with norepinephrine would decrease the length of stay in the ICU in patients submitted to cardiac surgery with a pump.

Role of vasopressin in the treatment of anaphylactic shock in a child undergoing surgery for congenital heart disease: a case report

IntroductionThe incidence of anaphylactic reactions during anesthesia is between 1:5000 and 1:25000 and it is one of the few causes of mortality directly related to general anesthesia. The most important requirements in the treatment of this clinical condition are early diagnosis and maintenance of vital organ perfusion. Epinephrine administration is generally considered as the first line treatment of anaphylactic reactions. However, recently, new pharmacological approaches have been described in the treatment of different forms of vasoplegic shock.Case presentationWe describe the case of a child who was undergoing surgery for ventricular septal defect, with an anaphylactic reaction to heparin that was refractory to epinephrine infusion and was effectively treated by low dose vasopressin infusion.ConclusionIn case of anaphylactic shock, continuous infusion of low-dose vasopressin might be considered after inadequate response to epinephrine, fluid resuscitation and corticosteroid administration.

Management of Uncontrolled Hemorrhagic Shock

Management of Uncontrolled Hemorrhagic Shock

Tranexamic acid attenuates inflammatory response in cardiopulmonary bypass surgery through blockade of fibrinolysis: a case control study followed by a randomized double-blind controlled trial

IntroductionExtracorporeal circulation induces hemostatic alterations that lead to inflammatory response (IR) and postoperative bleeding. Tranexamic acid (TA) reduces fibrinolysis and blood loss after cardiopulmonary bypass (CPB). However, its effects on IR and vasoplegic shock (VS) are not well known and elucidating these effects was the main objective of this study.MethodsA case control study was carried out to determine factors associated with IR after CPB. Patients undergoing elective CPB surgery were randomly assigned to receive 2 g of TA or placebo (0.9% saline) before and after intervention. We performed an intention-to-treat analysis, comparing the incidence of IR and VS. We also analyzed several biological parameters related to inflammation, coagulation, and fibrinolysis systems. We used SPSS version 12.2 for statistical purposes.ResultsIn the case control study, 165 patients were studied, 20.6% fulfilled IR criteria, and the use of TA proved to be an independent protective variable (odds ratio 0.38, 95% confidence interval 0.18 to 0.81; P < 0.01). The clinical trial was interrupted. Fifty patients were randomly assigned to receive TA (24) or placebo (26). Incidence of IR was 17% in the TA group versus 42% in the placebo group (P = 0.047). In the TA group, we observed a significant reduction in the incidence of VS (P = 0.003), the use of norepinephrine (P = 0.029), and time on mechanical ventilation (P = 0.018). These patients showed significantly lower D-dimer, plasminogen activator inhibitor 1, and creatine-kinase levels and a trend toward lower levels of soluble tumor necrosis factor receptor and interleukin-6 within the first 24 hours after CPB.ConclusionThe use of TA attenuates the development of IR and VS after CPB.Trial registration numberISRCTN05718824.

The Guanylyl Cyclase Inhibition by MB as Vasoplegic Circulatory Shock Therapeutical Target

There were strong evidences that NO has capital importance in the progressive vasodilatation that associates to the varied circulatory shock forms. The decreased systemic vascular resistance observed in irreversible hemorrhagic (hypovolemic) and septic shock may be due to the excess production of nitric oxide. Other forms of shock associated to anaphylaxis (anaphylactic shock, SIRS) and ischemia reperfusion injury (cardiogenic shock, organ transplants), may involve nitric oxide overproduction. In these situations, the nitric oxide-induced loss of vascular sensitivity to catecholamines and myocardial depression contributes to lethal hypotension. As NO vasodilatation is cyclic GMP-mediated, there were two therapeutical options: a) The unspecific NO synthesis inhibition by L-arginine analogs, iNOS-specific inhibition by corticoids and/or aminoguanidine and; b) Guanylyl cyclase inhibition by MB. As the NO synthesis inhibition is associated to tissue necrosis and adverse hemodynamic effects and its clinical use was associated with high mortality, the second option using MB is safer and more rational. The elaboration of this text was motivated to suggest the guanylyl cyclase inhibition by MB as vasoplegic circulatory shock therapeutical target.

Moderate to severe Alzheimer disease

<h3>Background</h3> The use of vasoactive agents like arginine vasopressin (AVP) and terlipressin to treat hypotension or persistent pulmonary hypertension in critically ill preterm neonates is increasing. Therefore, a systematic review of the available data on dosing, efficacy and safety of AVP and terlipressin in this patient population appears beneficial. <h3>Methods</h3> We will conduct a systematic review of the available evidence on the use of AVP and terlipressin for the treatment of hypotension or persistent pulmonary hypertension in preterm neonates. We will search Ovid MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science and Google Scholar from inception to March 2021. Two reviewers will independently screen titles and abstracts, review the full text of eligible studies, extract data, assess the risk of bias and judge the certainty of the evidence. Our primary outcome will be an (1) improvement of end-organ perfusion after initiation of AVP or terlipressin and (2) mortality prior to discharge. Our secondary outcomes will include (1) major neurosensory abnormality and (2) the occurrence of adverse events. <h3>Discussion</h3> The currently available evidence on the efficacy and safety of AVP and terlipressin in preterm neonates is limited. Yet, evidence on the pharmacology of these drugs and the pathophysiology of vasoplegic shock support the biological plausibility for their clinical effectiveness in this population. Therefore, we aim to address this gap concerning the use of vasopressin and terlipressin among critically ill preterm neonates. <h3>Trial registration</h3> This protocol has been submitted for registration to the international database of prospectively registered systematic reviews (PROSPERO, awaiting registration number).

Choc vasoplégique et infarctus du myocarde lors de l’administration d’iloprost

The association of vasoplegic shock and myocardial infarction in a patient under iloprost treatment for critical ischemia of the lower limbs has not previously been reported. A 56 year-old man suffering from type 2 diabetes, hypertension and dyslipidemia developed critical ischemia of the right leg and was treated with iloprost. On the 19th day of infusion, he developed a vasoplegic shock with myocardial infarction. The shock resolved and he recovered from the infarction. This case report indicates the need for reinforced blood pressure and electrocardiographic monitoring in diabetes patients treated with iloprost.

Resuscitation from experimental heatstroke by hyperbaric oxygen therapy

Heatstroke is characterized by hyperthermia, vasoplegic shock, and cerebral ischemia and hypoxia. Hyperbaric oxygen (HBO) has been shown to reduce brain ischemia and behavioral dysfunction during cerebral artery occlusion. The efficacy of HBO therapy for resuscitation from heatstroke remains to be determined in the laboratory. Anesthetized rats were randomized to several groups and administered: 1) no resuscitation (normobaric air) after onset of heatstroke, 2) HBO for 1 hr (100% oxygen at 253 kPa for 1 hr), 3) cyclic HBO intermitted by a 5-min air break for 1 hr of treatment (100% oxygen at 253 kPa), 4) hyperbaric air (air at 253 kPa for 1 hr), 5) normobaric hyperoxia (100% oxygen at 101 kPa for 1 hr), or 6) 8% HBO (hyperbaric 8% oxygen at 253 kPa for 1 hr). Laboratory investigation. Sprague-Dawley rats (300- to 400-g males). Rats were exposed to an ambient temperature of 43 degrees C to induce heatstroke. Their colonic temperature; mean arterial pressure; heart rate; arterial blood levels of pH, Paco2, Pao2, So2%, and tumor necrosis factor-alpha; the cortical levels of ischemic and damage markers, and cortical neuronal damage scores were determined. The moment at which mean arterial pressure began to decrease from peak levels was arbitrarily taken as the onset of heatstroke. Survival time (interval between onset of heatstroke and animal death) was 19 +/- 1 (n = 10), 131 +/- 18 (n = 14), 159 +/- 28 (n = 13), 72 +/- 14 (n = 10), 68 +/- 12 (n = 10), and 45 +/- 11 (n = 10) mins, respectively, for normobaric air, HBO for 1 hr, cyclic HBO, hyperbaric air, normobaric hyperoxia, and 8% HBO groups. The heatstroke induced arterial hypotension and bradycardia, decreased arterial levels of pH, Pao2, and So2%, increased arterial levels of tumor necrosis factor-alpha, and increased values of cellular ischemia and damage markers. In addition, neuronal damage scores in the cortex were significantly reduced by HBO for 1 hr and cyclic HBO resuscitation. We successfully demonstrated that HBO and, to some extent, hyperbaric air, normobaric hyperoxia, or HBO 8% was found beneficial in resuscitating rats with experimental heatstroke. HBO effectively reduced heatstroke-induced arterial hypotension, hypoxia, plasma tumor necrosis factor-alpha overproduction, and cerebral ischemia and damage and improved survival.

Hyperbaric oxygen therapy prevents vascular derangement during zymosan-induced multiple-organ-failure syndrome

This study investigated the effects of hyperbaric oxygen (HBO) therapy on the cardiovascular alteration (e.g. mean arterial pressure, vascular reactivity of thoracic aorta rings changes) caused by zymosan in rats. Rats. University research laboratory. We investigated the effects of HBO therapy (2 ATA at the fourth and eleventh hours after study onset) on the cardiovascular alteration caused by zymosan (500 mg/kg, administered i.p. as a suspension in saline) in rats. Cardiovascular alterations were assessed 18 h after administration of zymosan and/or HBO therapy. Treatment of rats with HBO therapy attenuated the vasoplegic response to zymosan. In fact, the analysis of arterial pressure curves revealed no signs of vasoplegic shock. The aorta rings of animals treated with zymosan and HBO had a significantly increased contraction to norepinephrine (NE) and endothelin-1 (ET-1) and dilation to acetylcholine (ACh) compared with the zymosan group. The HBO therapy also attenuated the increase of malondialdehyde (MDA) levels caused by zymosan in the aorta. Immunohistochemical analysis for nitrotyrosine and for iNOS revealed positive staining in the aorta from zymosan-treated rats. The degree of staining for nitrotyrosine and iNOS was markedly reduced in tissue sections obtained from zymosan-rats treated with HBO therapy. This study provides the first evidence that HBO therapy attenuates the degree of zymosan-induced cardiovascular derangement in the rat.

Risk factors for post-cardiopulmonary bypass vasoplegia in patients with preserved left ventricular function

Background. Although vasodilatory shock (VS) is one of the main complications of cardiopulmonary bypass (CPB), its pathophysiologic basis remains unclear. The aim of this study was to identify predisposing factors for the development of VS after CPB independent of ventricular function.Methods. Thirty-six patients undergoing coronary artery bypass grafting who developed VS were compared with 72 control patients without post-CPB cardiogenic or vasoplegic shock, in a 2:1 case control study. Patients and controls underwent the same anesthetic protocol and were matched by age, sex, operation date, and left ventricle ejection fraction.Results. Preoperative and intraoperative patient characteristics were not significantly different between the two groups. Preoperative use of angiotensin-converting enzyme inhibitors and intravenous heparin were independent predictors for post-CPB VS by multivariate analysis (relative risk of 2.26 and 2.78, respectively). Intensive care unit stay and hospital stay were significantly longer in VS cases than controls, without any difference in early postoperative mortality.Conclusions. The only independent risk factors for postoperative VS identified were preoperative use of angiotensin-converting enzyme inhibitors and intravenous heparin. These risk factors were independent of age, gender, anesthetic protocol, and left ventricle ejection fraction.

Stent fracture in a Carpentier-Edwards supra-annular porcine bioprosthesis implanted in the mitral position

J Thorac Cardiovasc Surg 1999;118:197-9

Severe Diltiazem Poisoning with Intestinal Pseudo-Obstruction: Case Report and Toxicological Data

This case report concerns a 30-year-old man who survived a 4.2 g diltiazem overdose. He sustained vasoplegic shock with a junctional escape rhythm which required high doses of norepinephrine and epinephrine. Among other complications, ileus with paralytic intestinal pseudo-obstruction developed on day three. Cecal distention was demonstrated by abdomen computed tomodensitometry. The ileus resolved on day seven following the poisoning. Diltiazem plasma concentrations were determined during the first three days. The possible role of other medications, activated charcoal and sufentanil, is noted.

Shock states during myocardial infarct: treatment of cardiogenic shock with dopamine

SummaryShock syndrome, with rigid criteria for diagnosis, developed in 79 (17,5 %) of 450 patients with acute myocardial infarction; 45 cases concerned typical cardiogenic shock (10 %); 34 other cases concerned various clinical states : shock associated with prolonged arrhythmia (16 cases), vagal shock (12 cases), hypovolemic shock (4 cases) and vasoplegic shock (2 cases).The prognosis of cardiogenic shock is very poor, compared with other clinical types. However dopamine was successful in approximately 1 out 4 cases of severe cardiogenic shock.Hemodynamic studies were obtained in 9 patients. Hemodynamic effects of dopamine were studied in 6 cases of cardiogenic shock.