Vasopressor Dose Research Articles

1244: CAN ADMINISTRATION OF HIGH-DOSE HYDROXOCOBALAMIN IMPROVE OUTCOMES IN REFRACTORY SEPTIC SHOCK?

Introduction: Multiple high dose vasopressors are often required to sustain life in critically ill patients but are unfortunately associated with high mortality (>50%) and morbidity. This case discusses the potential benefit in adding high dose IV hydroxocobalamin (B12) therapy (5g) to potentially reduce the use of additional vasopressors and their impact on morbidity and mortality. Description: A 72-year-old immunocompromised man with history of multiple myeloma, refractory to multiple lines of therapy, prior CAR-T treatment with now stable disease was found down, covered in feces. He was admitted to the medical ICU for severe septic shock secondary to pseudomonas bacteremia. The patient progressed to Multiorgan failure requiring mechanical ventilation, broad spectrum antibiotics, and multiple vasopressors at maximum doses. Echocardiogram (echo) showed biventricular heart failure with ejection fraction (EF) reduced from 64% 4 months prior to 25%. The bronchoalveolar lavage sample grew Pseudomonas aeruginosa, and antibiotics were adjusted. He was requiring norepinephrine (NE) at 0.3 mcg/kg/min, vasopressin (vaso) at 0.04 units/min, epinephrine (epi) to 0.3 mcg/kg/min, angiotensin II (ATII) between 10-40 ng/kg/min, and dobutamine (dobut) as high as 12.5 mcg/kg/min for 47 hours before B12 administration. The patient remained hypotensive (MAP < 65 mmHg) with maximal vasopressors. The left hand become cold and discolored, his legs and abdomen became severely mottled. Due to lack of response to therapy a trial of 5g B12 was given. There was improvement in the patient’s blood pressure. NE and ATII were stopped within 24 hours, Epi and vaso stopped within 96 hours, and dobut was weaned gradually. He was extubated on day 12. EF improved to 60% with normal right ventricular function on day 14. The skin gradually returned to normal. The left-hand fingers appeared better perfused with only the tip remaining discolored. Discussion: Bacterial endotoxins released in sepsis induce nitric oxide synthase, activating cGMP, which causes subsequent smooth muscle inhibition and vasodilation. B12 scavenges nitric oxide decreasing vasodilation. Use of B12 as an adjuvant to traditional vasopressor therapy could help reduce morbidity and mortality in septic shock by reducing overall dose/duration of vasopressors.

Initial evaluation of extracorporeal immunomodulatory therapy for the treatment of critically ill COVID-19 infected patients

Severe COVID-19 infection results in significant immune dysregulation resulting from excessive recruitment and activation of neutrophils. The aim of this study was to confirm feasibility, initial safety and detect signal of efficacy of a non-propriety device delivered using an intermittent extra-corporeal system (LMOD) allowing leucocytes modulation in the setting of Severe COVID-19 infection. Twelve patients were recruited. Inclusion criteria were > 18 years age, confirmed COVID-19, acute respiratory distress syndrome requiring mechanical support and hypotension requiring vasopressor support. Primary end point was vasopressor requirements (expressed as epinephrine dose equivalents) and principle secondary endpoints related to safety, ability to deliver the therapy and markers of inflammation assessed over five days after treatment initiation. LMOD treatment appeared safe, defined by hemodynamic stability and no evidence of white cell number depletion from blood. We demonstrated a significant decrease in vasopressor doses (−37%, p = 0.02) in patients receiving LMOD therapy (despite these patients having to tolerate an additional extracorporeal intermittent therapy). Vasopressor requirements unchanged/increasing in control group (+ 10%, p = 0.48). Although much about the use of this therapy in the setting of severe COVID-19 infection remains to be defined (e.g. optimal dose and duration), this preliminary study supports the further evaluation of this novel extracorporeal approach.

Successful Extracorporeal Blood Purification Therapy using Double Haemoadsorption Device in Severe Endotoxin Septic Shock: A Case Report.

In patients admitted to the Intensive Care Unit (ICU), sepsis can lead to acute kidney injury (AKI), which may require the initiation of continuous renal replacement therapy (CRRT) in 15-20% of cases. There is no consensus about the best extracorporeal treatment to choose in septic patients with AKI. We describe the case of a 70-year-old woman admitted to the ICU with a severe endotoxin septic shock due to Neisseria meningitidis serogroup C. Despite prompt medical intervention, including fluid resuscitation, high dose vasopressor, inotrope support, and broad-spectrum antimicrobial treatment, in a few hours patient's haemodynamic worsened and she developed multi-organ failure, including severe AKI, requiring CRRT. So, continuous veno-venous haemodiafiltration was started, using an oXiris® haemodiafilter set, in series with an adsorber device (CytoSorb®). After 48 hours of this combined extracorporeal treatment, haemodynamic parameters improved, allowing a significant reduction of the vasoactive therapy, with a concomitant decrease in endotoxin and inflammatory markers serum levels. In the following days patient's conditions still improved and renal function recovered. Timely extracorporeal blood purification therapy, using a double haemoadsorption device, may be effective in the management of severe septic shock.

Abstract 9457: Primary Cardiac Allograft Dysfunction Caused by Pretransplantation Amiodarone Therapy

Background: Primary graft dysfunction (PGD) is devastating. Amiodarone therapy prior to cardiac transplantation (TxP) is common but has recently been reported as potential cause of PGD. Case: 66-year-old male with non-ischemic cardiomyopathy, severely reduced LVEF with LVAD, recurrent VT on amiodarone for 6 months presented with ICD shocks. Amiodarone was increased due to VT storm in the setting of Rhinovirus infection. Infusions with amiodarone and lidocaine were started but repeat IV boli of lidocaine and amiodarone were needed. VT-ablation was not feasible due to multiple morphologies. He underwent TxP with an ideal organ from a 28 yo donor. Paragonix SherpaPak was used for transport. Pre-explanation EF was 70% with serologies positive for EBV (+/+), Strongyloides (+/-), negative for Toxoplasmosis (-/-), CMV (-/-). Donor heart was arrested with appropriate cardioplegia and no distention occurred. Total ischemic time was 3 hours 10 minutes, warm ischemic time 40 minutes, crossclamp time in recipient 2 hours 2 minutes with total cardiopulmonary bypass time 2 hours 58 minutes. Coming off bypass both ventricles appeared markedly dilated with severely reduced function and due to high doses of inotropic and vasopressor support veno-arterial ECMO was placed. The chest was left open and during postoperative course in the intensive care unit pressor and inotropes could slowly weaned. Induction therapy was administered with ATG, Solumedrol and mycophenolate mofetil. Strongyloides infection was treated with four doses of Ivermectin. On postoperative day LVEF recovered to 40-45% with moderately reduced RV function and patient was successfully decannulated from VA ECMO with chest closure. Endomyocardial biopsies showed no signs of rejection throughout. After prolonged ICU and rehab stay patient has now recovered to independent life. Conclusion: Amiodarone associated PGD may be underreported and increasing awareness of this etiology may warrant early empiric discontinuation of the medication if transplantation remains a therapeutic option in the future.

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.

Abstract 12005: Association of Prehospital Hypotension Depth and Dose With Survival Following Out-of-Hospital Cardiac Arrest

Introduction: Hypotension following resuscitation from out-of-hospital cardiac arrest (OHCA) may cause harm by exacerbating secondary brain injury; however, limited research has explored this relationship. Our objective was to examine the association between duration and depth of prehospital post return of spontaneous circulation (ROSC) hypotension and survival. Hypothesis: We hypothesized that increased severity and duration of post-ROSC hypotension in the prehospital setting would be associated with unfavorable patient outcomes. Methods: We utilized the 2019 and 2020 ESO Data Collaborative public use research data sets for this study (ESO, Austin, TX). Hypotension dose (mmHg*min.), average prehospital systolic blood pressure (SBP), and lowest recorded prehospital SBP were calculated. The association of these measures with survival to home (STH) and rearrest were explored using multivariable logistic regression. Time to hypotension resolution analyses were conducted using Cox proportional hazards models adjusted for known prognostic factors according to the Utstein template. We also assessed the association of hypotension management strategy (push dose vasopressors, vasopressor infusion, or fluid only) with survival, rearrest, and time to hypotension resolution. Results: 17,280 OHCA patients met inclusion criteria, of which 3,345 had associated hospital outcome data. Over one-third (37.8%; 6,526/17,280) of all patients had at least one recorded SBP below 90 mmHg. When modeled continuously, average prehospital SBP (1.19 [1.15, 1.23] per 10 mmHg), lowest prehospital SBP (1.20 [1.17, 1.24] per 10 mmHg), and hypotension dose (0.995 [0.993, 0.996] per mmHg*min.) were independently correlated with STH. Differences in hypotension management were not associated with differences in survival, rearrest, or time to hypotension resolution. Conclusion: Severity and duration of hypotension were significantly associated with poorer outcomes in this dataset. The incidence of hypotension was significantly associated with known unfavorable prognostic factors. Defining a threshold for hypotension requiring treatment above the classical SBP threshold of 90 mmHg may be warranted in the setting of prehospital post-resuscitation care.

Vasodilation in patients with calcium channel blocker poisoning treated with high-dose insulin: a comparison of amlodipine versus non-dihydropyridines

Background: High dose insulin (HDI), an inotrope and vasodilator, is a standard therapy for calcium channel blocker (CCB) poisoning. HDI causes vasodilation by stimulating endothelial nitric oxide synthase (eNOS). Most literature supporting HDI for CCB poisoning involves verapamil toxicity; however, amlodipine now causes more CCB poisonings. Unlike other CCBs, amlodipine stimulates eNOS and may cause synergistic vasodilation with HDI. The purpose of this study was to determine if amlodipine-poisoned patients treated with HDI had more evidence of vasodilation than similarly treated patients with non-dihydropyridine (non-DHP) poisoning. Methods: This was a retrospective study from a single poison center. Cases were identified via the generic code “Calcium Antagonists” in which the therapy “High Dose Insulin/Glucose” was “performed, whether or not recommended” from 2019–2021. Evidence of vasodilation was assessed via maximum number of vasopressor infusions per case, vasopressor doses, and use of rescue methylene blue to treat refractory vasoplegia. Results: Thirty-three patients were enrolled: 18 poisoned with amlodipine, 15 with non-DHPs (verapamil n = 10, diltiazem n = 5). The median number of maximum concomitant vasopressors in the amlodipine group was 3 (IQR: 2–5; range 0–6) and 2 in the non-DHP group (IQR: 1–3; range 0–5; p = 0.04); median difference in maximum concomitant vasopressors between groups was 1 (95% confidence interval: 0–2). Median maximum epinephrine dosing was higher in the amlodipine group (0.31 mcg/kg/min) compared to non-DHPs (0.09 mcg/kg/min; p = 0.03). Use of rescue methylene blue was more common in the amlodipine group (7/18 [39%]) than in the non-DHP group (0; p = 0.009). Conclusions: Amlodipine poisoned patients treated with HDI required more vasopressors, higher doses of epinephrine, and more often received rescue methylene blue than similarly treated patients with verapamil or diltiazem poisoning. These differences suggest amlodipine-poisoned patients had more evidence of vasodilation. Further study is warranted to determine if synergistic vasodilation occurs when HDI is used to treat amlodipine poisoning.

Biventricular unloading with impella and venoarterial extracorporeal membrane oxygenation in severe refractory cardiogenic shock: prognosis and implications from the combined use of the devices

Abstract Background Patients with refractory cardiogenic shock (RCS) may present with left ventricle (LV)-failure, biventricular failure or even combined cardiopulmonary failure. Mechanical support with Impella or veno-arterial membrane oxygenation (VA-ECMO) have emerged as an alternative strategy in order to stabilize the heart function without the detrimental effects of catecholamines or to bridge the patients in definite therapies. However, the selection of the appropriate MCS should be tailored according to the underlying pathophysiology and properties of the respective MCS device. Patients with Impella who initially presented with univentricular LV failure may develop additionally right ventricle (RV) dysfunction or pulmonary failure whereas patients with VA-ECMO may show signs of LV overloading, causing pulmonary edema, LV distension and thus compromising LV myocardial recovery. Purpose To present the main outcomes and predictors of survival and safety in RCS treated with Impella and VA-ECMO. Methods Single center study of consecutive patients with biventricular unloading with Impella and VA-ECMO for RCS admitted to Cardiology department of Philipps University in Marburg, Germany, from February 2013 until December 2019. The selection of the device was based on a standard algorithm (Figure 1). Results A total of 67 patients was included in the study. Mean age was 61.07±10.7 and 54 (80.6%) patients were male. Main cause of RCS was acute myocardial infarction (AMI) (74.6%), while 44 (65.7%) were resuscitated prior to admission. In 28 patients Impella was implanted first, whereas VA-ECMO was the first MCS device in 39 patients. The mean Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment Score (SOFA) score on admission was 73.54±16.03 and 12.25±2.71, respectively, corresponding to an expected mortality of higher than 80%. Vasopressor doses and lactate levels were significantly decreased within 72 h on biventricular support (p&amp;lt;0.05 for both). Overall, 17 (25.4%) patients were discharged to cardiac rehabilitation and 5 patients (7.5%) were bridged successfully to ventricular assist device implantation, leading to a total of 32.8% survival on hospital discharge. The 6-month survival was 31.3%. Lactate &amp;gt;6 mmol/L, vasoactive score &amp;gt;100 and pH &amp;lt;7.26 on initiation of biventricular support, as well as Charlson comorbity index (CCI) &amp;gt;3 and prior resuscitation were independent predictors of survival (Figure 2). Conclusions Biventricular support with Impella and VA-ECMO in patients with RCS is feasible and efficient leading to a better survival than predicted through traditional risk scores, mainly via significant hemodynamic improvement and reduction in lactate levels. Lactate, pH and vasoactive score on initiation of biventricular support, as well as age-adjusted CCI and prior resuscitation are independent risk factors associated with mortality in this group of patients. Funding Acknowledgement Type of funding sources: None.

Midodrine in treatment of post coronary revascularization vasoplagia; pilot, open label, assessor blinded randomized clinical trial

Abstract Purpose Post cardiac surgery hypotension and inotrope dependence are among major causes of prolonged intensive care unit (ICU) stay. Besides routine managements, catecholamine inotrope-vasopressors are the traditional treatment. However, there is an increasing interest to catecholamine-sparing agents, such as Midodrine, oral alfa1 agonist, in patients with vasoplegia. Up to now there are no randomized study with midodrine on post cardiac surgery patients. Material and method In this pilot, open label, assessor blind, randomized clinical trial from June 2020 to December 2021, 65 patients with refractory (more than 24 hours inotropes) hypotension after coronary revascularization were included. Patients were randomly assigned to receive Midodrine add-on therapy (10 mg stat and 5 mg po every 12 hours) or placebo add-on routine treatment. The primary outcome was liberation time from IV inotrope-support. Secondary outcomes were ICU admission time and total vasopressor dosage after randomization. Results 32 patients enrolled in Midodrine group, with a mean age of 60.72, and 33 patients received placebo with mean age of 63.27. Median liberation time from inotrope was 27 hours in Midodrine group and 49 hours in placebo group (p=0.022). ICU admission time for Midodrine and placebo groups were 115 and 121 hours, respectively (p=0.990). Total vasopressor dosage after randomization were similar in two studied groups, 4352 μg in Midodrine group and 5637 μg in placebo group (p=0.405). No adverse event was observed in Midodrine group. Conclusion Midodrine add-on inotrope therapy was a safe medication with appropriate compliance in ICU admitted patients after cardiac surgery, which seems to decrease the inotrope dependent time. Funding Acknowledgement Type of funding sources: None.

MIMICKER OF MYOCARDIAL INFARCTION (MI): PHENYLEPHRINE-ASSOCIATED CORONARY VASOSPASM

MIMICKER OF MYOCARDIAL INFARCTION (MI): PHENYLEPHRINE-ASSOCIATED CORONARY VASOSPASM

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.

Association of prehospital hypotension depth and dose with survival following out-of-hospital cardiac arrest

IntroductionHypotension following resuscitation from out-of-hospital cardiac arrest (OHCA) may cause harm by exacerbating secondary brain injury; however, limited research has explored this relationship. Our objective was to examine the association between duration and depth of prehospital post return of spontaneous circulation (ROSC) hypotension and survival. MethodsWe utilized the 2019 and 2020 ESO Data Collaborative public use research data sets for this study (ESO, Austin, TX). Hypotension dose (mmHg*min.), average prehospital systolic blood pressure (SBP), and lowest recorded prehospital SBP were calculated. The association of these measures with survival to home (STH) and rearrest were explored using multivariable logistic regression. Time to hypotension resolution analyses by hypotension management strategy (push dose vasopressors, vasopressor infusion, or fluid only) were conducted using adjusted Cox proportional hazards models. Results17,280 OHCA patients met inclusion criteria, of which 3,345 had associated hospital outcome data. Over one-third (37.8%; 6,526/17,280) of all patients had at least one recorded SBP below 90 mmHg. When modeled continuously, average prehospital SBP (1.19 [1.15, 1.23] per 10 mmHg), lowest prehospital SBP (1.20 [1.17, 1.24] per 10 mmHg), and hypotension dose (0.995 [0.993, 0.996] per mmHg*min.) were independently associated with STH. Differences in hypotension management were not associated with differences in survival or time to hypotension resolution. ConclusionSeverity and duration of hypotension were significantly associated with worse outcomes in this dataset. Defining a threshold for hypotension requiring treatment above the classical SBP threshold of 90 mmHg may be warranted in the setting of prehospital post-resuscitation care.

High-Dose IV Hydroxocobalamin (Vitamin B12) in Septic Shock: A Double-Blind, Allocation-Concealed, Placebo-Controlled Single-Center Pilot Randomized Controlled Trial (The Intravenous Hydroxocobalamin in Septic Shock Trial)

Elevated hydrogen sulfide (H2S) contributes to vasodilatation and hypotension in septic shock, and traditional therapies do not target this pathophysiologic mechanism. High-dose IV hydroxocobalamin scavenges and prevents H2S formation, which may restore vascular tone and may accentuate recovery. No experimental human studies have tested high-dose IV hydroxocobalamin in adults with septic shock. In adults with septic shock, is comparing high-dose IV hydroxocobalamin with placebo feasible? We conducted a phase 2 single-center, double-blind, allocation-concealed, placebo-controlled, parallel-group pilot randomized controlled trial comparing high-dose IV hydroxocobalamin with placebo in critically ill adults with septic shock. Patients meeting Sepsis 3 criteria were randomized 1:1 to receive a single 5-g dose of high-dose IV hydroxocobalamin or equivalent volume 0.9%saline solution as placebo. The primary outcome was study feasibility (enrollment rate, clinical and laboratory compliance rate, and contamination rate). Secondary outcomes included between-group differences in plasma H2S concentrations and vasopressor dose before and after infusion. Twenty patients were enrolled over 19months, establishing an enrollment rate of 1.05 patients per month. Protocol adherence rates were 100%with zero contamination. In the high-dose IV hydroxocobalamin group, compared to placebo, there was a greater reduction in vasopressor dose between randomization and postinfusion (-36%vs4%, P< .001) and randomization and 3-h postinfusion (-28%vs10%, P= .019). In the high-dose IV hydroxocobalamin group, the plasma H2S level was reduced over 45 mins by -0.80 ± 1.73 μM, as compared with -0.21 ± 0.64 μM in the placebo group (P= .3). This pilot trial established favorable feasibility metrics. Consistent with the proposed mechanism of benefit, high-dose IV hydroxocobalamin compared with placebo was associated with reduced vasopressor dose and H2S levels at all time points and without serious adverse events. These data provide the first proof of concept for feasibility of delivering high-dose IV hydroxocobalamin in septic shock. ClinicalTrials.gov; No.: NCT03783091; URL: www. gov.

The safety and efficacy of push dose vasopressors in critically ill adults

PurposeTo evaluate practice patterns, efficacy, and safety of push dose pressors (PDP) in critically ill patients outside of the operating room (OR) at a large academic medical center. Materials and methodsThis was a single-center, retrospective cohort study (June 2018 to July 2020) conducted at a 1273-bed academic medical center. The primary outcome was efficacy, defined as a 25% increase in systolic blood pressure, and the cohort was analyzed according to PDP response (i.e. responders versus non-responders). A logistic regression model was used to assess predictors of response to PDPs. Safety outcomes included the incidence of hypertension, bradycardia, and tachycardia. Results1727 patients were included in the final analysis. The median doses of phenylephrine and epinephrine administered were 400 μg (IQR 200–888 μg) and 50 μg (IQR 20–100 μg). The primary outcome was achieved in 102 (71.8%) patients in the epinephrine group and 1140 (55.9%) of patients in the phenylephrine group. Adverse effects after PDP receipt were minimal, with the most common being hypertension in 6.6% and 13.4% of the phenylephrine and epinephrine groups respectively. ConclusionsThis study demonstrates that PDP phenylephrine and epinephrine are safe and efficacious in treating the acute hypotensive period.

Endovascular Perfusion Augmentation After Resuscitative Endovascular Balloon Occlusion of the Aorta Improves Renal Perfusion and Decreases Vasopressors

IntroductionResuscitative endovascular balloon occlusion of the aorta (REBOA) causes a severe ischemia-reperfusion injury. Endovascular Perfusion Augmentation for Critical Care (EPACC) has emerged as a hemodynamic/mechanical adjunct to vasopressors and crystalloid for the treatment of post-REBOA ischemia-reperfusion injury. The objective of the study is to examine the impact of EPACC as a tool for a wean from complete REBOA compared to standard resuscitation techniques. MethodsNine swine underwent anesthesia and then a controlled 30% blood volume hemorrhage with 30 min of supraceliac total aortic occlusion to create an ischemia-reperfusion injury. Animals were randomized to standardized critical care (SCC) or 90 min of EPACC followed by SCC. The critical care phase lasted 270 min after injury. Hemodynamic markers and laboratory values of ischemia were recorded. ResultsDuring the first 90 min the intervention phase SCC spent 60% (54%-73%) and EPACC spent 91% (88%-92%) of the time avoiding proximal hypotension (<60 mm Hg), P = 0.03. There was also a statistically significant decrease in cumulative norepinephrine dose at the end of the experiment between SCC (80.89 mcg/kg) versus EPACC (22.03 mcg/kg), P = 0.03. Renal artery flow during EPACC was similar compared to SCC during EPACC, P = 0.19. But during the last hour of the experiment (after removal of aortic balloon) the renal artery flow in EPACC (2.9 mL/kg/min) was statistically significantly increased compared to SCC (1.57 mL/min/kg), P = 0.03. There was a statistically significant decrease in terminal creatinine in the EPACC (1.7 mg/dL) compared to SCC (2.1 mg/dL), P = 0.03. ConclusionsThe 90 min of EPACC as a weaning adjunct in the setting of a severe ischemia-reperfusion injury after complete supraceliac REBOA provides improved renal flow with improvement in terminal creatinine compared to SCC with stabilized proximal hemodynamics and decreased vasopressor dose.

Case Report: Role of transesophageal echocardiography in a patient with an initially misdiagnosed acute pulmonary embolism

Background: For the diagnosis of acute pulmonary embolism, chest computerized tomography (CT) angiography is considered as the gold standard. However, echocardiography could be useful especially in cases of high suspicion with normal CT scan or for patient with hemodynamic instability. Case presentation: We present a case of a 47-year-old man admitted to the intensive care unit with a diagnosis of respiratory failure and hemodynamic instability 24 hours after closed fracture of the right leg. Before his admission, a thoracic CT angiography was done but did not show any sign of acute pulmonary embolism. During the first hours, he presented a bad evolution with a respiratory status which failed to respond to high dose of vasopressor, oxide nitric and ventilatory support. Therefore, due to the poor echocardiographic window, transesophageal echocardiography examination was done in emergency. It revealed high-probability diagnosis of massive pulmonary embolism based on right ventricular dysfunction and the presence of thrombus in the right pulmonary artery. Anticoagulant therapy (non-fractioned heparin) was administrated immediately achieving a favorable clinical outcome with rapid withdrawal of dobutamine, nitric oxide and norepinephrine. Conclusions: This case illustrates the fundamental role of transesophageal echocardiography in a critically ill patient with shock due to high-probability pulmonary embolism. Echocardiography allows the initiation of adequate treatment without further delay.

The Relationship Between Norepinephrine Equivalent Dose of Vasopressors Within 24 Hours From the Onset of Septic Shock and In-Hospital Mortality Rate

The reported mortality rate of septic shock is 30% to 40%.1 However, these reported mortality rates do not take into consideration the severity of septic shock. There remains limited evidence on the prognosis of patients with septic shock whose condition requires higher doses of vasopressors. Although it is commonly perceived that higher doses of vasopressors translate into worsened clinical outcomes, the complex relationship between vasopressor dose and death has not been well-described. Therefore, we investigated the relationship between cumulative vasopressor dosage and in-hospital mortality rates in patients with septic shock.

The Association of High Dose Vasopressor and Delayed Vasopressor Titration with 28-Day Mortality in Adult Patients with Septic Shock

Objective: This study aimed to investigate any association between vasopressor dose and mortality, and to identify factors independently associated with 28-day mortality in adult patients with septic shock. Material and Methods: Adult septic shock patients admitted to internal medicine wards; from May 2018-November 2020, were retrospectively included. Collected data included: patient demographics and clinical characteristics, baseline vital signs, source of infection, vasopressor dose, treatment modalities and patient outcomes. The primary outcome was 28-day mortality. Results: From 253 patients, 54.9% survived, and 45.1% died. Compared to survivors, non-survivors had a significantly higher median Acute Physiology and Chronic Health Evaluation II score, higher median baseline serum lactate level and required a higher median-maximum dose of vasopressor. Multivariate analysis showed the maximum dose of vasopressor &gt;0.2 mcg/kg/min (odd ratio (OR): 2.91, 95% confidence interval (CI): 1.13-7.47; p-value=0.027), time to maximum dose of vasopressor after 24 hours (OR: 4.98, 95%Cl: 2.07-11.99; p-value&lt;0.001), Sequential Organ Failure Assessment score &gt;10 (OR: 2.92, 95%CI: 1.27-6.71; p-value=0.012), pneumonia (OR: 2.16, 95%CI: 1.01-4.61; p-value=0.047) and receiving fluid resuscitation during the first 24 hours &lt;3,000 mL (OR: 2.27, 95%CI: 1.05-4.89; p-value=0.037) to be independent predictors of 28-day mortality. Conclusions: A higher intensity of vasopressor and longer time to maximum dose of vasopressor were found to be independent predictors of septic shock mortality.

A Prospective Randomized Study Comparing the Bolus Doses of Norepinephrine and Phenylephrine for the Treatment of Spinal Induced Hypotension in Cesarean Section.

Background: Spinal anesthetic-induced hypotension is the most worrisome complication for patients undergoing cesarean section under spinal anesthesia. The present study compares norepinephrine and phenylephrine bolus for the treatment of hypotension during spinal anesthesia for cesarean section.Methods: One hundred twenty- six women aged between 22 and 40 years with singleton pregnancy classified to the American Society of Anesthesiologists (ASA) physical class I and II posted for elective cesarean section under spinal anesthesia were randomly divided into two groups of 63 each. Group I patients received phenylephrine 50 mcg (microgram) as an intravenous bolus, and Group II received 4 mcg of norepinephrine as an intravenous bolus to treat spinal hypotension.Results: On comparing the demographic data of the patients in terms of age, weight, height, ASA Grade, level of block and surgery time no significant differences were found between the groups. Similarly, the fetal parameters were found to be not significantly different between the groups. However, the number of bolus doses of vasopressors required for the treatment of spinal-induced hypotension was significantly reduced in Group II (p=0.02). The frequency of bradycardia was found to be higher in patients who were given phenylephrine as compared to patients administered noradrenaline boluses (p=0.03). Five (7.93%) patients had shivering in Group I, while similar episodes were observed in 10 (15.87%) patients (p=0.05). Moreover, no significant difference was observed in comparing the heart rate and mean arterial pressure between the groups.Conclusion: Intermittent boluses of norepinephrine are found to be effective in the management of spinal‑induced hypotension during caesarean section.

Evaluation of Vasopressor Dose and the Incidence of Pressure Injuries in Critically Ill Patients.

To evaluate risk factors associated with vasopressor use and development of hospital-acquired pressure injuries (HAPIs). The researchers conducted a retrospective chart review in a 12-bed medical ICU at a community hospital. A total of 123 patients who received a minimum of 24 hours of continuous vasopressor administration between January 2017 and January 2019 were included. The primary outcomes assessed were vasopressor dose and HAPI incidence, with a subgroup analysis based on type. Secondary outcomes included quantity of vasopressors, duration, mean arterial pressure, mechanical ventilation, time to injury, severity, and location. The overall incidence of HAPIs was 20.3%, with 17% incidence in the low-dose cohort and 22.4% in the high-dose cohort ( P = .317). There were no differences in the subgroup analysis based on vasopressor type. The most common locations for injuries were the sacrum and coccyx, with the majority being stage 1 or 2 based on the National Pressure Injury Advisory Panel severity staging. No correlations were found between HAPI incidence and factors such as multiple vasopressors use, mechanical ventilation, mean arterial pressure, or duration of vasopressor administration. The documentation of time to injury was significantly shorter in the high-dose cohort compared with the low-dose cohort (157.58 vs 330.86 hours, P < .05). The incidence of HAPIs did not differ between the low- and high-dose vasopressor cohorts. However, patients who received higher doses of vasopressors had documented pressure injuries sooner than the low-dose cohort, emphasizing the importance of close monitoring for HAPIs in patients receiving vasopressors.