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Benken ST, Thomas R, Fraidenburg DR, Benken JJ. Angiotensin II as a Vasopressor for Perioperative Hypotension in Solid Organ Transplant. Biomedicines 2024; 12:1817. [PMID: 39200281 PMCID: PMC11351893 DOI: 10.3390/biomedicines12081817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Revised: 07/29/2024] [Accepted: 08/07/2024] [Indexed: 09/02/2024] Open
Abstract
During the perioperative period of transplantation, patients experience hypotension secondary to the side effects of anesthesia, surgical stress, inflammatory triggering, and intraoperative fluid shifts, among others causes. Vasopressor support, in this context, must reverse systemic hypotension, but ideally, the agents used should benefit allograft function and avoid the adverse events commonly seen after transplantation. Traditional therapies to reverse hypotension include catecholamine vasopressors (norepinephrine, epinephrine, dopamine, and phenylephrine), but their utility is limited when considering allograft complications and adverse events such as arrhythmias with agents with beta-adrenergic properties. Synthetic angiotensin II (AT2S-[Giapreza]) is a novel vasopressor indicated for distributive shock with a unique mechanism of action as an angiotensin receptor agonist restoring balance to an often-disrupted renin angiotensin aldosterone system. Additionally, AT2S provides a balanced afferent and efferent arteriole vasoconstriction at the level of the kidney and could avoid the arrhythmic complications of a beta-adrenergic agonist. While the data, to date, are limited, AT2S has demonstrated safety in case reports, pilot studies, and small series in the kidney, liver, heart, and lung transplant populations. There are physiologic and hemodynamic reasons why AT2S could be a more utilized agent in these populations, but further investigation is warranted.
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Affiliation(s)
- Scott T. Benken
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL 60612, USA; (R.T.); (J.J.B.)
| | - Riya Thomas
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL 60612, USA; (R.T.); (J.J.B.)
| | - Dustin R. Fraidenburg
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago College of Medicine, Chicago, IL 60612, USA;
| | - Jamie J. Benken
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL 60612, USA; (R.T.); (J.J.B.)
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Johnson AJ, Tidwell W, McRae A, Henson CP, Hernandez A. Angiotensin-II for vasoplegia following cardiac surgery. Perfusion 2023:2676591231215920. [PMID: 37955639 DOI: 10.1177/02676591231215920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
INTRODUCTION The objective of this study was to describe the implementation and outcomes of a protocol outlining angiotensin-II utilization for vasoplegia following cardiac surgery. METHODS This was a retrospective chart review at a single-center university hospital. Included patients received angiotensin-II for vasoplegia refractory to standard interventions, including norepinephrine 20 mcg/min and vasopressin 0.04 units/min, following cardiac surgery between April 2021 and April 2022. RESULTS 30 patients received angiotensin-II for refractory vasoplegia. Adjunctive agents at angiotensin-II initiation included corticosteroids (26 patients; 87%), epinephrine (26 patients; 87%), dobutamine (17 patients; 57%), dopamine (9 patients; 30%), milrinone (2 patients; 7%), and hydroxocobalamin (4 patients; 13%). At 3 hours, the median mean arterial pressure increased from baseline (70 vs 61.5 mmHg, p = .0006). Median norepinephrine doses at angiotensin-II initiation, 1 hour, 3 hours, and angiotensin-II discontinuation were 0.22, 0.16 (p = .0023), 0.10 (p < .0001), and 0.07 (p < .0001) mcg/kg/min. Median dobutamine doses decreased throughout angiotensin-II infusion from eight to six mcg/kg/min (p = .0313). Other vasoactive medication doses were unchanged. Three patients (10%) subsequently received hydroxocobalamin. Thirteen (43.3%) and five (16.7%) patients experienced mortality by day 28 and venous or arterial thrombosis events, respectively. CONCLUSIONS The administration of angiotensin-II to vasoplegic patients following cardiac surgery was associated with increased mean arterial pressure, reduced norepinephrine dosages, and reduced dobutamine dosages.
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Affiliation(s)
- Andrew J Johnson
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - William Tidwell
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andrew McRae
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - C Patrick Henson
- Department of Anesthesia, Division of Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Antonio Hernandez
- Department of Anesthesia, Division of Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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ARNI Pre-Operative Use and Vasoplegic Syndrome in Patients Undergoing Heart Transplantation or Left Ventricular Assist Device Surgery. Med Sci (Basel) 2021; 10:medsci10010002. [PMID: 35076588 PMCID: PMC8788526 DOI: 10.3390/medsci10010002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/09/2021] [Accepted: 12/18/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Vasoplegic syndrome after orthotopic heart transplantation (OHT) or left ventricular assist device (LVAD) implantation is a rare but highly lethal syndrome with complex etiologies. The objective of this study was to assess if the preoperative use of sacubitril-valsartan combination is associated with an increased vasoplegic syndrome (VS) frequency after OHT or LVAD implantation and its relationship with 30-day mortality. Methods: A retrospective review of perioperative data, between January 2016 and December 2017, from 73 consecutive OHT and LVAD surgery adult patients at our institution was performed. VS was defined as normal cardiac output with persistent low systemic resistance requiring a norepinephrine intravenous perfusion > 0.5 µg/kg/min and the absence of sepsis or hemorrhagic shock within 48 h after surgery. Patients were all followed-up for adverse events and all-cause mortality at 30 days. Results: In our cohort of 73 patients (median age 51.7 years, 65% male patients), 25 (34%) patients developed VS. Twenty-two (30.1%) patients were on ARNI at the time of surgery, 31 (42.5%) were on other RAS blockers, 12 (16.4%) were on norepinephrine and 8 (11%) had no pre-operative drug. The pre-operative use of any vasoactive agent, was not significantly associated with VS (OR = 1.36; IC95% [0.78; 2.35]; p = 0.38). The pre-operative use of an ARNI compared to all other groups was not significantly associated with VS (OR = 2.0; IC95% [0.71; 5.62]; p = 0.19). The pre-operative use of an ARNI compared to other RAS blockers was also not significantly associated with VS (OR = 1.25; IC95% [0.37; 4.26]; p = 0.72). At 30 days, 18 (24.7%) patients had died. The pre-operative treatment with ARNI, or other RAS inhibitors was associated with a significantly lower rate of death compared to the absence of treatment (HR = 0.11; IC95% [0.02; 0.55]; p = 0.009 for ARNI and HR = 0.20; IC95% [0.06; 0.69]; p = 0.011 for other RASi). Conclusions: Preoperative use of sacubitril-valsartan was not significantly associated with development of vasoplegic syndrome in patients undergoing OHT or LVAD surgery. Furthermore, our data suggests a significant 30-day survival benefit with efficient renin-angiotensin blockade before surgery.
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Chow JH, Wittwer ED, Wieruszewski PM, Khanna AK. Evaluating the evidence for angiotensin II for the treatment of vasoplegia in critically ill cardiothoracic surgery patients. J Thorac Cardiovasc Surg 2021; 163:1407-1414. [PMID: 33875258 DOI: 10.1016/j.jtcvs.2021.02.097] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 02/11/2021] [Accepted: 02/17/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Jonathan H Chow
- Anesthesiology and Critical Care Medicine, George Washington University School of Medicine, Washington, DC
| | - Erica D Wittwer
- Anesthesiology & Critical Care Medicine, Mayo Clinic School of Medicine, Rochester, Minn
| | - Patrick M Wieruszewski
- Anesthesiology & Critical Care Medicine, Mayo Clinic School of Medicine, Rochester, Minn
| | - Ashish K Khanna
- Section on Critical Care Medicine, Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC; Outcomes Research Consortium, Cleveland, Ohio.
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Abstract
Purpose Vasoplegia is a common complication after cardiac surgery and is related to the use of cardiopulmonary bypass (CPB). Despite its association with increased morbidity and mortality, no consensus exists in terms of its treatment. In December 2017, angiotensin II (AII) was approved by the Food and Drug Administration (FDA) for use in vasodilatory shock; however, except for the ATHOS-3 trial, its use in vasoplegic patients that underwent cardiac surgery on CPB has mainly been reported in case reports. Thus, the aim of this review is to collect all the clinically relevant data and describe the pharmacologic mechanism, efficacy, and safety of this novel pharmacologic agent for the treatment of refractory vasoplegia in this population. Methods Two independent reviewers performed a systematic search in PubMed, Embase, Web of Science, and Cochrane Library using relevant MeSH terms (Angiotensin II, Vasoplegia, Cardiopulmonary Bypass, Cardiac Surgical Procedures). Results The literature search yielded 820 unique articles. In total, 9 studies were included. Of those, 2 were randomized clinical trials (RCTs) and 6 were case reports and 1 was a retrospective cohort study. Conclusions AII appears to be a promising means of treatment for patients with post-operative vasoplegia. It is demonstrated to be effective in raising blood pressure, while no major adverse events have been reported. It remains uncertain whether this agent will be broadly available and whether it will be more advantageous in the clinical management of vasoplegia compared to other available vasopressors. For that reason, we should contain our eagerness and enthusiasm regarding its use until supplementary knowledge becomes available. Electronic supplementary material The online version of this article (10.1007/s10557-020-07098-3) contains supplementary material, which is available to authorized users.
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Rodriguez R, Fernandez EM. Role of angiotensin II in treatment of refractory distributive shock. Am J Health Syst Pharm 2020; 76:101-107. [PMID: 31361800 DOI: 10.1093/ajhp/zxy014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Clinical data and gaps in knowledge regarding angiotensin II (AT2), which was approved by the Food and Drug Administration in December 2017 via priority review for treatment of septic and other vasodilatory shock, is discussed. SUMMARY AT2 is an endogenous peptide that raises blood pressure via vasoconstriction and increased aldosterone release. It was previously available but withdrawn from the US market; previous low-quality research describes increases in mean arterial pressure (MAP). The recent approval of AT2 was based on data from a Phase III randomized trial comparing i.v. AT2 (n = 163) with placebo use (n = 158) in patients with vasodilatory shock receiving high doses of other vasopressors. AT2 significantly increased achievement of the primary endpoint, MAP response at 3 hours after the start of infusion, relative to placebo use (69.9% [n = 114] versus 23.4% [n = 37], p < 0.0001). Serious adverse events occurred in 60.7% (n = 99) and 67.1% (n = 106) of patients treated with AT2 and placebo recipients, respectively, including venous and arterial thromboembolic events (12.9% [n = 21] and 5.1% [n = 8], respectively). No significant effects of AT2 on 7- or 28-day mortality were seen among all patients in the ATHOS-3 trial. However, post hoc analyses suggested that AT2 may reduce mortality in patients with low baseline AT2 levels, exaggerated response to AT2, and acute kidney injury receiving concomitant renal replacement therapy. Overall, due to shortcomings of the ATHOS-3 trial data and the absence of confirmatory studies, the optimal place in therapy of AT2 for vasodilatory shock cannot be determined with confidence. CONCLUSION Intravenous AT2 represents a novel treatment strategy for refractory septic or other vasodilatory shock, although findings of safety and efficacy have not been replicated and the drug's optimal place in therapy is uncertain.
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Affiliation(s)
- Ryan Rodriguez
- Drug Information Group, University of Illinois at Chicago College of Pharmacy, Chicago, IL
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Busse LW, McCurdy MT, Ali O, Hall A, Chen H, Ostermann M. The effect of angiotensin II on blood pressure in patients with circulatory shock: a structured review of the literature. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:324. [PMID: 29282149 PMCID: PMC5745607 DOI: 10.1186/s13054-017-1896-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 11/28/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Circulatory shock is a common syndrome with a high mortality and limited therapeutic options. Despite its discovery and use in clinical and experimental settings more than a half-century ago, angiotensin II (Ang II) has only been recently evaluated as a vasopressor in distributive shock. We examined existing literature for associations between Ang II and the resolution of circulatory shock. METHODS We searched PubMed, MEDLINE, Ovid, and Embase to identify all English literature accounts of intravenous Ang II in humans for the treatment of shock (systolic blood pressure [SBP] ≤ 90 mmHg or a mean arterial pressure [MAP] ≤ 65 mmHg), and hand-searched the references of extracted papers for further studies meeting inclusion criteria. Of 3743 articles identified, 24 studies including 353 patients met inclusion criteria. Complete data existed for 276 patients. Extracted data included study type, publication year, demographics, type of shock, dosing of Ang II or other vasoactive medications, and changes in BP, lactate, and urine output. BP effects were grouped according to type of shock, with additional analyses completed for patients with absent blood pressure. Shock was distributive (n = 225), cardiogenic (n = 38), or from other causes (n = 90). Blood pressure as absent in 18 patients. RESULTS For the 276 patients with complete data, MAP rose by 23.4% from 63.3 mmHg to 78.1 mmHg in response to Ang II (dose range: 15 ng/kg/min to 60 mcg/min). SBP rose by 125.2% from 56.9 mmHg to 128.2 mmHg (dose range: 0.2 mcg/min to a 1500 mcg bolus). A total of 271 patients with complete data were determined to exhibit a BP effect which was directly associated with Ang II. Subgroups (patients with cardiogenic, septic, and other types of shock) exhibited similar increases in BP. In patients with absent BP, deemed to be cardiac arrest, return of spontaneous circulation (ROSC) was achieved, and BP increased by an average of 107.3 mmHg in 11 of 18 patients. The remaining seven patients with cardiac arrest did not respond. CONCLUSIONS Intravenous Ang II is associated with increased BP in patients with cardiogenic, distributive, and unclassified shock. A role may exist for Ang II in restoring circulation in cardiac arrest.
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Affiliation(s)
- Laurence W Busse
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Emory University, Emory St. Joseph's Hospital, 5665 Peachtree Dunwoody Road, Atlanta, GA, 30342, USA.
| | - Michael T McCurdy
- Division of Pulmonary & Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Osman Ali
- Division of Pulmonary & Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Anna Hall
- Department of Critical Care, King's College London, Guy's & St Thomas' NHS Foundation Hospital, London, SE1 7EH, UK
| | - Huaizhen Chen
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Emory University, Emory St. Joseph's Hospital, 5665 Peachtree Dunwoody Road, Atlanta, GA, 30342, USA
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' NHS Foundation Hospital, London, SE1 7EH, UK
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Effects of Angiotensin Converting Enzyme Inhibitors Before, During, and After Coronary Artery Bypass Graft Surgery on Hemodynamic Responses and Vasoactive Drugs Requirement. Anesth Pain Med 2014. [DOI: 10.5812/aapm.16510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Hasija S, Makhija N, Choudhury M, Hote M, Chauhan S, Kiran U. Prophylactic Vasopressin in Patients Receiving the Angiotensin-Converting Enzyme Inhibitor Ramipril Undergoing Coronary Artery Bypass Graft Surgery. J Cardiothorac Vasc Anesth 2010; 24:230-8. [DOI: 10.1053/j.jvca.2009.08.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Indexed: 01/14/2023]
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Abstract
Heart failure (HF) is one of the few cardiac conditions that is increasing. Despite a better understanding of how hormones and other signaling systems underlie the pathophysiology, and despite improved outcomes from pharmacologic therapy, many HF patients receive no effective treatment. Patients with HF commonly require medical diagnosis and management in operating rooms and critical care units; thus anesthesiologists are obliged to remain up-to-date both with advances in outpatient (chronic) medical management and with inpatient treatments for acute exacerbations of HF. Accordingly, we reviewed angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-adrenergic receptor blockers, and aldosterone antagonists because these drugs prolong life and are included in current clinical practice guidelines for treating patients with chronic HF. We also reviewed the implications of chronic HF for patients undergoing surgery and anesthesia and discuss how best to provide intensive treatment for acute exacerbations of symptoms, such as might be caused by excessive intravascular volume, inappropriate drug "holidays," or worsening of the underlying cardiac disease.
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Affiliation(s)
- Leanne Groban
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1009, USA.
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Ozal E, Kuralay E, Yildirim V, Kilic S, Bolcal C, Kücükarslan N, Günay C, Demirkilic U, Tatar H. Preoperative methylene blue administration in patients at high risk for vasoplegic syndrome during cardiac surgery. Ann Thorac Surg 2006; 79:1615-9. [PMID: 15854942 DOI: 10.1016/j.athoracsur.2004.10.038] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2004] [Indexed: 12/15/2022]
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors, calcium channel blockers, and preoperative intravenous heparin use are independent risk factors for vasoplegic syndrome after cardiac surgery. We prospectively studied whether preoperative methylene blue administration would prevent the vasoplegic syndrome in these high-risk patients. METHODS One hundred patients scheduled for coronary artery bypass graft surgery who were at high risk for vasoplegia because they were preoperatively using angiotensin-converting enzyme inhibitors, calcium channel blockers, and heparin were randomly assigned to either receive preoperative methylene blue (group 1, n = 50) or not receive it (group 2, controls, n = 50). Methylene blue (1% solution) was administered intravenously at a dose of 2 mg/kg for more than 30 minutes, beginning in the intensive care unit 1 hour before surgery. RESULTS Although similar in terms of all demographic and operative variables, the two groups differed significantly in terms of vasoplegic syndrome incidence (0% in group 1[0 of 50] vs 26% in group 2 [13 of 50]; p < 0.001). In 6 patients, the vasoplegic syndrome was refractory to norepinephrine. Four of these patients survived; the other 2 had vasoplegic syndromes that were refractory to aggressive vasopressor therapy, and they ultimately died of multiorgan failure. Stroke occurred in 1 patient. The two study groups also differed significantly in terms of average intensive care unit stay (1.2 +/- 0.5 days in group 1 vs 2.1 +/- 1.2 days in group 2; p < 0.001) and average hospital stay (6.1 +/- 1.7 days in group 1 vs 8.4 +/- 2.0 days in group 2; p < 0.001). CONCLUSIONS Our results suggest that preoperative methylene blue administration reduces the incidence and severity of vasoplegic syndrome in high-risk patients, thus ensuring adequate systemic vascular resistance in both operative and postoperative periods and shortening both intensive care unit and hospital stays.
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Affiliation(s)
- Ertuğrul Ozal
- Department of Cardiovascular Surgery, Gülhane Military Medical Academy, Ankara, Turkey
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Kwapisz MM, Müller M, Schindler E, Demir S, Veit M, Roth P, Hempelmann G. The effect of intravenous quinaprilat on plasma cytokines and hemodynamic variables during cardiac surgery. J Cardiothorac Vasc Anesth 2004; 18:53-8. [PMID: 14973800 DOI: 10.1053/j.jvca.2003.10.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Perioperative treatment with angiotensin-converting enzyme (ACE) inhibitors in cardiac surgery with cardiopulmonary bypass is still controversial. Using ACE inhibitors during cardiac surgery might be associated with an increased risk of critical hypotensive episodes. On the other hand, ACE inhibitors could have beneficial effects with respect to the development of the systemic inflammatory response syndrome. DESIGN The effect of acute administration of quinaprilat on hemodynamic variables and plasma cytokines was assessed under double-blind, randomized, and placebo-controlled conditions. SETTING Department of anesthesiology and cardiovascular surgery clinic in a university hospital. PARTICIPANTS Forty patients without preexisting cardiac failure, undergoing coronary artery bypass grafting. INTERVENTIONS Patients received 0.08 mg/kg of intravenous quinaprilat or intravenous isotonic saline solution after induction of anesthesia. MEASUREMENTS AND RESULTS Blood samples were taken after induction of anesthesia (T0), before cardiopulmonary bypass (T1), at the end of surgery (T2), and 4 hours after the end of surgery (T3). There was no difference between the 2 groups regarding mean arterial pressure and inotropic or vasopressor support. Systemic vascular resistance index was significantly lower in the quinaprilat group at T2 (p = 0.016) and T3 (p = 0.017). No difference in proinflammatory cytokine levels was observed between the 2 groups. CONCLUSIONS The present investigation shows that acute administration of an intravenous ACE inhibitor, quinaprilat, has no influence on proinflammatory cytokines during cardiac surgery with cardiopulmonary bypass. The patients treated with quinaprilat showed an improved systemic vascular resistance index with no increased risk of deleterious hemodynamic episodes.
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Affiliation(s)
- Myron M Kwapisz
- Department of Anaesthesiology, Intensive Care Medicine, Pain Therapy University Hospital Giessen, Giessen, Germany
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Booth JV, Schinderle D, Welsby IJ. Pro: Vasopressin is the vasoconstrictor of choice after cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2002; 16:773-5. [PMID: 12486663 DOI: 10.1053/jcan.2002.128432] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- John V Booth
- Division of Cardiothoracic Anesthesia and Critical Care, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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Zimmerman MA, Albright TN, Raeburn CD, Selzman CH. Vasopressin in cardiovascular patients: therapeutic implications. Expert Opin Pharmacother 2002; 3:505-12. [PMID: 11996629 DOI: 10.1517/14656566.3.5.505] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Vasopressin is a vital homeostatic protein which regulates fluid balance via its antidiuretic effects and vascular tone via its vasoconstrictive effects. Endogenous vasopressin deficiency has been implicated in several disease states resulting in vasodilatory shock. In particular, vasopressin levels are low in patients following cardiac surgery and in those with ventricular dysrhythmias. Several recent studies have demonstrated the effectiveness of exogenous vasopressin in providing haemodynamic support in patients with postcardiopulmonary bypass vasodilatory shock and refractory ventricular fibrillation. This manuscript reviews the pathophysiological and clinical basis for vasopressin replacement in patients with cardiovascular collapse.
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Affiliation(s)
- Michael A Zimmerman
- Division of Cardiothoracic Surgery, Box C-310, University of Colorado Health Sciences Center, 4200 East Ninth Avenue, Denver, Colorado 80262, USA.
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Broomé M, Aneman A, Lehtipalo S, Arnerlöv C, Johansson G, Winsö O, Biber B. Splanchnic vasoconstriction by angiotensin II is arterial pressure dependent. Acta Anaesthesiol Scand 2002; 46:57-63. [PMID: 11903073 DOI: 10.1034/j.1399-6576.2002.460110.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Our hypothesis was that splanchnic vasoconstriction by exogenous angiotensin II (Ang II) is significantly potentiated by local mechanisms increasing vasomotor tone and that splanchnic tissue oxygenation during administration of Ang II is perfusion pressure dependent. The aim was to study local splanchnic circulatory effects and tissue oxygenation during intravenous infusion of Ang II at different levels of regional arterial driving pressure in a whole-body large animal model. METHODS Ang II was infused in incremental doses (0-200 microg x h-1) in anaesthetised instrumented pigs (n=8). Mean superior mesenteric arterial pressure (PSMA) was adjusted by a local variable perivascular occluder. Perivascular ultrasound and laser-Doppler flowmetry were used for measurements of mesenteric venous blood flow and superficial intestinal blood flow, respectively. Intestinal oxygenation was evaluated by oxygen tissue tension (PtiO2) and lactate fluxes. RESULTS Ang II produced prominent and dose-dependent increases in mesenteric vascular resistance (RSMA) when the intestine was exposed to systemic arterial pressure, but Ang II increased RSMA only minimally when PSMA was artificially kept constant at a lower level (50 mmHg) by the occluder. Although Ang II decreased PtiO2 at a PSMA of 50 mmHg, splanchnic lactate production was not observed. CONCLUSION We demonstrate that splanchnic vasoconstriction by exogenous Ang II is dependent on arterial driving pressure, suggesting significant potentiation through autoregulatory increases in vasomotor tone. Intestinal hypoxaemia does not seem to occur during short-term infusion of Ang II in doses that significantly increases systemic arterial pressure.
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Affiliation(s)
- M Broomé
- Dept. of Surgical and Perioperative Science, Anaesthesiology and Intensive Care, Umeå University Hospital, Umeå, Sweden.
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Bennett SR, McKeown J, Drew P, Griffin S. Angiotensin in cardiac surgery: efficacy in patients on angiotensin converting enzyme inhibitors. Eur J Heart Fail 2001; 3:587-92. [PMID: 11595607 DOI: 10.1016/s1388-9842(01)00155-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Patients presenting for cardiac surgery are often treated with angiotensin converting enzyme inhibitors (ACEIs), either for heart failure or hypertension. Control of systemic vascular resistance (SVR) during surgery can be difficult in such patients. Angiotensin II has been available as an unlicensed vasoconstrictor, but there is concern about renal damage and its use. AIM This study compared a standard vasoconstrictor with angiotensin II and examined the effect on renal function after cardiac surgery. METHOD Twenty consecutive, consenting patients scheduled for cardiac surgery that had been taking ACEIs for at least 6 months, were randomly assigned to receive either phenylephrine or angiotensin II for the control of SVR during and for 24 h after cardiac surgery. A pulmonary artery catheter was used to guide therapy. Creatinine clearance was measured before, 24 and 48 h after surgery. RESULTS Low SVR and blood pressure requiring intervention was seen in all patients, particularly during cardiopulmonary bypass. One patient in the control group failed to respond to P, but responded normally to angiotensin II. Neither drug caused renal impairment. CONCLUSION Angiotensin II is a safe alternative to phenylephrine in patients on ACEIs and should be considered in patients who fail to respond to conventional vasoconstrictors.
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Affiliation(s)
- S R Bennett
- Department of Anaesthesia, Castle Hill Hospital, Cottingham, East Yorkshire HU16 5JQ, UK.
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Mekontso-Dessap A, Houël R, Soustelle C, Kirsch M, Thébert D, Loisance DY. Risk factors for post-cardiopulmonary bypass vasoplegia in patients with preserved left ventricular function. Ann Thorac Surg 2001; 71:1428-32. [PMID: 11383777 DOI: 10.1016/s0003-4975(01)02486-9] [Citation(s) in RCA: 111] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- A Mekontso-Dessap
- Service de Chirurgie Thoracique et Cardiovasculaire, CNRS UPRES-A 7053, Centre Hospitalo-Universitaire Henri Mondor, Créteil, France
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Carrel T, Englberger L, Mohacsi P, Neidhart P, Schmidli J. Low systemic vascular resistance after cardiopulmonary bypass: incidence, etiology, and clinical importance. J Card Surg 2000; 15:347-53. [PMID: 11599828 DOI: 10.1111/j.1540-8191.2000.tb00470.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Low systemic vascular resistance during and immediately after cardiac surgery in which cardiopulmonary bypass is utilized is a well-known phenomenon, characterized as vasoplegia, which appears with an incidence ranging between 5% and 15%. The etiology is not completely elucidated and the clinical importance remains speculative. METHODS In this prospective clinical trial, we assessed the incidence of postoperative low systemic vascular resistance in 800 consecutive patients undergoing elective coronary artery bypass grafting and/or valve replacement. We have attempted to identify the predictive factors responsible for the presence of low systemic vascular resistance and we have examined the subsequent postoperative outcome of those patients who developed early postoperative vasoplegia. The severity of vasoplegia was divided into three groups according either to the value of systemic resistance and/or the dose of vasoconstrictive agents necessary to correct the hemodynamic. RESULTS Six hundred twenty-five patients (78.1%) did not develop vasoplegia, 115 patients (14.4%) developed a mild vasoplegia, and 60 patients (7.5%) suffered from severe vasoplegia. Low systemic vascular resistance did not affect hospital mortality but was the cause for delayed extubation and prolonged stay on the intensive care unit (ICU). Logistic regression analysis identified temperature and duration of cardiopulmonary bypass, total cardioplegic volume infused, reduced left ventricular function, and preoperative treatment with angiotensin-converting enzyme (ACE)-inhibitors, out of 25 parameters, as predictive factors for early postoperative vasoplegia. CONCLUSION The occurrence of low systemic vascular resistance following cardiopulmonary bypass is as high as 21.8%. The etiology of this clinical condition is most probably multifactorial. Mortality is not affected by vasoplegia, but there is a trend to higher morbidity and prolonged stay in the ICU.
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Affiliation(s)
- T Carrel
- Clinic for Cardiovascular Surgery, University Hospital Berne, Switzerland.
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Argenziano M, Chen JM, Cullinane S, Choudhri AF, Rose EA, Smith CR, Edwards NM, Landry DW, Oz MC. Arginine vasopressin in the management of vasodilatory hypotension after cardiac transplantation. J Heart Lung Transplant 1999; 18:814-7. [PMID: 10512533 DOI: 10.1016/s1053-2498(99)00038-8] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Vasodilatory hypotension requiring the administration of catecholamine pressors may occur following cardiopulmonary bypass. We investigated the hemodynamic response to arginine vasopressin (AVP) in 20 patients who developed vasodilatory hypotension after cardiac transplantation. In this cohort, AVP infusion (0.1 U/min) significantly increased mean arterial pressure and decreased norepinephrine requirements, allowing rapid discontinuation of norepinephrine infusions in 7 patients. Judicious use of this novel agent in appropriately selected patients may minimize end-organ sequelae of hypotension and high-dose catecholamine therapy.
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Affiliation(s)
- M Argenziano
- Department of Surgery, Columbia University College of Physicians, New York, NY, USA
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Eyraud D, Brabant S, Nathalie D, Fleron MH, Gilles G, Bertrand M, Coriat P. Treatment of Intraoperative Refractory Hypotension with Terlipressin in Patients Chronically Treated with an Antagonist of the Renin-Angiotensin System. Anesth Analg 1999. [DOI: 10.1213/00000539-199905000-00003] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Eyraud D, Brabant S, Nathalie D, Fléron MH, Gilles G, Bertrand M, Coriat P. Treatment of intraoperative refractory hypotension with terlipressin in patients chronically treated with an antagonist of the renin-angiotensin system. Anesth Analg 1999; 88:980-4. [PMID: 10320155 DOI: 10.1097/00000539-199905000-00003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED The goal of the present study was to determine whether terlipressin, an agonist of the vasopressin system, could counteract perioperative hypotension refractory to common vasopressor therapy and to analyze its circulatory effects. We enrolled 51 consecutive vascular surgical patients chronically treated with angiotensin-converting enzyme inhibitors or antagonists of the receptor of angiotensin II, who received a standardized opioid-propofol anesthetic. Of these 51 patients, 32 had at least one episode of hypotension, which responded to epinephrine or phenylephrine. In 10 other patients, systolic arterial pressure (SAP) did not remain above 100 mm Hg for 1 min, despite three bolus doses of ephedrine or phenylephrine. In these patients, we injected a bolus of 1 mg of terlipressin, repeated twice if necessary. Hemodynamic and echocardiographic variables were recorded every 30 s over 6 min. In eight patients, arterial pressure was restored with one injection of terlipressin; in two other patients, three injections were necessary. One minute after the last injection of terlipressin, the SAP increased from 88+/-3 to 100+/-4 mm Hg and reached 117+/-5 mm Hg (P = 0.001) 3 min after the injection and remained stable around this value. This increase in SAP was associated with significant changes in left ventricular end-diastolic area (17.9+/-2 vs 20.2+/-2.2 cm2; P = 0.003), end-systolic area (8.1+/-1.3 vs 9.6+/-1.5 cm2; P = 0.004), end-systolic wall stress (45+/-8 vs 66+/-12; P = 0.001), and heart rate (60+/-4 vs 55+/-3 bpm; P = 0.001). Fractional area change and velocity of fiber shortening did not change significantly. No additional injection of vasopressor was required during the perioperative period. No change in ST segment was observed after the injection. IMPLICATIONS Terlipressin is effective to rapidly correct refractory hypotension in patients chronically treated with antagonists of the renin-angiotensin system without impairing left ventricular function.
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Affiliation(s)
- D Eyraud
- Department of Anesthesiology and Critical Care, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
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Argenziano M, Chen JM, Choudhri AF, Cullinane S, Garfein E, Weinberg AD, Smith CR, Rose EA, Landry DW, Oz MC. Management of vasodilatory shock after cardiac surgery: identification of predisposing factors and use of a novel pressor agent. J Thorac Cardiovasc Surg 1998; 116:973-80. [PMID: 9832689 DOI: 10.1016/s0022-5223(98)70049-2] [Citation(s) in RCA: 234] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cardiopulmonary bypass can be associated with vasodilatory hypotension requiring pressor support. We have previously found arginine vasopressin to be a remarkably effective pressor in a variety of vasodilatory shock states. We investigated the incidence and clinical predictors of vasodilatory shock in a general population of cardiac surgical patients and the effects of low-dose arginine vasopressin as treatment of this syndrome in patients with heart failure. METHODS Patients undergoing cardiopulmonary bypass (n = 145) were studied prospectively. Preoperative ejection fraction, medications, and perioperative hemodynamics were recorded, and postbypass serum arginine vasopressin levels were measured. Vasodilatory shock was defined as a mean arterial pressure lower than 70 mm Hg, a cardiac index greater than 2.5 L/min/m2, and norepinephrine dependence. Predictors of vasodilatory shock were investigated by logistic regression analysis. The hemodynamic responses of patients who received arginine vasopressin infusions for vasodilatory shock after cardiopulmonary bypass for left ventricular assist device placement or heart transplantation were analyzed retrospectively. RESULTS Eleven of 145 general cardiac surgery patients (8%) met criteria for postbypass vasodilatory shock. By multivariate analysis, an ejection fraction lower than 0.35 and angiotensin-converting enzyme inhibitor use were independent predictors of postbypass vasodilatory shock (relative risks of 9.1 and 11.9, respectively). Vasodilatory shock was associated with inappropriately low serum arginine vasopressin concentrations (12.0 +/- 6.6 pg/mL). Retrospective analysis found 40 patients with postbypass vasodilatory shock who received low-dose arginine vasopressin infusions, resulting in increased mean arterial pressure and decreased norepinephrine requirements. CONCLUSIONS Low ejection fraction and angiotensin-converting enzyme inhibitor use are risk factors for postbypass vasodilatory shock, and this syndrome is associated with vasopressin deficiency. In patients exhibiting this syndrome after high-risk cardiac operations, replacement of arginine vasopressin increases blood pressure and reduces catecholamine pressor requirements.
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Affiliation(s)
- M Argenziano
- Departments of Surgery and Medicine, Columbia University College of Physicians and Surgeons, New York, USA
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Mets B, Michler RE, Delphin ED, Oz MC, Landry DW. Refractory vasodilation after cardiopulmonary bypass for heart transplantation in recipients on combined amiodarone and angiotensin-converting enzyme inhibitor therapy: a role for vasopressin administration. J Cardiothorac Vasc Anesth 1998; 12:326-9. [PMID: 9636919 DOI: 10.1016/s1053-0770(98)90017-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- B Mets
- Department of Anesthesiology, College of Physicians and Surgeons of Columbia University, New York, NY, USA
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Eyraud D, Mouren S, Teugels K, Bertrand M, Coriat P. Treating anesthesia-induced hypotension by angiotensin II in patients chronically treated with angiotensin-converting enzyme inhibitors. Anesth Analg 1998; 86:259-63. [PMID: 9459229 DOI: 10.1097/00000539-199802000-00007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED Although angiotensin II bolus administration may be used to increase blood pressure in patients chronically treated with angiotensin-converting enzyme inhibitors (ACEI) who have severe hypotension on anesthetic induction, no data are available describing its time course and its effects on the left ventricular function. Fourteen patients chronically treated with ACEI for hypertension and scheduled for vascular surgery were prospectively studied. Patients with cardiac insufficiency were excluded. A transesophageal echocardiography probe was inserted to assess systolic left ventricular function. When hypotension was observed (systolic arterial pressure [SAP] <85 mm Hg), an I.V. bolus of 2.5 microg of angiotensin II (AII) was given, and hemodynamic variables were recorded each 30 s over 5.5 min. Results are expressed as mean +/- SEM. Sixty seconds after the AII bolus injection, the SAP increased from 78 +/- 3 to 152 +/- 6 mm Hg. SAP remained higher than control until the 5th min. This was associated with significant increases in end-diastolic area (from 15.1 +/- 0.6 to 19.3 +/- 1.0 cm2, P < or = 0.001), end-systolic area (from 6.6 +/- 0.4 to 10.7 +/- 0.7 cm2, P < or = 0.001), end-systolic wall stress (from 32 +/- 0.05 to 82 +/- 7 kdynes/cm2, P < or = 0.001). In addition, a decrease in fiber-shortening velocity (from 1.1 +/- 0.05 to 0.76 +/- 0.04 circ/s, P < or = 0.05) and in fractional area change (from 0.57 +/- 0.02 to 0.44 +/- 0.02, P < or = 0.05) was observed. Heart rate did not significantly change during the study. Increases in preload and afterload were observed. However, the administration of AII causes a transient impairment in left ventricular function. We conclude that AII, given as an I.V. bolus of 2.5 microg, is effective in restoring arterial blood pressure within 60 s in patients chronically treated with ACEI. IMPLICATIONS Severe hypotension on anesthetic induction in patients chronically treated with angiotensin-converting enzyme inhibitors for hypertension could be treated with an I.V. bolus of 2.5 microg of angiotensin II.
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Affiliation(s)
- D Eyraud
- Department of Anesthesiology and Intensive Care, Hôpital de la Pitié-Salpétrière, Paris, France
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Eyraud D, Mouren S, Teugels K, Bertrand M, Coriat P. Treating Anesthesia-Induced Hypotension by Angiotensin II in Patients Chronically Treated with Angiotensin-Converting Enzyme Inhibitors. Anesth Analg 1998. [DOI: 10.1213/00000539-199802000-00007] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Myles PS, Leong CK, Currey J. Endogenous nitric oxide and low systemic vascular resistance after cardiopulmonary bypass. J Cardiothorac Vasc Anesth 1997; 11:571-4. [PMID: 9263087 DOI: 10.1016/s1053-0770(97)90006-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To investigate the relationship between excessive endogenous production of nitric oxide (NO) and the low systemic vascular resistance (SVR) syndrome after cardiac surgery. DESIGN Prospective, case-control. Cases defined by low SVR postoperatively (< 750 dyn/s/cm-5), and matched with controls (> 900 dyn/s/cm-5). SETTING Cardiothoracic intensive care unit (ICU) in a tertiary care hospital. PARTICIPANTS Forty-four patients after cardiac surgery. INTERVENTIONS Collection of plasma and urine samples after identification. MEASUREMENTS AND MAIN RESULTS Plasma and urine nitrate concentrations were measured as an index of endogenous NO production. Hemodynamic, inotropic, and outcome data were collected. Median nitrate concentrations did not differ between cases and controls (plasma, 58 mumol/L, v 62 mumol/L, p = 0.43; urine, 399 mumol/L v 404 mumol/L, p = 0.38). Times to extubation and intensive care unit (ICU) discharge were prolonged in patients with low SVR (17.8 hours v 8.7 hours, p = 0.021; 2.5 days v 1.2 days, p = 0.019, respectively). CONCLUSIONS No association between "low SVR syndrome" and endogenous NO production was found. Patients with low SVR after cardiac surgery required a longer period of inotropic and ventilator support, with delay in discharge from the ICU. The risk and cost implications of this syndrome support further research.
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Affiliation(s)
- P S Myles
- Department of Anaesthesia and Pain Management, Alfred Hospital, Melbourne, Australia
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Suojaranta-Ylinen R, Ruokonen E, Pulkki K, Mertsola J, Takala J. Preoperative glutamine loading does not prevent endotoxemia in cardiac surgery. Acta Anaesthesiol Scand 1997; 41:385-91. [PMID: 9113185 DOI: 10.1111/j.1399-6576.1997.tb04704.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The presence of endotoxemia is relatively common in cardiac surgery patients and it may modify the metabolic and hemodynamic responses peri- and postoperatively. Impaired gut fuel metabolism may contribute to the disturbed function and deterioration of the intestinal mucosal barrier and the development of bacterial translocation and endotoxemia. Glutamine may protect the gut mucosal barrier during marginal or insufficient perfusion. METHODS We studied the effects of glutamine supplementation on endotoxemia and blood levels of tumor necrosis factor (TNF) during and after extracorporeal circulation (ECC) and the effects of endotoxemia on systemic and regional (splanchnic and leg) hemodynamics and metabolism after cardiac surgery. Nineteen elective coronary bypass patients were randomly assigned to receive preoperatively for 12 h either an infusion of glucose and a balanced amino acid solution (AA-group) or a solution containing 1/5 of total nitrogen as alanyl-glutamine (ALAGLN-group). RESULTS Glutamine and amino acid loading before ECC did not protect from peri- or postoperative endotoxemia. Endotoxemia was detected in 5 vs. 7 of patients during ECC and 6 vs. 5 of patients postoperatively in the ALAGLN-group vs. AA-group, respectively. More than half of the patients at every measurement had an increased level of TNF. There was no consistent difference between the arterial and hepatic vein endotoxin- or TNF-concentrations. Endotoxemia did not modify systemic or regional hemodynamics and metabolism after cardiac operation. CONCLUSION Glutamine did not prevent endotoxemia during or after cardiac surgery. An increased level of TNF was common and observed also in some patients without endotoxemia. Endotoxemia did not modify regional or whole-body metabolic patterns or hemodynamics.
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Peterzén B, Lönn U, Babić A, Granfeldt H, Casimir-Ahn H, Rutberg H. Postoperative management of patients with hemopump support after coronary artery bypass grafting. Ann Thorac Surg 1996. [DOI: 10.1016/0003-4975(96)00315-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Myles P, Buckland M, Cannon G, Bujor M, Anderson J, Salamonsen B, Davis B. The association among gastric mucosal pH, endotoxemia, and low systemic vascular resistance after cardiopulmonary bypass. J Cardiothorac Vasc Anesth 1996; 10:195-200. [PMID: 8850396 DOI: 10.1016/s1053-0770(96)80236-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Previously, it was found that a number of patients suffer a "low systemic vascular resistance syndrome" after cardiopulmonary bypass, and this was hypothesized to be secondary to endotoxemia, resulting from intestinal ischemia during bypass. DESIGN Prospective cohort. SETTING University teaching hospital. PARTICIPANTS Thirty-two patients undergoing cardiac surgery. INTERVENTIONS A number of variables relating to adequacy of tissue perfusion were measured at seven time periods perioperatively: cardiac output, systemic vascular resistance, oxygen delivery and consumption, oxygen extraction ratio, gastric mucosal pH, serum lactate, and endotoxin levels. MEASUREMENTS AND MAIN RESULTS Investigators could not find any association between systemic vascular resistance and mucosal pH or endotoxin levels after bypass. There were significant changes in oxygen flux and extraction ratio (p < 0.001) as well as serum lactate (p < 0.001). There was no significant change in endotoxin levels or mucosal pH. The systemic vascular resistance at 6 hours postbypass could be predicted from the vascular resistance reading at 1 hour postbypass by a regression equation. A significant correlation between systemic vascular resistance and mixed venous oxygen was found at 4 and 6 hours postbypass (p < 0.01) as well as with oxygen extraction (p < 0.01). There was a negative correlation between mucosal pH and serum lactate, particularly at 6 hours postbypass (p < 0.01). There was no correlation between mucosal pH and endotoxin levels, oxygen flux, or cardiac output. CONCLUSIONS The investigators therefore could not find any evidence that intestinal ischemia during bypass, as measured by gastric mucosal pH, predisposes to endotoxemia, or low systemic vascular resistance after cardiac surgery.
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Affiliation(s)
- P Myles
- Alfred Hospital, Melbourne, Australia
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Tuman KJ, McCarthy RJ, OʼConnor CJ, Holm WE, Ivankovich AD. Angiotensin-Converting Enzyme Inhibitors Increase Vasoconstrictor Requirements After Cardiopulmonary Bypass. Anesth Analg 1995. [DOI: 10.1213/00000539-199503000-00007] [Citation(s) in RCA: 103] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Tuman KJ, McCarthy RJ, O'Connor CJ, Holm WE, Ivankovich AD. Angiotensin-converting enzyme inhibitors increase vasoconstrictor requirements after cardiopulmonary bypass. Anesth Analg 1995; 80:473-9. [PMID: 7864410 DOI: 10.1097/00000539-199503000-00007] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Preoperative use of angiotensin-converting enzyme (ACE) inhibitors is common and has been associated with hypotension at separation from cardiopulmonary bypass (CPB). This study prospectively examined the influence of chronic preoperative ACE inhibitor use and other perioperative factors on the incidence of vasoconstrictor therapy required to maintain systolic blood pressure at more than 85 mm Hg despite a normal cardiac output after CPB in 4301 adults undergoing elective coronary artery and/or valve surgery. Hypothermic, nonpulsatile CPB and either opioid or ketamine-benzodiazepine anesthesia were common features of the operations. At least two vasoconstrictor infusions (phenylephrine, norepinephrine, or dopamine) were required for low perfusion pressure despite adequate cardiac output after CPB in 7.7% of 519 ACE-inhibited patients and 4.0% of 3782 patients not receiving ACE inhibitors (P = 0.0001). In the first 4 h after arrival in the intensive care unit, the need for vasoconstrictor infusions to treat hypotension with adequate cardiac output did not differ, although more ACE-inhibited patients (6.4%) exhibited low values of systemic vascular resistance (< 600 dyne.s.cm-5) than patients not receiving ACE inhibitors (2.8%; P = 0.0002). Logistic regression analysis identified preoperative ACE inhibitor use, congestive heart failure, poor left ventricular function, duration of CPB, reoperative surgery, age, and opioid anesthesia as independent risk factors for requiring > or = 2 vasoconstrictor infusions after CPB. No other preoperative drug therapy significantly altered this outcome.
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Affiliation(s)
- K J Tuman
- Department of Anesthesiology, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois 60612
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Christakis GT, Fremes SE, Koch JP, Harwood S, Juhasz S, Sharpe E, Deemar KA, Hamilton C, Chen E, Rao V. Determinants of low systemic vascular resistance during cardiopulmonary bypass. Ann Thorac Surg 1994; 58:1040-9. [PMID: 7944747 DOI: 10.1016/0003-4975(94)90451-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Although low systemic vascular resistance occurs during normothermic and hypothermic cardiopulmonary bypass, the determinants of depressed systemic vascular resistance and its effect on outcomes are unknown. To assess the predictors and clinical effects of low systemic vascular resistance, 555 patients undergoing isolated coronary artery bypass grafting were evaluated prospectively. The extent of low systemic vascular resistance during bypass was estimated by the amount of the vasoconstrictor phenylephrine administered: group 1, 0 to 160 micrograms; group 2, 161 to 800 micrograms; group 3, more than 800 micrograms. Multivariate analysis identified bypass temperature, bypass time, and ventricular function as determinants of low systemic vascular resistance. Patients on normothermic bypass accounted for 65% of the patients in group 3 and only 34% of the patients in group 1 (p < 0.0001). The bypass time was longer in the patients in group 3 (97 +/- 28 minutes) than in the patients in group 1 (89 +/- 24 minutes; p < 0.006). Patients with a preoperative left ventricular ejection fraction of 0.40 or less required less phenylephrine during cardiopulmonary bypass (498 +/- 68 micrograms) than did patients with a fraction exceeding 0.40 (1,087 +/- 88 micrograms; p < 0.001). By multivariate analysis, advanced age and the presence of peripheral vascular disease were found to decrease the likelihood of low systemic vascular resistance during normothermic bypass. Diabetes, the left ventricular ejection fraction, the bypass time, and the total cardioplegia infused were found to influence the likelihood of low systemic vascular resistance during hypothermic bypass. Patients in group 3 had a higher cardiac index and lower-mean arterial pressure and systemic vascular resistance postoperatively. In those patients who received a left internal mammary artery graft, the incidences of the low-output syndrome (group 1, 4.9%; group 3, 2.7%; p = not significant) and myocardial infarction (group 1, 1.4%; group 3, 1.8%; p = not significant) were not influenced by the amount of phenylephrine infused during cardiopulmonary bypass. In those patients who were at high risk of suffering a stroke preoperatively, the hypotension induced by the low systemic vascular resistance and its treatment with phenylephrine was not associated with an increased incidence of stroke (group 1, 5.8%; group 3, 2.8%; p = not significant).
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Affiliation(s)
- G T Christakis
- Division of Cardiovascular Surgery and Clinical Epidemiology Unit, Sunnybrook Health Science Centre, University of Toronto, Ontario, Canada
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Trilli LE, Johnson KA. Lisinopril overdose and management with intravenous angiotensin II. Ann Pharmacother 1994; 28:1165-8. [PMID: 7841571 DOI: 10.1177/106002809402801006] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE This report describes a case of lisinopril overdose managed in part with an infusion of angiotensin II in a patient with dilated cardiomyopathy and reviews other literature reporting angiotensin-converting enzyme (ACE) inhibitor overdose. DATA SOURCES Information concerning this patient was obtained through review of the medical chart, conversation with the attending physician, and personal involvement late in the course of the patient's therapy. We conducted MEDLINE and PAPERCHASE searches of the English language literature (restricted to human studies) from 1976 to the present, manually searched Current Contents and references from each publication reviewed, and contacted the manufacturer of lisinopril for any further references they could provide. STUDY SELECTION All case reports that described an ACE inhibitor overdose. DATA EXTRACTION Case reports were evaluated for the ACE inhibitor involved, amount ingested, and therapeutic management. DATA SYNTHESIS Ten patients with ACE inhibitor overdose have been reported, most of whom required only intravenous fluids for blood pressure support. The case presented here is the second report in which the patient's blood pressure was not adequately controlled with fluid and traditional vasopressors and required an infusion of angiotensin II. CONCLUSIONS Although only a few cases of ACE inhibitor overdose have been reported, it is possible that with widespread use of these agents, overdose may become a more common problem. Management of ACE inhibitor overdose should include general supportive care, gut decontamination when possible, intravenous fluids, and vasopressors if necessary. Intravenous angiotensin II may be effective in situations in which traditional vasopressors fail, and is a physiologically rational treatment.
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Affiliation(s)
- L E Trilli
- Veterans Affairs Medical Center, Pittsburgh, PA
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Licker M, Neidhart P, Lustenberger S, Kalonji T. Vascular alpha-1 adrenergic responsivness during cardiac surgery in patients on chronic angiotensin-converting enzyme inhibitors. J Cardiothorac Vasc Anesth 1994. [DOI: 10.1016/1053-0770(94)90440-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
Besides the long-term regulation of extracellular fluid volume, the RAS plays an important physiologic role in maintaining venous return and blood pressure during acute hemodynamic stresses. ACE inhibitors may therefore alter venous return and cardiac output regulation during anesthesia and surgery. This may be regarded as a drawback of ACE inhibition when other factors interfere with cardiovascular homeostasis; deleterious hemodynamic events may therefore occur when blood volume is decreased, which may be frequent during cardiovascular anesthesia and surgery. However, the alternative solution should not be to stop ACE inhibitors preoperatively. This would allow recovery of RAS control of blood pressure, but at the expense of some regional circulations. From this point of view, preliminary results from early studies during cardiovascular anesthesia and surgery showing redistribution of regional blood flow with inhibition of ACE are encouraging; whether postoperative outcome can be improved deserves further studies. At this time, the evidence is that ACE inhibition does not allow the anesthesiologist to be tolerant of hypovolemia.
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Affiliation(s)
- P Colson
- Department of Anesthesiology, Centre Hospitalo-Universitaire, Montpellier, France
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