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Ortoleva J, Dalia AA, Pisano DV, Shapeton A. Diagnosis and Management of Vasoplegia in Temporary Mechanical Circulatory Support: A Narrative Review. J Cardiothorac Vasc Anesth 2024; 38:1378-1389. [PMID: 38490900 DOI: 10.1053/j.jvca.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/10/2024] [Accepted: 02/18/2024] [Indexed: 03/17/2024]
Abstract
Refractory vasodilatory shock, or vasoplegia, is a pathophysiologic state observed in the intensive care unit and operating room in patients with a variety of primary diagnoses. Definitions of vasoplegia vary by source but are qualitatively defined clinically as a normal or high cardiac index and low systemic vascular resistance causing hypotension despite high-dose vasopressors in the setting of euvolemia. This definition can be difficult to apply to patients undergoing mechanical circulatory support (MCS). A large body of mostly retrospective literature exists on vasoplegia in the non-MCS population, but the increased use of temporary MCS justifies an examination of vasoplegia in this population. MCS, particularly extracorporeal membrane oxygenation, adds complexity to the diagnosis and management of vasoplegia due to challenges in determining cardiac output (or total blood flow), lack of clarity on appropriate dosing of noncatecholamine interventions, increased thrombosis risk, the difficulty in determining the endpoints of adequate volume resuscitation, and the unclear effects of rescue agents (methylene blue, hydroxocobalamin, and angiotensin II) on MCS device monitoring and function. Care teams must combine data from invasive and noninvasive sources to diagnose vasoplegia in this population. In this narrative review, the available literature is surveyed to provide guidance on the diagnosis and management of vasoplegia in the temporary MCS population, with a focus on noncatecholamine treatments and special considerations for patients supported by extracorporeal membrane oxygenation, transvalvular heart pumps, and other ventricular assist devices.
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Affiliation(s)
- Jamel Ortoleva
- Department of Anesthesiology, Boston Medical Center, Boston, MA.
| | - Adam A Dalia
- Division of Cardiac Anesthesiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Alexander Shapeton
- Veterans Affairs Boston Healthcare System, Department of Anesthesia, Critical Care and Pain Medicine, and Tufts University School of Medicine, Boston, MA
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2
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Hwang KY, Phoon PHY, Hwang NC. Adverse Clinical Effects Associated With Non-catecholamine Pharmacologic Agents for Treatment of Vasoplegic Syndrome in Adult Cardiac Surgery. J Cardiothorac Vasc Anesth 2024; 38:802-819. [PMID: 38218651 DOI: 10.1053/j.jvca.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/23/2023] [Accepted: 12/11/2023] [Indexed: 01/15/2024]
Abstract
Vasoplegic syndrome is a relatively common complication that can happen during and after major adult cardiac surgery. It is associated with a higher rate of complications, including postoperative renal failure, longer duration of mechanical ventilation, and intensive care unit stay, as well as increased mortality. The underlying pathophysiology of vasoplegic syndrome is that of profound vascular hyporesponsiveness, and involves a complex interplay among inflammatory cytokines, cellular surface receptors, and nitric oxide (NO) production. The pharmacotherapy approaches for the treatment of vasoplegia include medications that increase vascular smooth muscle contraction via increasing cytosolic calcium in myocytes, reduce the vascular effects of NO and inflammation, and increase the biosynthesis of and vascular response to norepinephrine. Clinical trials have demonstrated the clinical efficacy of non-catecholamine pharmacologic agents in the treatment of vasoplegic syndrome. With an increase in their use today, it is important for clinicians to understand the adverse clinical outcomes and patient risk profiles associated with these agents, which will allow better-tailored medical therapy.
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Affiliation(s)
- Kai Yin Hwang
- Department of Anaesthesiology, National University Hospital, Singapore
| | - Priscilla Hui Yi Phoon
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore
| | - Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore.
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3
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Dyrud M, Niu J, Kohler L. Elevated methemoglobin levels in patients treated with high-dose hydroxocobalamin. Lab Med 2024; 55:50-55. [PMID: 37226975 DOI: 10.1093/labmed/lmad037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
OBJECTIVE The aim of this study was to assess the impact of hydroxocobalamin (OHCbl) infusion on arterial blood gas and oximetry values in patients with vasoplegic syndrome. METHODS Blood samples collected from 95 patients receiving OHCbl infusion were assayed using the ABL90 FLEX Plus blood gas analyzer for the concentration of methemoglobin (MetHb), total hemoglobin (tHb), carboxyhemoglobin (COHb), arterial oxygen saturation (SaO2), arterial oxygen partial pressure (PaO2), and arterial carbon dioxide partial pressure (PaCO2). Interference of OHCbl on these variables was evaluated using the measured difference between the preinfusion and postinfusion samples. RESULTS Blood MetHb (%) measured after the infusion of OHCbl (5g) were significantly higher than the baseline levels, with a median of 4.8 (IQR, 3.0-6.5) versus 1.0 (IQR, 1.0-1.2) (P < .001). Blood COHb (%) increased from a median of 1.3 (IQR, 1.0-1.8) to 1.7 (IQR, 1.3-2.2) (P < .001) following the OHCbl infusion. No differences were seen in median levels of tHb, PaO2, PaCO2, and SaO2 between pre- and post-OHCbl treatment. CONCLUSION The presence of OHCbl in blood clearly interfered with the oximetry measurements of the hemoglobin component fractions by falsely increasing the levels of MetHb and COHb. Blood levels of MetHb and COHb cannot be reliably determined by the co-oximetry when OHCbl is known or suspected.
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Affiliation(s)
- Martinus Dyrud
- Memorial Cardiac & Vascular Institute, Memorial Healthcare System, Hollywood, FL, US
| | - Jianli Niu
- Memorial Cardiac & Vascular Institute, Memorial Healthcare System, Hollywood, FL, US
| | - Lisa Kohler
- Memorial Cardiac & Vascular Institute, Memorial Healthcare System, Hollywood, FL, US
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Suero OR, Park Y, Wieruszewski PM, Chatterjee S. Management of Vasoplegic Shock in the Cardiovascular Intensive Care Unit after Cardiac Surgery. Crit Care Clin 2024; 40:73-88. [PMID: 37973358 DOI: 10.1016/j.ccc.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Vasoplegic shock after cardiac surgery is characterized by hypotension, a high cardiac output, and vasodilation. Much of the understanding of this pathologic state is informed by the understanding of septic shock. Adverse outcomes and mortality are increased with vasoplegic shock. Early recognition and a systematic approach to its management are critical. The need for vasopressors to sustain an adequate blood pressure as well as pharmacologic adjuncts to mitigate the inflammatory inciting process are necessary. The rationale behind vasopressor escalation and consideration of adjuncts are discussed.
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Affiliation(s)
- Orlando R Suero
- Baylor St. Lukes Medical Center, 6720 Bertner Avenue, Room 0-520, Houston, TX 77030, USA
| | - Yangseon Park
- Baylor St. Lukes Medical Center, 6720 Bertner Avenue, Room 0-520, Houston, TX 77030, USA
| | - Patrick M Wieruszewski
- Department of Pharmacy, Mayo Clinic, RO_MB_GR_722PH, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, TX, USA.
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Bacchi B, Cabrucci F, Chiarello B, Dokollari A, Bonacchi M. Severe Refractory Vasoplegic Shock Syndrome after OPCABG Successfully Treated with Hydroxycobalamin: A Case Report and Review of the Literature. J Clin Med 2023; 13:169. [PMID: 38202178 PMCID: PMC10779867 DOI: 10.3390/jcm13010169] [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: 11/11/2023] [Revised: 12/15/2023] [Accepted: 12/25/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Vasoplegic shock syndrome (VSS) after an off-pump coronary artery bypass graft (OPCABG) is an extremely rare condition. Inotropic support is usually the first-line therapy, though it can precipitate several complications or be ineffective. We report the first case of severe refractory VSS after OPCABG successfully treated with hydroxycobalamin. METHODS A 77-year-old gentleman underwent OPCABG for three vessels coronary artery disease. Preoperative LV ejection fraction was 28%, and the patient before surgery started sacubitril/valsartan titrated, then, at the highest dose. Surgery was uneventful and, by the end of the procedure, TEE showed improved biventricular contractility. RESULTS The patient was transferred to the ICU without inotropic support, but soon developed hypotension. TEE ruled out pericardial tamponade and confirmed fair contractility. Norepinephrine was titrated to a medium-high dose, vasopressin was started and a Swan-Ganz catheter was placed. SVR was 480 dyn·s·cm-5. Despite aggressive pharmacologic treatment (including methylprednisolone and methylene blue), no improvements were noticed. Ten grams of hydroxycobalamin were administered. One hour later, hemodynamic status re-assessment showed SVR > 800 dyn·s·cm-5. Afterward, vasopressors were gradually reduced. CONCLUSIONS Our case demonstrated the importance of adequate early treatment in VSS after OPCABG. This case report shows, for the first time, that hydroxycobalamin was effectively used to restore homeostasis.
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Affiliation(s)
- Beatrice Bacchi
- Cardiac Surgery F.U., Experimental and Clinical Medicine Department, University of Florence, 50134 Firenze, Italy; (B.B.); (F.C.); (B.C.)
| | - Francesco Cabrucci
- Cardiac Surgery F.U., Experimental and Clinical Medicine Department, University of Florence, 50134 Firenze, Italy; (B.B.); (F.C.); (B.C.)
| | - Bruno Chiarello
- Cardiac Surgery F.U., Experimental and Clinical Medicine Department, University of Florence, 50134 Firenze, Italy; (B.B.); (F.C.); (B.C.)
| | - Aleksander Dokollari
- Cardiac Surgery Department, St. Boniface Hospital, University of Manitoba, Winnipeg, MB R2H 2A6, Canada;
| | - Massimo Bonacchi
- Cardiac Surgery F.U., Experimental and Clinical Medicine Department, University of Florence, 50134 Firenze, Italy; (B.B.); (F.C.); (B.C.)
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Khandekar DA, Seelhammer TG, Mara KC, Stephens EH, Wittwer ED, Wieruszewski PM. Intraoperative Versus Postoperative Hydroxocobalamin for Vasoplegic Shock in Cardiothoracic Surgery. J Cardiothorac Vasc Anesth 2023; 37:2538-2545. [PMID: 37723020 DOI: 10.1053/j.jvca.2023.08.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/20/2023] [Accepted: 08/21/2023] [Indexed: 09/20/2023]
Abstract
OBJECTIVES Hydroxocobalamin inhibits nitric oxide pathways contributing to vasoplegic shock in patients undergoing cardiopulmonary bypass (CPB). The objective of this study was to evaluate the effect of intraoperative versus postoperative application of hydroxocobalamin for vasoplegic shock in patients undergoing CPB. DESIGN This was a historic cohort study. SETTING The study was conducted at a quaternary academic cardiovascular surgery program. PARTICIPANTS Adults undergoing cardiac surgery using CPB were participants in the study. INTERVENTIONS Hydroxocobalamin (5 g) intravenously over 15 minutes. MEASUREMENTS AND MAIN RESULTS The treatment groups were assigned based on the receipt location of hydroxocobalamin (ie, intensive care unit [ICU] versus operating room [OR]). The primary outcome was vasopressor-free days in the first 14 days after CPB. Of the 112 patients included, 37 patients received hydroxocobalamin in the OR and 75 in the ICU. Patients in the OR group were younger than those in the ICU group (57.5 v 63.9 years, p = 0.007), with statistically similar American Society of Anesthesiologists scores. The mean CPB duration was 3.4 hours in the OR group and 2.9 hours in the ICU group (p = 0.09). In both groups, the norepinephrine-equivalent dose of vasopressors at hydroxocobalamin was 0.27 µg/kg/min. Days alive and free of vasopressors were not different between the OR and ICU groups (estimated difference 0.48 [95% CI -1.76-2.72], p = 0.67). The odds of postoperative renal failure, mesenteric ischemia, ICU, hospital length of stay, and in-hospital mortality were also similar between groups. CONCLUSIONS A difference in vasopressor-free days after CPB was not found between patients who received hydroxocobalamin intraoperatively versus postoperatively for vasoplegic shock.
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Affiliation(s)
| | | | - Kristin C Mara
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
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Hiruy A, Ciapala S, Donaldson C, Wang L, Hohlfelder B. Hydroxocobalamin Versus Methylene Blue for the Treatment of Vasoplegic Shock Associated With Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2023; 37:2228-2235. [PMID: 37586951 DOI: 10.1053/j.jvca.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 06/24/2023] [Accepted: 07/14/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVES To compare changes in vasopressor requirements and hemodynamic responses after hydroxocobalamin or methylene blue administration for vasoplegic shock (VS). DESIGN Retrospective cohort analysis. SETTING Single-center, academic medical center. PATIENTS Cardiothoracic surgery adult patients. INTERVENTIONS Hydroxocobalamin or methylene blue. MEASUREMENTS The primary outcome was a change in vasopressor requirements over the first 24 hours (1, 3, 6, 12, and 24 hours) after hydroxocobalamin or methylene blue initiation. Secondary outcomes included changes in mean arterial pressure (MAP), systemic vascular resistance, and lactate. MAIN RESULTS A total of 120 adult patients who received hydroxocobalamin (n = 77) or methylene blue (n = 43) were included. Vasopressor requirements at baseline were 0.34 µg/kg/min (95% CI 0.28-0.4) norepinephrine equivalent (NEE) in the hydroxocobalamin group, and 0.59 µg/kg/min (95% CI 0.52-0.66) NEE in the methylene blue group; p < 0.001. Vasopressor requirements decreased significantly at each time point within each group (hour 1 mean [95% CI] NEE, hydroxocobalamin 0.27 µg/kg/min [0.21-0.33]; methylene blue 0.44 µg/kg/min [0.38-0.51]; p < 0.001). The mean MAP at baseline was 65 mmHg (95% CI 63-67) in the hydroxocobalamin group, and 57 mmHg (95% CI 54-59) in the methylene blue group; p < 0.001. The mean MAP increased significantly from baseline at each time point within each group (hour 1 mean [95% CI] hydroxocobalamin 73 mmHg [71-75]; methylene blue 67 mmHg [65-70]; p < 0.001). After adjusting for baseline characteristics, a significantly greater reduction in vasopressor requirements and an increase in MAP were noted in the hydroxocobalamin group compared with the methylene blue group. CONCLUSIONS Hydroxocobalamin was associated with a greater reduction in vasopressor requirements than methylene blue in treating VS associated with cardiopulmonary bypass.
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Affiliation(s)
- Aklil Hiruy
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH.
| | | | - Chase Donaldson
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, OH
| | - Lu Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
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8
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Ayasa LA, Azar J, Odeh A, Ayyad M, Shbaita S, Zidan T, Awwad NAD, Kawa NM, Awad W. Hydroxocobalamin as Rescue Therapy in a Patient With Refractory Amlodipine-Induced Vasoplegia. Cureus 2023; 15:e38400. [PMID: 37265888 PMCID: PMC10231868 DOI: 10.7759/cureus.38400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2023] [Indexed: 06/03/2023] Open
Abstract
Vasoplegic syndrome is a type of distributive shock characterized by mean arterial pressure of less than 65 mmHg, with normal to high cardiac output and often refractory to fluid resuscitation, high doses of intravenous vasopressors, and inotropes. It is usually observed after cardiac and solid organ transplantation surgeries. Here, we report a 56-year-old female patient who presented with a profound vasoplegia manifesting as lethargy and confusion in the setting of amlodipine toxicity. This case of severe vasoplegia was refractory to all conditional lines of medical management reported in the literature. The mainstay treatment modalities for vasoplegia include volume resuscitation, catecholamines, vasopressin, angiotensin II, and possibly methylene blue in unresponsive cases. Our patient was given hydroxocobalamin in favor of methylene blue, given the history of serotonin reuptake inhibitors use, which would have caused a life-threatening serotonin syndrome. Hydroxycobolamine resulted in a dramatic clinical recovery, suggesting its potentially significant role in refractory vasoplegia.
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Affiliation(s)
- Laith A Ayasa
- Internal Medicine, Al-Quds University, Jerusalem, PSE
| | - Jehad Azar
- Respiratory Institute, Cleveland Clinic, Cleveland, USA
| | - Anas Odeh
- Faculty of Medicine, An Najah National University, Nablus, PSE
| | | | - Sara Shbaita
- Faculty of Medicine, An Najah National University, Nablus, PSE
| | - Thabet Zidan
- Faculty of Medicine, An Najah National University, Nablus, PSE
| | | | - Nagham M Kawa
- Faculty of Medicine, An Najah National University, Nablus, PSE
| | - Wafaa Awad
- Pediatrics, Al Makassed Hospital, Jerusalem, PSE
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Brokmeier HM, Seelhammer TG, Nei SD, Gerberi DJ, Mara KC, Wittwer ED, Wieruszewski PM. Hydroxocobalamin for Vasodilatory Hypotension in Shock: A Systematic Review With Meta-Analysis for Comparison to Methylene Blue. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00241-0. [PMID: 37147207 DOI: 10.1053/j.jvca.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/30/2023] [Accepted: 04/03/2023] [Indexed: 05/07/2023]
Abstract
Hydroxocobalamin inhibits nitric oxide-mediated vasodilation, and has been used in settings of refractory shock. However, its effectiveness and role in treating hypotension remain unclear. The authors systematically searched Ovid Medline, Embase, EBM Reviews, Scopus, and Web of Science Core Collection for clinical studies reporting on adult persons who received hydroxocobalamin for vasodilatory shock. A meta-analysis was performed with random-effects models comparing the hemodynamic effects of hydroxocobalamin to methylene blue. The Risk of Bias in Nonrandomized Studies of Interventions tool was used to assess the risk of bias. A total of 24 studies were identified and comprised mainly of case reports (n = 12), case series (n = 9), and 3 cohort studies. Hydroxocobalamin was applied mainly for cardiac surgery vasoplegia, but also was reported in the settings of liver transplantation, septic shock, drug-induced hypotension, and noncardiac postoperative vasoplegia. In the pooled analysis, hydroxocobalamin was associated with a higher mean arterial pressure (MAP) at 1 hour than methylene blue (mean difference 7.80, 95% CI 2.63-12.98). There were no significant differences in change in MAP (mean difference -4.57, 95% CI -16.05 to 6.91) or vasopressor dosage (mean difference -0.03, 95% CI -0.12 to 0.06) at 1 hour compared to baseline between hydroxocobalamin and methylene blue. Mortality was also similar (odds ratio 0.92, 95% CI 0.42-2.03). The evidence supporting the use of hydroxocobalamin for shock is limited to anecdotal reports and a few cohort studies. Hydroxocobalamin appears to positively affect hemodynamics in shock, albeit similar to methylene blue.
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Affiliation(s)
| | | | - Scott D Nei
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | | | - Kristin C Mara
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | | | - Patrick M Wieruszewski
- Department of Pharmacy, Mayo Clinic, Rochester, MN; Department of Anesthesiology, Mayo Clinic, Rochester, MN.
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10
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Blaha M, Blais M, Olson L. The Durability of Intravenous Hydroxocobalamin in Vasoplegia. Cureus 2023; 15:e38307. [PMID: 37255913 PMCID: PMC10226765 DOI: 10.7759/cureus.38307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2023] [Indexed: 06/01/2023] Open
Abstract
Objectives Refractory distributive shock (vasoplegia) has been treated with intravenous (IV) hydroxocobalamin (B12), but its use is poorly characterized. The objective of this study was to quantify the duration of hemodynamic improvement after B12 administration. Materials and methods This was a retrospective chart review of adult patients who received IV B12 while on vasopressors in the intensive care unit. Patients were divided into two groups: responders (≥10% decrease in baseline vasopressor requirements within 60 minutes of B12 administration) and non-responders. Results A total of 16 patients were included, and five (31%) met the 'responder' criteria. The median time to respond was 15 minutes, and the response was maintained for a median of 210 minutes. The baseline median norepinephrine equivalent (NEE) rate was 32.9 mcg/min in responders and 24.7 mcg/min in non-responders. Responders' NEE requirements decreased to 16.7 mcg/min after 15 minutes and 14.8 mcg/min after 60 minutes. All responders and 10 (91%) non-responders were mechanically ventilated; both groups were mostly male (60% and 91%) and had a median age of 54 years and 58 years, respectively. A total of 4 (80%) responders and 10 (91%) non-responders died while hospitalized. IV B12 was administered as 5 g over 15 minutes in all but two patients (one responder and one non-responder), who each received 5 g of B12 over 360 minutes. Conclusion Vasopressor requirements decreased rapidly in 31% of patients after B12 administration and remained so for a median of 210 minutes.
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Affiliation(s)
| | - Meghan Blais
- Department of Pharmacy, Nebraska Medicine, Omaha, USA
| | - Logan Olson
- Department of Pharmacy, Nebraska Medicine, Omaha, USA
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11
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Ortoleva J, Shapeton AD. Seeing Red: Hydroxocobalamin and Result Interference. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00186-6. [PMID: 37120323 DOI: 10.1053/j.jvca.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/10/2023] [Indexed: 05/01/2023]
Affiliation(s)
- Jamel Ortoleva
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Alexander D Shapeton
- Department of Anesthesia, Critical Care and Pain Medicine, Veterans Affairs Boston Healthcare System, Tufts University School of Medicine, Boston, MA.
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12
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Hwang NC, Sivathasan C. Review of Postoperative Care for Heart Transplant Recipients. J Cardiothorac Vasc Anesth 2023; 37:112-126. [PMID: 36323595 DOI: 10.1053/j.jvca.2022.09.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 09/10/2022] [Accepted: 09/14/2022] [Indexed: 11/11/2022]
Abstract
The early postoperative management strategies after heart transplantation include optimizing the function of the denervated heart, correcting the causes of hemodynamic instability, and initiating and maintaining immunosuppressive therapy, allograft rejection surveillance, and prophylaxis against infections caused by immunosuppression. The course of postoperative support is influenced by the quality of allograft myocardial protection prior to implantation and reperfusion, donor-recipient heart size matching, surgical technique of orthotopic heart transplantation, and patient factors (eg, preoperative condition, immunologic compatibility, postoperative vasomotor tone, severity and reversibility of pulmonary vascular hypertension, pulmonary function, mediastinal blood loss, and end-organ perfusion). This review provides an overview of the early postoperative care of recipients and includes a brief description of the surgical techniques for orthotopic heart transplantation.
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Affiliation(s)
- Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anesthesia, National Heart Centre, Singapore.
| | - Cumaraswamy Sivathasan
- Mechanical Cardiac Support and Heart Transplant Program, Department of Cardiothoracic Surgery, National Heart Centre, Singapore
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Haouzi P, MacCann M, Brenner M, Mahon S, Bebarta VS, Chan A, Judenherc-Haouzi A, Tubbs N, Boss GR. Treatment of life-threatening H2S intoxication: Lessons from the trapping agent tetranitrocobinamide. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 2022; 96:103998. [PMID: 36228991 DOI: 10.1016/j.etap.2022.103998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 10/05/2022] [Accepted: 10/07/2022] [Indexed: 06/16/2023]
Abstract
We sought to evaluate the efficacy of trapping free hydrogen sulfide (H2S) following severe H2S intoxication. Sodium hydrosulfide solution (NaHS, 20 mg/kg) was administered intraperitoneally in 69 freely moving rats. In a first group (protocol 1), 40 rats were randomly assigned to receive saline (n = 20) or the cobalt compound tetranitrocobinamide (TNCbi) (n = 20, 75 mg/kg iv), one minute into coma, when free H2S was still present in the blood. A second group of 27 rats received TNCbi or saline, following epinephrine, 5 min into coma, when the concentration of free H2S has drastically decreased in the blood. In protocol 1, TNCbi significantly increased immediate survival (65 vs 20 %, p < 0.01) while in protocol 2, administration of TNCbi led to the same outcome as untreated animals. We hypothesize that the decreased efficacy of TNCbi with time likely reflects the rapid spontaneous disappearance of the pool of free H2S in the blood following H2S exposure.
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Affiliation(s)
- Philippe Haouzi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Pennsylvania State University, College of Medicine, Hershey, PA, USA.
| | - Marissa MacCann
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Matthew Brenner
- Beckman Laser Institute and Medical Clinic, University of California, Irvine, CA, USA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, Irvine, CA, USA
| | - Sari Mahon
- Beckman Laser Institute and Medical Clinic, University of California, Irvine, CA, USA
| | - Vikhyat S Bebarta
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
| | - Adriano Chan
- Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Annick Judenherc-Haouzi
- Heart and Vascular Institute, Department of Medicine, Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Nicole Tubbs
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Gerry R Boss
- Department of Medicine, University of California, San Diego, La Jolla, CA, USA
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Ltaief Z, Ben-Hamouda N, Rancati V, Gunga Z, Marcucci C, Kirsch M, Liaudet L. Vasoplegic Syndrome after Cardiopulmonary Bypass in Cardiovascular Surgery: Pathophysiology and Management in Critical Care. J Clin Med 2022; 11:6407. [PMID: 36362635 PMCID: PMC9658078 DOI: 10.3390/jcm11216407] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 09/13/2023] Open
Abstract
Vasoplegic syndrome (VS) is a common complication following cardiovascular surgery with cardiopulmonary bypass (CPB), and its incidence varies from 5 to 44%. It is defined as a distributive form of shock due to a significant drop in vascular resistance after CPB. Risk factors of VS include heart failure with low ejection fraction, renal failure, pre-operative use of angiotensin-converting enzyme inhibitors, prolonged aortic cross-clamp and left ventricular assist device surgery. The pathophysiology of VS after CPB is multi-factorial. Surgical trauma, exposure to the elements of the CPB circuit and ischemia-reperfusion promote a systemic inflammatory response with the release of cytokines (IL-1β, IL-6, IL-8, and TNF-α) with vasodilating properties, both direct and indirect through the expression of inducible nitric oxide (NO) synthase. The resulting increase in NO production fosters a decrease in vascular resistance and a reduced responsiveness to vasopressor agents. Further mechanisms of vasodilation include the lowering of plasma vasopressin, the desensitization of adrenergic receptors, and the activation of ATP-dependent potassium (KATP) channels. Patients developing VS experience more complications and have increased mortality. Management includes primarily fluid resuscitation and conventional vasopressors (catecholamines and vasopressin), while alternative vasopressors (angiotensin 2, methylene blue, hydroxocobalamin) and anti-inflammatory strategies (corticosteroids) may be used as a rescue therapy in deteriorating patients, albeit with insufficient evidence to provide any strong recommendation. In this review, we present an update of the pathophysiological mechanisms of vasoplegic syndrome complicating CPB and discuss available therapeutic options.
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Affiliation(s)
- Zied Ltaief
- Service of Adult Intensive Care, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Nawfel Ben-Hamouda
- Service of Adult Intensive Care, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Valentina Rancati
- Service of Anesthesiology, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Ziyad Gunga
- Service of Cardiac Surgery, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Carlo Marcucci
- Service of Anesthesiology, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Matthias Kirsch
- Service of Cardiac Surgery, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Lucas Liaudet
- Service of Adult Intensive Care, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
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15
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Boettcher BT, Woehlck HJ, Makker H, Pagel PS, Freed JK. Hydroxocobalamin for treatment of catecholamine-resistant vasoplegia during liver transplantation: A single-center series of 20 cases. Int J Surg Case Rep 2022; 98:107488. [PMID: 35981485 PMCID: PMC9399471 DOI: 10.1016/j.ijscr.2022.107488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/03/2022] [Accepted: 08/07/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Catecholamine-resistant vasoplegia is a potentially devastating complication during liver transplantation. Hydroxocobalamin has emerged as a treatment for vasoplegia associated with cardiac surgery, liver transplantation, and septic shock. Presentation of case We performed a retrospective review of patients who underwent liver transplantation between October 2015 and May 2020 to evaluate the efficiency of hydroxocobalamin in this setting. Discussion A total of 137 patients underwent liver transplantation, of which 20 received hydroxocobalamin for vasoplegia. Administration of hydroxocobalamin increased mean arterial pressure and reduced vasoactive drug requirements. Conclusion This case series adds to the previous individual reports describing the use of hydroxocobalamin during liver transplantation suggesting hydroxocobalamin can mitigate refractory hypotension from catecholamine resistant vasoplegia during liver transplantation. Hypotension or vasoplegia is commonly encountered in end-stage liver disease. Vasoplegia during liver transplant is a common and potentially devastating condition. Hydroxocobalamin has been reported to improve catecholamine resistant vasoplegia. Hydroxocobalamin is believed to work by scavenging gasotransmitters NO, CO, and H2S.
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16
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Albertson TE, Chenoweth JA, Lewis JC, Pugashetti JV, Sandrock CE, Morrissey BM. The pharmacotherapeutic options in patients with catecholamine-resistant vasodilatory shock. Expert Rev Clin Pharmacol 2022; 15:959-976. [PMID: 35920615 DOI: 10.1080/17512433.2022.2110067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Septic and vasoplegic shock are common types of vasodilatory shock (VS) with high mortality. After fluid resuscitation and the use of catecholamine-mediated vasopressors (CMV), vasopressin, angiotensin II, methylene blue (MB) and hydroxocobalamin can be added to maintain blood pressure. AREAS COVERED VS treatment utilizes a phased approach with secondary vasopressors added to vasopressor agents to maintain an acceptable mean arterial pressure (MAP). This review covers additional vasopressors and adjunctive therapies used when fluid and catecholamine-mediated vasopressors fail to maintain target MAP. EXPERT OPINION Evidence supporting additional vasopressor agents in catecholamine resistant VS is limited to case reports, series, and a few randomized control trials (RCTs) to guide recommendations. Vasopressin is the most common agent added next when MAPs are not adequately supported with CMV. VS patients failing fluids and vasopressors with cardiomyopathy may have cardiotonic agents such as dobutamine or milrinone added before or after vasopressin. Angiotensin II, another class of vasopressor is used in VS to maintain adequate MAP. MB and/or hydoxocobalamin, vitamin C, thiamine and corticosteroids are adjunctive therapies used in refractory VS. More RCTs are needed to confirm the utility of these drugs, at what doses, which combinations and in what order they should be given.
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Affiliation(s)
- Timothy E Albertson
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA.,Department of Clinical Pharmacy, University of California, San Francisco, CA, USA
| | - James A Chenoweth
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA
| | - Justin C Lewis
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Clinical Pharmacy, University of California, San Francisco, CA, USA
| | - Janelle V Pugashetti
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA
| | - Christian E Sandrock
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA
| | - Brian M Morrissey
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA
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17
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Pérez Vela JL, Llanos Jorge C, Duerto Álvarez J, Jiménez Rivera JJ. Clinical management of postcardiotomy shock in adults. Med Intensiva 2022; 46:312-325. [PMID: 35570187 DOI: 10.1016/j.medine.2022.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/14/2021] [Accepted: 08/21/2021] [Indexed: 06/15/2023]
Abstract
Postcardiotomy cardiogenic shock represents the most serious expression of low cardiac output syndrome after cardiac surgery. Although infrequent, it is a relevant condition due to its specific and complex pathophysiology and important morbidity-mortality. The diagnosis requires a high index of suspicion and multimodal hemodynamic monitoring, where echocardiography and the pulmonary arterial catheter play a main role. Early and multidisciplinary management should focus on the management of postoperative or mechanical complications and the optimization of determinants of cardiac output through fluid therapy or diuretic treatments, inotropic drugs and vasopressors/vasodilators and, in the absence of a response, early mechanical circulatory support. The aim of this paper is to review and update the pathophysiology, diagnosis and management of postcardiotomy cardiogenic shock.
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Affiliation(s)
- J L Pérez Vela
- Servicio de Medicina Intensiva, Hospital Universitario Doce de Octubre, Madrid, Spain.
| | - C Llanos Jorge
- Servicio de Medicina Intensiva, Hospital Quirónsalud Tenerife, Santa Cruz de Tenerife, Spain
| | - J Duerto Álvarez
- Servicio de Medicina Intensiva, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - J J Jiménez Rivera
- Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Canarias, San Cristóbal de La Laguna, Santa Cruz de Tenerife, Spain
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18
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The Roles of Antidotes in Emergency Situations. Emerg Med Clin North Am 2022; 40:381-394. [DOI: 10.1016/j.emc.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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19
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Pérez Vela J, Llanos Jorge C, Duerto Álvarez J, Jiménez Rivera J. Manejo clínico del shock poscardiotomía en pacientes adultos. Med Intensiva 2021. [DOI: 10.1016/j.medin.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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20
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Ritter LA, Maldarelli M, McCurdy MT, Yamane DP, Davison D, Parrino C, Yim DN, Lee M, Mazzeffi MA, Chow JH. Effects of a single bolus of hydroxocobalamin on hemodynamics in vasodilatory shock. J Crit Care 2021; 67:66-71. [PMID: 34689063 DOI: 10.1016/j.jcrc.2021.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE Hydroxocobalamin has been observed to cause transient hypertension in healthy subjects, but rigorous studies examining its efficacy are lacking. MATERIALS AND METHODS Adults in shock who received hydroxocobalamin from 2017 to 2021 were analyzed retrospectively. Hourly hemodynamics from 24 h before and after treatment were collected, and the difference and hourly change of mean arterial pressure (MAP), systolic blood pressure (SBP), diastolic blood pressure (DBP), and norepinephrine-equivalent dose (NED) were examined in mixed-effects models. RESULTS This study included 3992 hemodynamic data points from 35 patients and is the largest case series to date. In the mixed effects model, there was no difference in MAP 24-h after hydroxocobalamin administration (estimated fixed effect [EFE] -0.2 mmHg, p = 0.89). A two-piecewise mixed model found that the hourly change in MAP was not different from zero in either the pre-administration (EFE 0.0 mmHg/h, p = 0.80) or post-administration segments (EFE 0.0 mmHg/h, p = 0.55). Analysis of the SBP, DBP, and NED also found similar insignificant results. CONCLUSIONS Although hydroxocobalamin has been observed to cause hypertension in healthy subjects, our results suggest that in patients with shock, hydroxocobalamin may not be effective in improving hemodynamics at 24 h after administration.
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Affiliation(s)
- Lindsay A Ritter
- MedStar Washington Hospital Center, Department of Critical Care, Washington, DC, USA.
| | - Mary Maldarelli
- University of Maryland School of Medicine, Department of Medicine, Baltimore, MD, USA.
| | - Michael T McCurdy
- University of Maryland School of Medicine, Department of Medicine, Division of Pulmonary and Critical Care, Baltimore, MD, USA.
| | - David P Yamane
- George Washington University School of Medicine and Health Sciences, Department of Anesthesiology and Critical Care Medicine, Department of Emergency Medicine, Washington, DC, USA.
| | - Danielle Davison
- George Washington University School of Medicine and Health Sciences, Department of Anesthesiology and Critical Care Medicine, Washington, DC, USA.
| | | | - David N Yim
- University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Myounghee Lee
- University of Maryland Medical Center, Baltimore, MD, USA.
| | - Michael A Mazzeffi
- George Washington University School of Medicine and Health Sciences, Department of Anesthesiology and Critical Care Medicine, Washington, DC, USA.
| | - Jonathan H Chow
- George Washington University School of Medicine and Health Sciences, Department of Anesthesiology and Critical Care Medicine, Washington, DC, USA.
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21
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Bezinover D, Mukhtar A, Wagener G, Wray C, Blasi A, Kronish K, Zerillo J, Tomescu D, Pustavoitau A, Gitman M, Singh A, Saner FH. Hemodynamic Instability During Liver Transplantation in Patients With End-stage Liver Disease: A Consensus Document from ILTS, LICAGE, and SATA. Transplantation 2021; 105:2184-2200. [PMID: 33534523 DOI: 10.1097/tp.0000000000003642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hemodynamic instability (HDI) during liver transplantation (LT) can be difficult to manage and increases postoperative morbidity and mortality. In addition to surgical causes of HDI, patient- and graft-related factors are also important. Nitric oxide-mediated vasodilatation is a common denominator associated with end-stage liver disease related to HDI. Despite intense investigation, optimal management strategies remain elusive. In this consensus article, experts from the International Liver Transplantation Society, the Liver Intensive Care Group of Europe, and the Society for the Advancement of Transplant Anesthesia performed a rigorous review of the most current literature regarding the epidemiology, causes, and management of HDI during LT. Special attention has been paid to unique LT-associated conditions including the causes and management of vasoplegic syndrome, cardiomyopathies, LT-related arrhythmias, right and left ventricular dysfunction, and the specifics of medical and fluid management in end-stage liver disease as well as problems specifically related to portal circulation. When possible, management recommendations are made.
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Affiliation(s)
- Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Pennsylvania State University, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA. Represents ILTS and LICAGE
| | - Ahmed Mukhtar
- Department of Anesthesia and Surgical Intensive Care, Cairo University, Almanyal, Cairo, Egypt. Represents LICAGE
| | - Gebhard Wagener
- Department of Anesthesiology, Columbia University Medical Center, New York, NY. Represents SATA and ILTS
| | - Christopher Wray
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA. Represents SATA
| | - Annabel Blasi
- Department of Anesthesia, IDIBAPS (Institut d´investigació biomèdica Agustí Pi i Sunyé) Hospital Clinic, Villaroel, Barcelona, Spain. Represents LICAGE and ILTS
| | - Kate Kronish
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA. Represents SATA
| | - Jeron Zerillo
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY. Represents SATA and ILTS
| | - Dana Tomescu
- Department of Anesthesiology and Intensive Care, Carol Davila University of Medicine and Pharmacy, Fundeni Clinical Institute, Bucharest, Romania. Represents LICAGE
| | - Aliaksei Pustavoitau
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Johns Hopkins School of Medicine, Baltimore, MD. Represents ILTS
| | - Marina Gitman
- Department of Anesthesiology, University of Illinois Hospital, Chicago, IL. Represents SATA and ILTS
| | - Anil Singh
- Department of Liver Transplant and GI Critical Care, Sir HN Reliance Foundation Hospital, Cirgaon, Mumbai, India. Represents ILTS
| | - Fuat H Saner
- Department of General, Visceral and Transplant Surgery, Essen University Medical Center, Essen, Germany. Represents LICAGE
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22
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Peyko V, Finamore M. Use of Intravenous Hydroxocobalamin without Methylene Blue for Refractory Vasoplegic Syndrome After Cardiopulmonary Bypass. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e930890. [PMID: 34143764 PMCID: PMC8218885 DOI: 10.12659/ajcr.930890] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Case series Patients: Male, 71-year-old • Male, 71-year-old Final Diagnosis: Vasoplegic syndrome Symptoms: Refractory hypotension Medication: — Clinical Procedure: Cardiopulmonary bypass Specialty: Anesthesiology
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Affiliation(s)
- Vincent Peyko
- Department of Pharmacy, Mercy Health - St Elizabeth's Boardman Hospital, Boardman, OH, USA
| | - Michael Finamore
- Department of Anesthesiology, Bel-Park Anesthesia Associated, Inc., Canfield, OH, USA
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23
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Weinberg D, Running K, Kalarickal PL, Patel GP. Use of Intravenous Hydroxocobalamin for Vasoplegic Syndrome in Simultaneous Liver-Kidney Transplant: A Case Report. Transplant Proc 2020; 53:1300-1302. [PMID: 33246585 DOI: 10.1016/j.transproceed.2020.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/09/2020] [Accepted: 09/21/2020] [Indexed: 11/28/2022]
Abstract
Vasoplegic syndrome can occur after reperfusion in liver transplantation. Generally, vasopressor infusions along with volume resuscitation are used to combat this process. There are case reports of the use of hydroxocobalamin to improve vasoplegia in liver transplant and cardiac surgery. In this case report, we describe a patient who received hydroxocobalamin for a simultaneous liver-kidney transplant. Use of this medication facilitated a prompt decrease of very high-dose vasopressor infusions and allowed completion of the kidney transplantation portion of this case. To our knowledge, use in combined liver-kidney transplant has not been described. In light of the dearth of medications to improve vasoplegia outside of vasopressor infusions, the use of hydroxocobalamin as a therapeutic intervention may gain importance.
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Affiliation(s)
- Devin Weinberg
- Department of Anesthesiology, Emory University, Atlanta, Georgia
| | - Kati Running
- Department of Anesthesiology, Emory University, Atlanta, Georgia
| | | | - Gaurav P Patel
- Department of Anesthesiology, Emory University, Atlanta, Georgia.
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24
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Rescue of Nimodipine-Induced Refractory Vasoplegia With Hydroxocobalamin in Subarachnoid Hemorrhage: A Case Report. Crit Care Explor 2020; 2:e0205. [PMID: 33063021 PMCID: PMC7523754 DOI: 10.1097/cce.0000000000000205] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background: We report a case of refractory vasoplegia after nimodipine administration that was unresponsive to triple vasopressor therapy and was rescued by IV hydroxocobalamin. Case Summary: An 84-year-old male presented comatose from a subarachnoid hemorrhage and developed severe hypotension unresponsive to three vasopressors following a single dose of enteral nimodipine. Multisystem point-of-care ultrasonography ruled out alternate etiologies of shock, indicating that this was likely a vasoplegic state caused by nimodipine. We administered 5 grams of IV hydroxocobalamin over 15 minutes due to the possibility of impaired nitric oxide metabolism as the driver of vasoplegia. This led to immediate improvement in hemodynamics and rapid discontinuation of vasopressors. The patient experienced chromaturia but no other adverse effects due to hydroxocobalamin. Conclusions: Nimodipine administration is a standard practice for patients with aneurysmal subarachnoid hemorrhage to reduce unfavorable outcomes from cerebral vasospasm. Although mild hypotension is a common side effect of nimodipine, in rare cases, it may become profound, leading to refractory vasoplegia. There is no evidence-base for reversal agents for nimodipine-induced vasoplegia, and this case is the first to demonstrate successful use of hydroxocobalamin as a potential rescue therapy. We also propose an algorithm for treatment of vasoplegia with consideration of medications that act on nitric oxide–mediated vasodilation and their side-effect profiles.
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25
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Ayers B, Wood K, Falvey J, Bernstein W, Gosev I. The use of hydroxocobalamin for vasoplegic syndrome in left ventricular assist device patients. Clin Case Rep 2020; 8:1722-1727. [PMID: 32983485 PMCID: PMC7495745 DOI: 10.1002/ccr3.2967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 11/18/2022] Open
Abstract
We demonstrate evidence supporting the efficacy of hydroxocobalamin in reducing vasopressor requirements for LVAD patients with refractory vasoplegia. Further study is needed to substantiate these findings and determine its optimal use in practice.
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Affiliation(s)
- Brian Ayers
- Division of Cardiac SurgeryUniversity of Rochester Medical CenterRochesterNYUSA
| | - Katherine Wood
- Division of Cardiac SurgeryUniversity of Rochester Medical CenterRochesterNYUSA
| | | | - Wendy Bernstein
- Department of Anesthesiology and Perioperative MedicineUniversity of Rochester Medical CenterRochesterNYUSA
| | - Igor Gosev
- Division of Cardiac SurgeryUniversity of Rochester Medical CenterRochesterNYUSA
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26
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Furnish C, Mueller SW, Kiser TH, Dufficy L, Sullivan B, Beyer JT. Hydroxocobalamin Versus Methylene Blue for Vasoplegic Syndrome in Cardiothoracic Surgery: A Retrospective Cohort. J Cardiothorac Vasc Anesth 2020; 34:1763-1770. [DOI: 10.1053/j.jvca.2020.01.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/14/2020] [Accepted: 01/15/2020] [Indexed: 02/02/2023]
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27
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Kidd B, Flynn BC. Repurposing in 2020: Teaching Old Drugs New Tricks. J Cardiothorac Vasc Anesth 2020; 34:1771-1773. [DOI: 10.1053/j.jvca.2020.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 02/14/2020] [Indexed: 11/11/2022]
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28
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Barnes TJ, Hockstein MA, Jabaley CS. Vasoplegia after cardiopulmonary bypass: A narrative review of pathophysiology and emerging targeted therapies. SAGE Open Med 2020; 8:2050312120935466. [PMID: 32647575 PMCID: PMC7328055 DOI: 10.1177/2050312120935466] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 05/21/2020] [Indexed: 12/29/2022] Open
Abstract
Cardiovascular disease remains the leading cause of death in the United States,
and cardiopulmonary bypass is a cornerstone in the surgical management of many
related disease states. Pathophysiologic changes associated both with
extracorporeal circulation and shock can beget a syndrome of low systemic
vascular resistance paired with relatively preserved cardiac output, termed
vasoplegia. While increased vasopressor requirements accompany vasoplegia,
related pathophysiologic mechanisms may also lead to true catecholamine
resistance, which is associated with further heightened mortality. The
introduction of a second non-catecholamine vasopressor, angiotensin II, and
non-specific nitric oxide scavengers offers potential means by which to manage
this challenging phenomenon. This narrative review addresses both the
definition, risk factors, and pathophysiology of vasoplegia and potential
therapeutic interventions.
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Affiliation(s)
- Theresa J Barnes
- Department of Anesthesiology, Emory University, Atlanta, GA, USA
| | | | - Craig S Jabaley
- Department of Anesthesiology, Emory University, Atlanta, GA, USA
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29
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Busse LW, Barker N, Petersen C. Vasoplegic syndrome following cardiothoracic surgery-review of pathophysiology and update of treatment options. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:36. [PMID: 32019600 PMCID: PMC7001322 DOI: 10.1186/s13054-020-2743-8] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/16/2020] [Indexed: 12/18/2022]
Abstract
Vasoplegic syndrome is a common occurrence following cardiothoracic surgery and is characterized as a high-output shock state with poor systemic vascular resistance. The pathophysiology is complex and includes dysregulation of vasodilatory and vasoconstrictive properties of smooth vascular muscle cells. Specific bypass machine and patient factors play key roles in occurrence. Research into treatment of this syndrome is limited and extrapolated primarily from that pertaining to septic shock, but is evolving with the expanded use of catecholamine-sparing agents. Recent reports demonstrate potential benefit in novel treatment options, but large clinical trials are needed to confirm.
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Affiliation(s)
- Laurence W Busse
- Department of Medicine, Emory University, Emory Critical Care Center, Atlanta, GA, USA. .,Emory Johns Creek Hospital, 6325 Hospital Parkway, Johns Creek, GA, 30097, USA.
| | - Nicholas Barker
- Department of Pharmacy, Emory St. Joseph's Hospital, Atlanta, GA, USA
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30
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Desai SR, Hwang NC. Strategies for Left Ventricular Decompression During Venoarterial Extracorporeal Membrane Oxygenation - A Narrative Review. J Cardiothorac Vasc Anesth 2020; 34:208-218. [DOI: 10.1053/j.jvca.2019.08.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 07/26/2019] [Accepted: 08/17/2019] [Indexed: 01/21/2023]
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31
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Ortoleva J, Shapeton A, Vanneman M, Dalia AA. Vasoplegia During Cardiopulmonary Bypass: Current Literature and Rescue Therapy Options. J Cardiothorac Vasc Anesth 2019; 34:2766-2775. [PMID: 31917073 DOI: 10.1053/j.jvca.2019.12.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/04/2019] [Accepted: 12/09/2019] [Indexed: 11/11/2022]
Abstract
Vasoplegia syndrome in the cardiac surgical intensive care unit and postoperative period has been an area of interest to clinicians because of its prevalence and effects on morbidity and mortality. However, there is a paucity of evidence regarding the treatment of vasoplegia syndrome during cardiopulmonary bypass (on-CPB VS). This review aims to detail the incidence, outcomes, and possible treatment options for patients who develop vasoplegia during bypass. The pharmacologic rescue agents discussed are used in cases in which vasoplegia during CPB is refractory to standard catecholamine agents, such as norepinephrine, epinephrine, and phenylephrine. Methods to improve vasoplegia during CPB can be both pharmacologic and nonpharmacologic. In particular, optimization of CPB parameters plays an important nonpharmacologic role in vasoplegia during CPB. Pharmacologic agents that have been demonstrated as being effective in vasoplegia include vasopressin, terlipressin, methylene blue, hydroxocobalamin, angiotensin II (Giapreza), vitamin C, flurbiprofen (Ropion), and hydrocortisone. Although these agents have not been specifically evaluated for vasoplegia during CPB, they have shown signs of effectiveness for vasoplegia postoperatively to varying degrees. Understanding the evidence for, dosing, and side effects of these agents is crucial for cardiac anesthesiologists when treating vasoplegia during CPB bypass.
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Affiliation(s)
- Jamel Ortoleva
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Alexander Shapeton
- Department of Anesthesia, Critical Care and Pain Medicine, Veterans Affairs Boston Healthcare System, Harvard Medical School, Boston, MA
| | - Mathew Vanneman
- Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Adam A Dalia
- Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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Saifee NH, Sedgwick S, Wu Y. Hydroxocobalamin administration for treatment of vasoplegic syndrome associated with cardiopulmonary bypass causes red plasma. Transfusion 2019; 60:447-448. [DOI: 10.1111/trf.15615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 11/11/2019] [Accepted: 11/11/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Nabiha Huq Saifee
- Department of Laboratory MedicineUniversity of Washington Seattle Washington
- Bloodworks Northwest Seattle Washington
| | | | - Yanyun Wu
- Bloodworks Northwest Seattle Washington
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33
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Pagel PS, Tawil JN, Freed JK. Cobalt Blues: A New Complication of Hydroxocobalamin Therapy for Vasopressor-Resistant Vasoplegia in Patients Treated With Chronic Renal Replacement Therapy? J Cardiothorac Vasc Anesth 2019; 33:3406-3408. [DOI: 10.1053/j.jvca.2019.08.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 08/16/2019] [Indexed: 01/09/2023]
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Abstract
In this case report, we describe 2 patients with septic shock requiring high-dose vasopressors for hemodynamic support despite aggressive fluid resuscitation. After the administration of high-dose hydroxocobalamin for presumed septic vasoplegic syndrome, both patients had an immediate response to hydroxocobalamin with a rapid and lasting improvement of blood pressure that significantly reduced the need for vasopressor support.
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Affiliation(s)
- Yichun Lin
- From the Department of Anesthesiology and Pain Medicine, University of California Davis Health, Sacramento, California
| | - Trung Q Vu
- Department of Anesthesiology and Perioperative Care, University of California Irvine Health Orange, California
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36
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Vitamin B12 for the treatment of vasoplegia in cardiac surgery and liver transplantation: a narrative review of cases and potential biochemical mechanisms. Can J Anaesth 2019; 66:1501-1513. [DOI: 10.1007/s12630-019-01449-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 05/14/2019] [Accepted: 05/14/2019] [Indexed: 02/06/2023] Open
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37
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Armour S, Armour TK, Joppa WR, Maltais S, Nelson JA, Wittwer E. Use of Hydroxocobalamin (Vitamin B12a) in Patients With Vasopressor Refractory Hypotension After Cardiopulmonary Bypass. Anesth Analg 2019; 129:e1-e4. [DOI: 10.1213/ane.0000000000003648] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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38
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Patel JJ, Venegas-Borsellino C, Willoughby R, Freed JK. High-Dose Vitamin B12 in Vasodilatory Shock: A Narrative Review. Nutr Clin Pract 2019; 34:514-520. [PMID: 31187494 DOI: 10.1002/ncp.10327] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Vasodilatory shock, as observed in postoperative states and sepsis, is hallmarked by low systemic vascular resistance and low blood pressure compensated by increased cardiac output. Gasotransmitters, such as nitric oxide and hydrogen sulfide, are implicated in the development and perpetuation of vasodilatory shock. Established therapies do not target these physiologic drivers of vasodilation. Due to their nontoxic and pleotropic effects, micronutrients are being used as rescue therapy in postoperative vasoplegia and septic shock. Here, we outline the pathophysiology of vasodilatory shock, describe the rationale for vitamin B12 (hydroxocobalamin) in vasodilatory shock, and identify literature evaluating its use in vasoplegic states.
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Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Rodney Willoughby
- Division of Pediatric Infectious Disease, Children's Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Julie K Freed
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA.,Division of Cardiac Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
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Sakpal SV, Reedstrom H, Ness C, Klinkhammer T, Saucedo-Crespo H, Auvenshine C, Santella RN, Steers J. High-dose hydroxocobalamin in end-stage liver disease and liver transplantation. DRUGS & THERAPY PERSPECTIVES 2019; 35:442-446. [PMID: 32288505 PMCID: PMC7102271 DOI: 10.1007/s40267-019-00643-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Distributive shock is a serious complication in patients with chronic or end-stage liver disease, and can be exacerbated by vasoplegia in this patient population. Vasoplegic syndrome (VS) is a state of shock refractory to catecholamines and vasopressin that is often multifactorial in liver failure patients, and can occur in any phase of liver transplantation (LT) [i.e., pre-transplantation, intraoperative, and post-transplantation]. Methylene blue (MB) has been a well-established pharmacologic therapy for VS. However, it has been known to cause dose-related toxicity. Hydroxocobalamin (HXC) is not currently FDA approved for the management of VS, but studies have demonstrated its ability to cause an increase in systolic blood pressure by hypothesized mechanisms with only minimal side effects. To date, only three other reports have demonstrated the use of HXC in LT patients, which highlighted its use both intraoperatively and post-transplantation. Our report illustrates the utility of HXC in four LT patients with VS. Two of these cases illustrate the usefulness of HXC in the pre-transplantation period, which has never been previously reported. HXC is a useful pharmaceutical agent in the management of VS, especially if contraindications to MB exist or in cases of MB-resistant vasoplegia. Further studies with large sample sizes are necessary to ascertain the optimal dosage of HXC in LT patients.
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Affiliation(s)
- Sujit Vijay Sakpal
- 1Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant & Liver Surgery, Plaza 3, 1315 S. Cliff Ave. Suite 1100, Sioux Falls, SD 57105 USA.,2Department of Surgery, University of South Dakota-Sanford School of Medicine, Sioux Falls, SD USA.,3Department of Internal Medicine, University of South Dakota-Sanford School of Medicine, Sioux Falls, SD USA
| | - Hannah Reedstrom
- 4Department of Pharmacy, Avera McKennan Hospital & University Health Center, Sioux Falls, SD USA
| | - Cody Ness
- 2Department of Surgery, University of South Dakota-Sanford School of Medicine, Sioux Falls, SD USA
| | - Tobin Klinkhammer
- 4Department of Pharmacy, Avera McKennan Hospital & University Health Center, Sioux Falls, SD USA
| | - Hector Saucedo-Crespo
- 1Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant & Liver Surgery, Plaza 3, 1315 S. Cliff Ave. Suite 1100, Sioux Falls, SD 57105 USA.,2Department of Surgery, University of South Dakota-Sanford School of Medicine, Sioux Falls, SD USA
| | - Christopher Auvenshine
- 1Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant & Liver Surgery, Plaza 3, 1315 S. Cliff Ave. Suite 1100, Sioux Falls, SD 57105 USA.,2Department of Surgery, University of South Dakota-Sanford School of Medicine, Sioux Falls, SD USA
| | - Robert N Santella
- 1Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant & Liver Surgery, Plaza 3, 1315 S. Cliff Ave. Suite 1100, Sioux Falls, SD 57105 USA.,3Department of Internal Medicine, University of South Dakota-Sanford School of Medicine, Sioux Falls, SD USA
| | - Jeffery Steers
- 1Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant & Liver Surgery, Plaza 3, 1315 S. Cliff Ave. Suite 1100, Sioux Falls, SD 57105 USA
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Feih JT, Rinka JR, Zundel MT. Methylene Blue Monotherapy Compared With Combination Therapy With Hydroxocobalamin for the Treatment of Refractory Vasoplegic Syndrome: ARetrospective Cohort Study. J Cardiothorac Vasc Anesth 2019; 33:1301-1307. [DOI: 10.1053/j.jvca.2018.11.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Indexed: 11/11/2022]
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41
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Ortoleva JP, Cobey FC. A Systematic Approach to the Treatment of Vasoplegia Based on Recent Advances in Pharmacotherapy. J Cardiothorac Vasc Anesth 2019; 33:1310-1314. [DOI: 10.1053/j.jvca.2018.11.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Indexed: 12/31/2022]
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Crouch C, Hendrickse A, Gilliland S, Mandell MS. Unexpected Complication of Hydroxocobalamin Administration for Refractory Vasoplegia in Orthotopic Liver Transplant: A Case Report. Semin Cardiothorac Vasc Anesth 2019; 23:409-412. [PMID: 30985242 DOI: 10.1177/1089253219842662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 40-year-old male with alcoholic cirrhosis and end-stage renal disease presented for simultaneous liver and kidney transplantation. Hemodialysis was utilized intraoperatively during liver transplantation. During the procedure, the patient developed refractory hypotension and ultimately received hydroxocobalamin for vasoplegia. Shortly after administration, the hemodialysis machine ceased working after a "blood leak" alarm developed. Without the ability to continue intraoperative dialysis, the kidney transplantation portion of his surgery was postponed. The patient was transferred to the intensive care unit, where he underwent continuous renal replacement therapy overnight, and his kidney transplant proceeded the following morning.
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Affiliation(s)
- Cara Crouch
- University of Colorado Hospital, Aurora, CO, USA
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44
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Shapeton AD, Mahmood F, Ortoleva JP. Hydroxocobalamin for the Treatment of Vasoplegia: A Review of Current Literature and Considerations for Use. J Cardiothorac Vasc Anesth 2019; 33:894-901. [DOI: 10.1053/j.jvca.2018.08.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Indexed: 12/15/2022]
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45
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Turner KR. Right Ventricular Failure After Left Ventricular Assist Device Placement—The Beginning of the End or Just Another Challenge? J Cardiothorac Vasc Anesth 2019; 33:1105-1121. [DOI: 10.1053/j.jvca.2018.07.047] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Indexed: 12/19/2022]
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46
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Hydroxocobalamin treatment of refractory vasoplegia in patients with mechanical circulatory support. J Heart Lung Transplant 2019; 38:467-469. [DOI: 10.1016/j.healun.2019.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 12/28/2018] [Accepted: 01/03/2019] [Indexed: 11/19/2022] Open
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47
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Bolliger D, Erb JM. Vasopressin—Magic Bullet in Vasoplegia Syndrome After Cardiac Surgery? J Cardiothorac Vasc Anesth 2018; 32:2233-2235. [DOI: 10.1053/j.jvca.2018.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Indexed: 12/31/2022]
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48
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Jentzer JC, Vallabhajosyula S, Khanna AK, Chawla LS, Busse LW, Kashani KB. Management of Refractory Vasodilatory Shock. Chest 2018; 154:416-426. [DOI: 10.1016/j.chest.2017.12.021] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 12/18/2017] [Accepted: 12/21/2017] [Indexed: 12/24/2022] Open
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49
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Cai Y, Mack A, Ladlie BL, Martin AK. The use of intravenous hydroxocobalamin as a rescue in methylene blue-resistant vasoplegic syndrome in cardiac surgery. Ann Card Anaesth 2018; 20:462-464. [PMID: 28994688 PMCID: PMC5661322 DOI: 10.4103/aca.aca_88_17] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Vasoplegic syndrome is a well-recognized complication during cardiopulmonary bypass (CPB) and is associated with increased morbidity and mortality, especially when refractory to conventional vasoconstrictor therapy. This is the first reported case of vasoplegia on CPB unresponsive to methylene blue whereas responsive to hydroxocobalamin, which indicates that the effect of hydroxocobalamin outside of the nitric oxide system is significant or that the two drugs have a synergistic effect in one or multiple mechanisms.
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Affiliation(s)
- Yi Cai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, FL, USA
| | - Anwar Mack
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, FL, USA
| | - Beth L Ladlie
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, FL, USA
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50
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Koratala A, Chamarthi G, Segal MS. Not all that is red is blood: a curious case of chromaturia. Clin Case Rep 2018; 6:1179-1180. [PMID: 29881591 PMCID: PMC5986001 DOI: 10.1002/ccr3.1514] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 03/09/2018] [Accepted: 03/13/2018] [Indexed: 11/05/2022] Open
Abstract
Hydroxocobalamin causes reddish discoloration of the urine, mimicking hematuria. Clinicians should be aware of this common side effect of the rarely used drug to prevent unnecessary consultations and work-up. Additional benign causes of red urine include foods such as beets, rhubarb, and medications such as rifampin, phenazopyridine.
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Affiliation(s)
- Abhilash Koratala
- Division of Nephrology, Hypertension and Renal TransplantationUniversity of FloridaGainesvilleFlorida
| | - Gajapathiraju Chamarthi
- Division of Nephrology, Hypertension and Renal TransplantationUniversity of FloridaGainesvilleFlorida
| | - Mark S. Segal
- Division of Nephrology, Hypertension and Renal TransplantationUniversity of FloridaGainesvilleFlorida
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