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Ouellet S, Drolet C, Morissette G, Pellerin A, Hébert A. Vasopressin in newborns with refractory acute pulmonary hypertension. Pediatr Res 2024; 95:1572-1577. [PMID: 38212386 DOI: 10.1038/s41390-023-02995-3] [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: 06/12/2023] [Revised: 11/20/2023] [Accepted: 12/15/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Acute pulmonary hypertension (aPH) in newborns can be life threatening and challenging to manage. In newborns with refractory aPH, there is currently limited therapeutic agents. METHODS Retrospective single-center cohort study in newborns less than one month old who were treated with vasopressin for a minimum of one hour in the context of refractory aPH in the neonatal and pediatric intensive care units of a tertiary university center between 2016 and 2022. The objective was to evaluate the efficacy and safety of vasopressin in newborns as an adjuvant treatment for refractory aPH. RESULTS Twenty-five patients met inclusion criteria. In patients who received vasopressin, oxygenation index improved from 28.4 to 14.4 (p = 0.004) after twelve hours of continuous infusion. Oxygen requirements (FiO2) decreased from 0.91 to 0.50 (p = 0.004) and mean arterial pressure increased from 41 to 51 mmHg (p = 0.001). In our cohort, 68% of patients presented an episode of hyponatremia (serum sodium <130 mmol/L). CONCLUSIONS The use of vasopressin may be associated with improvement in oxygenation and hemodynamic status of neonatal patients with aPH refractory to initial therapy. Further prospective studies are needed to establish the safety profile of vasopressin in newborns, particularly in preterm infants. IMPACT Vasopressin may be an effective cardiotropic agent to improve oxygenation and hemodynamic status in newborns with acute pulmonary hypertension. Careful monitoring of serum sodium levels are warranted in newborns who are receiving vasopressin infusion. This provides additional evidence for the consideration of vasopressin in newborns with acute pulmonary hypertension refractory to inhaled nitric oxide.
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Affiliation(s)
- Simon Ouellet
- Department of Pediatrics, CHU de Québec, Université Laval, Quebec City, Canada
| | - Christine Drolet
- Department of Pediatrics, CHU de Québec, Université Laval, Quebec City, Canada
- Division of Neonatology, CHU de Québec, Université Laval, Quebec City, Canada
| | - Geneviève Morissette
- Department of Pediatrics, CHU de Québec, Université Laval, Quebec City, Canada
- Division of Pediatric Intensive Care, CHU de Québec, Université Laval, Quebec City, Canada
| | - Annie Pellerin
- Department of Pharmacy, CHU de Québec, Université Laval, Quebec City, Canada
| | - Audrey Hébert
- Department of Pediatrics, CHU de Québec, Université Laval, Quebec City, Canada.
- Division of Neonatology, CHU de Québec, Université Laval, Quebec City, Canada.
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Loosen G, Taboada D, Ortmann E, Martinez G. How Would I Treat My Own Chronic Thromboembolic Pulmonary Hypertension in the Perioperative Period? J Cardiothorac Vasc Anesth 2024; 38:884-894. [PMID: 37716891 DOI: 10.1053/j.jvca.2023.07.014] [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: 02/20/2023] [Revised: 07/04/2023] [Accepted: 07/14/2023] [Indexed: 09/18/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) results from an incomplete resolution of acute pulmonary embolism, leading to occlusive organized thrombi, vascular remodeling, and associated microvasculopathy with pulmonary hypertension (PH). A definitive CTEPH diagnosis requires PH confirmation by right-heart catheterization and evidence of chronic thromboembolic pulmonary disease on imaging studies. Surgical removal of the organized fibrotic material by pulmonary endarterectomy (PEA) under deep hypothermic circulatory arrest represents the treatment of choice. One-third of patients with CTEPH are not deemed suitable for surgical treatment, and medical therapy or interventional balloon pulmonary angioplasty presents alternative treatment options. Pulmonary endarterectomy in patients with technically operable disease significantly improves symptoms, functional capacity, hemodynamics, and quality of life. Perioperative mortality is <2.5% in expert centers where a CTEPH multidisciplinary team optimizes patient selection and ensures the best preoperative optimization according to individualized risk assessment. Despite adequate pulmonary artery clearance, patients might be prone to perioperative complications, such as right ventricular maladaptation, airway bleeding, or pulmonary reperfusion injury. These complications can be treated conventionally, but extracorporeal membrane oxygenation has been included in their management recently. Patients with residual PH post-PEA should be considered for medical or percutaneous interventional therapy.
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Affiliation(s)
- Gregor Loosen
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Dolores Taboada
- Pulmonary Vascular Diseases Unit, Cambridge National Pulmonary Hypertension Service, Royal Papworth Hospital NHS, Department of Cardiothoracic Anesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Erik Ortmann
- Department of Anesthesiology, Schuechtermann-Heart-Centre, Bad Rothenfelde, Germany
| | - Guillermo Martinez
- Pulmonary Vascular Diseases Unit, Cambridge National Pulmonary Hypertension Service, Royal Papworth Hospital NHS, Department of Cardiothoracic Anesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom.
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Sugawara Y, Mizuno Y, Oku S, Sawada Y, Goto T. Role of protein kinase D1 in vasoconstriction and haemodynamics in rats. Microvasc Res 2024; 152:104627. [PMID: 37963515 DOI: 10.1016/j.mvr.2023.104627] [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] [Received: 08/12/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 11/16/2023]
Abstract
AIMS Protein kinase D (PKD), once considered an effector of protein kinase C (PKC), now plays many pathophysiological roles in various tissues. However, little is known about role of PKD in vascular function. We investigated the role of PKD in contraction of rat aorta and human aortic smooth muscle cells (HASMCs) and in haemodynamics in rats. METHODS AND RESULTS Isometric tension of rat aortic was measured to examine norepinephrine-induced contraction in the presence of PKD, PKC and Rho-kinase inhibitors. Phosphorylation of PKD1, myosin targeting subunit-1 (MYPT1), myosin light chain (MLC), CPI-17 and heat-shock protein 27 (HSP27), and actin polymerization were measured in the aorta. Phosphorylation of MYPT1 and MLC was also measured in HASMCs knocked down with specific siRNAs of PKD 1, 2 and 3. Intracellular calcium concentrations and cell shortening were measured in HASMCs. Norepinephrine-induced aortic contraction was accompanied by increased phosphorylation of PKD1, MYPT1 and MLC and actin polymerization, all of which were attenuated with PKD inhibitor CRT0066101. PKD1 phosphorylation was not inhibited by PKC inhibitor, chelerythrine or Rho kinase inhibitor, fasudil. In HASMCs, the phosphorylation of MYPT1 and MLC was attenuated by PKD1, but not PKD2, 3 knockdown. In HASMCs, CRT0066101 inhibited norepinephrine-induced cell shortening without affecting calcium concentration. Administration of CRT0066101 decreased systemic vascular resistance and blood pressure without affecting cardiac output in rats. CONCLUSIONS PKD1 may play roles in aorta contraction and haemodynamics via phosphorylation of MYPT1 and actin polymerization in a calcium-independent manner.
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Affiliation(s)
- Yoh Sugawara
- Department of Anaesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yusuke Mizuno
- Department of Anaesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan.
| | - Shinya Oku
- Department of Anaesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yuri Sawada
- Department of Anaesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Takahisa Goto
- Department of Anaesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Murray-Torres RM, Chilson K, Sharma A. Anesthetic management of children with medically refractory pulmonary hypertension undergoing surgical Potts shunt. Paediatr Anaesth 2024; 34:79-85. [PMID: 37800662 DOI: 10.1111/pan.14764] [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: 01/03/2023] [Revised: 09/04/2023] [Accepted: 09/08/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION Pulmonary hypertension in children is associated with high rates of adverse events under anesthesia. In children who have failed medical therapy, a posttricuspid shunt such as a Potts shunt can offload the right ventricle and possibly delay or replace the need for lung transplantation. Intraoperative management of this procedure, during which an anastomosis between the pulmonary artery and the descending aorta is created, is complex and requires a deep understanding of the pathophysiology of acute and chronic right ventricular failure. This retrospective case review describes the intraoperative management of children undergoing surgical creation of a Potts shunt at a single center. METHODS A retrospective case review of all patients under the age of 18 who underwent Potts shunt between April 2013 and June 2022. Medical records were examined, and clinical data of demographics, intraoperative vital signs, anesthetic management, and postoperative outcomes were extracted. RESULTS Twenty-nine children with medically refractory pulmonary hypertension underwent surgical Potts shunts with a median age of 12 years (range 4 months to 17.4 years). Nineteen Potts shunts (65%) were placed via thoracotomy and 10 (35%) were placed via median sternotomy with use of cardiopulmonary bypass. Ketamine was the most frequently utilized induction agent (17 out of 29, 59%), and the majority of patients were initiated on vasopressin prior to intubation (20 out of 29, 69%). Additional inotropic support with epinephrine (45%), milrinone (28%), norepinephrine (17%), and dobutamine (14%) was used prior to shunt placement. Following opening of the Potts shunt, hemodynamic support was continued with vasopressin (66%), epinephrine (62%), milrinone (59%), dobutamine (14%), and norepinephrine (10%). Major intraoperative complications included severe hypoxemia (21 out of 29, 72%) and hypotension requiring boluses of epinephrine (10 out of 29, 34.5%) but no patient suffered intraoperative cardiac arrest. There were four in-hospital mortalities. DISCUSSION A Potts shunt offers another palliative option for children with medically refractory pulmonary hypertension. General anesthesia in these children carries high risk for pulmonary hypertensive crises. Anesthesiologists must understand underlying physiological mechanisms responsble for acute hemodynaic decompensation during acute pulmonary hypertneisve crises. Severe physiological perturbations imposed by thoracic surgery and use of cardiopulmonay bypass can be mitigated by aggresive heodynamic support of ventricle function and maintainence of systemic vascular resistance. Early use of vasopressin, before or immidiately after anesthesia induction, in combination with other inotropes is a useful agent during the perioperative care of thes. Early use of vasopressin during anesthesia induction, and aggressive inotropic support of right ventricular function can help mitigate effects of induction and intubation, single-lung ventilation, and cardiopulmonary bypass. CONCLUSIONS Our single center expereince shows that the Potts shunt surgery, despite high short-term mortaility, may offer another option for palliation in children with medically refractory pulmonary hypertension.
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Affiliation(s)
- Reese Michael Murray-Torres
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kelly Chilson
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Anshuman Sharma
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
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Jenkins DP, Martinez G, Salaunkey K, Reddy SA, Pepke-Zaba J. Perioperative Management in Pulmonary Endarterectomy. Semin Respir Crit Care Med 2023; 44:851-865. [PMID: 37487525 DOI: 10.1055/s-0043-1770123] [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: 07/26/2023]
Abstract
Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (PH), provided lesions are proximal enough in the pulmonary vasculature to be surgically accessible and the patient is well enough to benefit from the operation in the longer term. It is a major cardiothoracic operation, requiring specialized techniques and instruments developed over several decades to access and dissect out the intra-arterial fibrotic material. While in-hospital operative mortality is low (<5%), particularly in high-volume centers, careful perioperative management in the operating theater and intensive care is mandatory to balance ventricular performance, fluid balance, ventilation, and coagulation to avoid or treat complications. Reperfusion pulmonary edema, airway hemorrhage, and right ventricular failure are the most problematic complications, often requiring the use of extracorporeal membrane oxygenation to bridge to recovery. Successful PEA has been shown to improve both morbidity and mortality in large registries, with survival >70% at 10 years. For patients not suitable for PEA or with residual PH after PEA, balloon pulmonary angioplasty and/or PH medical therapy may prove beneficial. Here, we describe the indications for PEA, specific surgical and perioperative strategies, postoperative monitoring and management, and approaches for managing residual PH in the long term.
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Affiliation(s)
- David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Guillermo Martinez
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Kiran Salaunkey
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - S Ashwin Reddy
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
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Zhang H, Song H. A 1-month-old infant with pulmonary hypertensive crisis after cardiac surgery was successfully rescued with connection of left atrial and right ventricular pressure measurement tubes: a case report. Eur Heart J Case Rep 2023; 7:ytad527. [PMID: 38025123 PMCID: PMC10665012 DOI: 10.1093/ehjcr/ytad527] [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: 02/24/2023] [Revised: 08/19/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023]
Abstract
Background Pulmonary hypertensive crisis is a complication with extremely high mortality after surgery of congenital heart disease. However, there are still no treatment guidelines or expert consensus on the standard treatment of pulmonary hypertensive crisis, and the effect of conventional treatment is still unsatisfactory. We present a case of a patient who developed pulmonary hypertensive crisis after cardiac surgery, and was successfully rescued with a pioneering method, which has never been reported so far. Case summary An infant with congenital heart disease had undergone cardiac surgery successfully. Due to obvious myocardial oedema, sternal closure was delayed. The left atrial and right ventricular pressure monitoring tubes, both of which were connected through a triplet, were inserted into right pulmonary vein and pulmonary artery, respectively, and the triplet was in closed condition. On the night of the surgery, pulmonary hypertensive crisis occurred. Emergency bedside thoracotomy was given, and the triplet was turned on urgently to make the left atrial and right ventricular pressure monitoring tubes connected. Meantime, conventional treatment was performed. Eventually, the pulmonary hypertensive crisis was quickly relieved, and the infant was discharged 9 days later. Discussion The left atrial and right ventricular pressure monitoring tubes are placed intraoperatively in patients who both need delayed sternal closure and have high risk factors for pulmonary hypertensive crisis, by which could not only monitor the pressure of left atrium and right ventricle in real time but also effectively relieve the right ventricular pressure instantaneously when pulmonary hypertensive crisis occurs, as well as remedy ischaemia of systemic and coronary circulation.
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Affiliation(s)
- Huijun Zhang
- Cardiac Surgery, The First Hospital of Hebei Medical University, Hebei Medical University, 89 Donggang Road, Shijiazhuang, Hebei 050031, China
| | - Hailong Song
- Cardiac Surgery, The First Hospital of Hebei Medical University, Hebei Medical University, 89 Donggang Road, Shijiazhuang, Hebei 050031, China
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Benes J, Kasperek J, Smekalova O, Tegl V, Kletecka J, Zatloukal J. Individualizing Fluid Management in Patients with Acute Respiratory Distress Syndrome and with Reduced Lung Tissue Due to Surgery—A Narrative Review. J Pers Med 2023; 13:jpm13030486. [PMID: 36983668 PMCID: PMC10056120 DOI: 10.3390/jpm13030486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 02/28/2023] [Accepted: 03/03/2023] [Indexed: 03/11/2023] Open
Abstract
Fluids are the cornerstone of therapy in all critically ill patients. During the last decades, we have made many steps to get fluid therapy personalized and based on individual needs. In patients with lung involvement—acute respiratory distress syndrome—finding the right amount of fluids after lung surgery may be extremely important because lung tissue is one of the most vulnerable to fluid accumulation. In the current narrative review, we focus on the actual perspectives of fluid therapy with the aim of showing the possibilities to tailor the treatment to a patient’s individual needs using fluid responsiveness parameters and other therapeutic modalities.
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Affiliation(s)
- Jan Benes
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, University Hospital in Plzen, 32300 Plzeň, Czech Republic
- Biomedical Centre, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
- Correspondence:
| | - Jiri Kasperek
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
- Fachkrankenhaus Coswig GmbH, Zentrum für Pneumologie, Allergologie, Beatmungsmedizin, Thoraxchirurgie, 01640 Coswig, Germany
| | - Olga Smekalova
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, University Hospital in Plzen, 32300 Plzeň, Czech Republic
| | - Vaclav Tegl
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, University Hospital in Plzen, 32300 Plzeň, Czech Republic
- Biomedical Centre, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
| | - Jakub Kletecka
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, University Hospital in Plzen, 32300 Plzeň, Czech Republic
| | - Jan Zatloukal
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
- Department of Anesthesiology and Intensive Care Medicine, University Hospital in Plzen, 32300 Plzeň, Czech Republic
- Biomedical Centre, Faculty of Medicine in Plzen, Charles University, 32300 Plzen, Czech Republic
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Abud KCO, Machado CM, Vilas Boas LS, Maeda NY, Carvalho ES, Souza MFS, Gaiolla PV, Castro CRP, Pereira J, Rabinovitch M, Lopes AA. Respiratory viruses and postoperative hemodynamics in patients with unrestrictive congenital cardiac communications: a prospective cohort study. Eur J Med Res 2023; 28:38. [PMID: 36670454 PMCID: PMC9852807 DOI: 10.1186/s40001-023-01003-y] [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] [Received: 01/05/2023] [Accepted: 01/08/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Pulmonary vascular abnormalities pose a risk for severe life-threatening hemodynamic disturbances following surgical repair of congenital cardiac communications (CCCs). In the distal lung, small airways and vessels share a common microenvironment, where biological crosstalks take place. Because respiratory cells infected by viruses express a number of molecules with potential impact on airway and vascular remodeling, we decided to test the hypothesis that CCC patients carrying viral genomes in the airways might be at a higher risk for pulmonary (and systemic) hemodynamic disturbances postoperatively. METHODS Sixty patients were prospectively enrolled (age 11 [7-16] months, median with interquartile range). Preoperative pulmonary/systemic mean arterial pressure ratio (PAP/SAP) was 0.78 (0.63-0.88). The presence or absence of genetic material for respiratory viruses in nasopharyngeal and tracheal aspirates was investigated preoperatively in the absence of respiratory symptoms using real-time polymerase chain reaction (kit for detection of 19 pathogens). Post-cardiopulmonary bypass (CPB) inflammatory reaction was analyzed by measuring serum levels of 36 inflammatory proteins (immunoblotting) 4 h after its termination. Postoperative hemodynamics was assessed using continuous recording of PAP and SAP with calculation of PAP/SAP ratio. RESULTS Viral genomes were detected in nasopharynx and the trachea in 64% and 38% of patients, respectively. Rhinovirus was the most prevalent agent. The presence of viral genomes in the trachea was associated with an upward shift of postoperative PAP curve (p = 0.011) with a PAP/SAP of 0.44 (0.36-0.50) in patients who were positive versus 0.34 (0.30-0.45) in those who were negative (p = 0.008). The presence or absence of viral genomes in nasopharynx did not help predict postoperative hemodynamics. Postoperative PAP/SAP was positively correlated with post-CPB levels of interleukin-1 receptor antagonist (p = 0.026), macrophage migration inhibitory factor (p = 0.019) and monocyte chemoattractant protein-1 (p = 0.031), particularly in patients with virus-positive tracheal aspirates. CONCLUSIONS Patients with CCCs carrying respiratory viral genomes in lower airways are at a higher risk for postoperative pulmonary hypertension, thus deserving special attention and care. Preoperative exposure to respiratory viruses and post-CPB inflammatory reaction seem to play a combined role in determining the postoperative behavior of the pulmonary circulation.
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Affiliation(s)
- Kelly C. O. Abud
- grid.11899.380000 0004 1937 0722Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil
| | - Clarisse M. Machado
- grid.11899.380000 0004 1937 0722Virology Laboratory, Institute of Tropical Medicine, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Lucy S. Vilas Boas
- grid.11899.380000 0004 1937 0722Virology Laboratory, Institute of Tropical Medicine, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - Eloisa S. Carvalho
- grid.11899.380000 0004 1937 0722Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil
| | - Maria Francilene S. Souza
- grid.11899.380000 0004 1937 0722Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil
| | - Paula V. Gaiolla
- grid.11899.380000 0004 1937 0722Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil
| | - Claudia R. P. Castro
- grid.11899.380000 0004 1937 0722Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil
| | - Juliana Pereira
- grid.11899.380000 0004 1937 0722Laboratory of Medical Investigation on Pathogenesis and Targeted Therapy in Onco-Immuno-Hematology (LIM-31), University of São Paulo, São Paulo, Brazil
| | - Marlene Rabinovitch
- grid.168010.e0000000419368956Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA USA
| | - Antonio Augusto Lopes
- grid.11899.380000 0004 1937 0722Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil
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Capolupo I, De Rose DU, Mazzeo F, Monaco F, Giliberti P, Landolfo F, Di Pede A, Toscano A, Conforti A, Bagolan P, Dotta A. Early vasopressin infusion improves oxygenation in infants with congenital diaphragmatic hernia. Front Pediatr 2023; 11:1104728. [PMID: 37063685 PMCID: PMC10090559 DOI: 10.3389/fped.2023.1104728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/14/2023] [Indexed: 04/18/2023] Open
Abstract
Objective Congenital Diaphragmatic Hernia (CDH) is a complex disease including a diaphragmatic defect, lung hypoplasia, and pulmonary hypertension. Despite its increasing use in neonates, the literature on the use of vasopressin in neonates is limited. The aim of this work is to analyze the changes in clinical and hemodynamic variables in a cohort of CDH infants treated with vasopressin. Methods Among CDH infants managed at the Neonatal Intensive Care Unit (NICU) of our hospital from May 2014 to January 2019, all infants who were treated with vasopressin, because of systemic hypotension and pulmonary hypertension, were enrolled in this retrospective study. The primary outcome was the change in oxygenation index (OI) after the start of the infusion of vasopressin. The secondary outcomes were the changes in cerebral and splanchnic fractional tissue oxygen extraction (FTOEc and FTOEs) at near-infrared spectroscopy, to understand the balance between oxygen supply and tissue oxygen consumption after the start of vasopressin infusion. We also reported as secondary outcomes the changes in ratio of arterial oxygen partial pressure (PaO2) to fraction of inspired oxygen (FiO2), heart rate, mean arterial pressure, serum pH, and serum sodium. Results We included 27 patients with isolated CDH who received vasopressin administration. OI dramatically dropped when vasopressin infusion started, with a significant reduction according to ANOVA for repeated measures (p = 0.003). A global significant improvement in FTOEc and FTOEs was detected (p = 0.009 and p = 0.004, respectively) as a significant reduction in heart rate (p = 0.019). A global significant improvement in PaO2/FiO2 ratio was observed (p < 0.001) and also at all time points: at 6 h since infusion (p = 0.015), 12 h (p = 0.009), and 24 h (p = 0.006), respectively. A significant reduction in sodium levels was observed as expected side effect (p = 0.012). No significant changes were observed in the remaining outcomes. Conclusion Our data suggest that starting early vasopressin infusion in CDH infants with pulmonary hypertension could improve oxygenation index and near-infrared spectroscopy after 12 and 24 h of infusion. These pilot data represent a background for planning future larger randomized trials to evaluate the efficacy and safety of vasopressin for the CDH population.
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Affiliation(s)
- Irma Capolupo
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
- Correspondence: Irma Capolupo
| | - Domenico Umberto De Rose
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
| | - Francesca Mazzeo
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
| | - Francesca Monaco
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
| | - Paola Giliberti
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
| | - Francesca Landolfo
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
| | - Alessandra Di Pede
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
| | - Alessandra Toscano
- Perinatal Cardiology, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
| | - Andrea Conforti
- Neonatal Surgery Unit, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
| | - Pietro Bagolan
- Neonatal Surgery Unit, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Andrea Dotta
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
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Szczepańska-Sadowska E, Żera T. Vasopressin: a possible link between hypoxia and hypertension. EXPLORATION OF MEDICINE 2022. [DOI: 10.37349/emed.2022.00103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Cardiovascular and respiratory diseases are frequently associated with transient and prolonged hypoxia, whereas hypoxia exerts pro-hypertensive effects, through stimulation of the sympathetic system and release of pressor endocrine factors. This review is focused on the role of arginine vasopressin (AVP) in dysregulation of the cardiovascular system during hypoxia associated with cardiovascular disorders. AVP is synthesized mainly in the neuroendocrine neurons of the hypothalamic paraventricular nucleus (PVN) and supraoptic nucleus (SON), which send axons to the posterior pituitary and various regions of the central nervous system (CNS). Vasopressinergic neurons are innervated by multiple neuronal projections releasing several neurotransmitters and other regulatory molecules. AVP interacts with V1a, V1b and V2 receptors that are present in the brain and peripheral organs, including the heart, vessels, lungs, and kidneys. Release of vasopressin is intensified during hypernatremia, hypovolemia, inflammation, stress, pain, and hypoxia which frequently occur in cardiovascular patients, and blood AVP concentration is markedly elevated in cardiovascular diseases associated with hypoxemia. There is evidence that hypoxia stimulates AVP release through stimulation of chemoreceptors. It is suggested that acting in the carotid bodies, AVP may fine-tune respiratory and hemodynamic responses to hypoxia and that this effect is intensified in hypertension. There is also evidence that during hypoxia, augmentation of pro-hypertensive effects of vasopressin may result from inappropriate interaction of this hormone with other compounds regulating the cardiovascular system (catecholamines, angiotensins, natriuretic peptides, steroids, nitric oxide). In conclusion, current literature indicates that abnormal mutual interactions between hypoxia and vasopressin may significantly contribute to pathogenesis of hypertension.
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Affiliation(s)
- Ewa Szczepańska-Sadowska
- Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Tymoteusz Żera
- Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, 02-097 Warsaw, Poland
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11
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Wu SG, He W. Anesthesia management of a patient undergoing implantation of a left ventricular assist system: A case report. World J Anesthesiol 2022; 11:1-7. [DOI: 10.5313/wja.v11.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 08/14/2022] [Accepted: 09/14/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Heart failure is generally regarded as a progressive and irreversible medical condition. The EVAHEART is an implantable left ventricular assist system.
CASE SUMMARY We report the anesthesia management of a 56-year-old male patient with dilated cardiomyopathy undergoing an EVAHEART implantation. Transesophageal echocardiography is crucial to ensure the correct positioning of the device and the proper aortic valve outflow. Because the continuous blood flow device functions best under low systemic and pulmonary vascular resistance, milrinone is the preferred drug. Our patient was accompanied by pulmonary hypertension, so during the operation, nitric oxide was used to reduce pulmonary artery pressure.
CONCLUSION The cardiac output achieved by the patient with the assistance of EVAHEART can reach 4 L/min, which of course depends on the front load, rear load, and pump speed.
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Affiliation(s)
- Shu-Guang Wu
- Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 340002, Zhejiang Province, China
| | - Wei He
- Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 340002, Zhejiang Province, China
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12
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Nakano M, Koga M, Hashimoto T, Matsushita N, Masukawa D, Mizuno Y, Uchimura H, Niikura R, Miyazaki T, Nakamura F, Zou S, Shimizu T, Saito M, Tamura K, Goto T, Goshima Y. Right ventricular overloading is attenuated in monocrotaline-induced pulmonary hypertension model rats with a disrupted Gpr143 gene, the gene that encodes the 3,4-l-dihydroxyphenyalanine (l-DOPA) receptor. J Pharmacol Sci 2022; 148:214-220. [PMID: 35063136 DOI: 10.1016/j.jphs.2021.11.008] [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: 08/31/2021] [Revised: 11/18/2021] [Accepted: 11/29/2021] [Indexed: 12/17/2022] Open
Abstract
Pulmonary hypertension (PH) is a severe and progressive disease that causes elevated right ventricular systolic pressure, right ventricular hypertrophy and ultimately right heart failure. However, the underlying pathophysiologic mechanisms are poorly understood. We previously showed that 3,4-l-dihydroxylphenyalanine (DOPA) sensitizes vasomotor response to sympathetic tone via coupling between the adrenergic receptor alpha1 (ADRA1) and a G protein-coupled receptor 143 (GPR143), a DOPA receptor. We investigated whether DOPA similarly enhances ADRA1-mediated contraction in pulmonary arteries isolated from rats, and whether GPR143 is involved in the PH pathogenesis. Pretreating the isolated pulmonary arteries with DOPA 1 μM enhanced vasoconstriction in response to phenylephrine, an ADRA1 agonist, but not to U-46619, a thromboxane A2 agonist or endothelin-1. We generated Gpr143 gene-deficient (Gpr143-/y) rats, and confirmed that DOPA did not augment phenylephrine-induced contractile response in Gpr143-/y rat pulmonary arteries. We utilized a rat model of monocrotaline (MCT)-induced PH. In the MCT model, the right ventricular systolic pressure was attenuated in the Gpr143-/y rats than in WT rats. Phenylephrine-induced cell migration and proliferation were also suppressed in Gpr143-/y pulmonary artery smooth muscle cells than in WT cells. Our result suggests that GPR143 is involved in the PH pathogenesis in the rat models of PH.
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MESH Headings
- 15-Hydroxy-11 alpha,9 alpha-(epoxymethano)prosta-5,13-dienoic Acid/pharmacology
- Animals
- Disease Models, Animal
- Heart Failure/etiology
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/genetics
- Hypertrophy, Right Ventricular/etiology
- In Vitro Techniques
- Male
- Monocrotaline/adverse effects
- Pulmonary Artery/physiology
- Rats, Sprague-Dawley
- Receptors, Adrenergic, alpha-1/physiology
- Receptors, G-Protein-Coupled/physiology
- Receptors, Neurotransmitter/genetics
- Systole
- Vasoconstriction/drug effects
- Vasoconstriction/genetics
- Ventricular Dysfunction, Right/etiology
- Ventricular Function, Right/genetics
- Rats
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Affiliation(s)
- Masayuki Nakano
- Department of Molecular Pharmacology and Neurobiology, Graduate School of Medicine, Yokohama City University, Yokohama, 236-0004, Japan; Department of Medical Science and Cardiorenal Medicine, Graduate School of Medicine, Yokohama City University, Yokohama, 236-0004, Japan
| | - Motokazu Koga
- Department of Molecular Pharmacology and Neurobiology, Graduate School of Medicine, Yokohama City University, Yokohama, 236-0004, Japan; Department of Anesthesiology, Graduate School of Medicine, Yokohama City University, Yokohama, 236-0004, Japan; Department of Anesthesiology, Kanagawa Cancer Center, Yokohama, 241-8515, Japan
| | - Tatsuo Hashimoto
- Department of Molecular Pharmacology and Neurobiology, Graduate School of Medicine, Yokohama City University, Yokohama, 236-0004, Japan; Department of Internal Medicine, Graduate School of Dentistry, Kanagawa Dental University, Yokosuka 238-8680, Japan, Yokosuka, 238-8570, Japan
| | - Natsuki Matsushita
- Division of Laboratory Animal Research, Aichi Medical University, Nagakute, 480-1195, Aichi, Japan
| | - Daiki Masukawa
- Department of Molecular Pharmacology and Neurobiology, Graduate School of Medicine, Yokohama City University, Yokohama, 236-0004, Japan
| | - Yusuke Mizuno
- Department of Anesthesiology, Graduate School of Medicine, Yokohama City University, Yokohama, 236-0004, Japan
| | - Hiraku Uchimura
- Department of Molecular Pharmacology and Neurobiology, Graduate School of Medicine, Yokohama City University, Yokohama, 236-0004, Japan; Department of Psychiatry, Graduate School of Medicine, Yokohama City University, Yokohama, 236-0004, Japan
| | - Ryo Niikura
- Department of Anesthesiology, Graduate School of Medicine, Yokohama City University, Yokohama, 236-0004, Japan
| | - Tomoyuki Miyazaki
- Department of Anesthesiology, Graduate School of Medicine, Yokohama City University, Yokohama, 236-0004, Japan; Department of Physiology, Graduate School of Medicine, Yokohama City University, Yokohama, 236-0004, Japan
| | - Fumio Nakamura
- Department of Molecular Pharmacology and Neurobiology, Graduate School of Medicine, Yokohama City University, Yokohama, 236-0004, Japan; Department of Biochemistry, School of Medicine, Tokyo Women's Medical University, Tokyo, 162- 8666, Japan
| | - Suo Zou
- Department of Pharmacology, Kochi Medical School, Kochi University, Nankoku, Kochi, 783-8505, Japan
| | - Takahiro Shimizu
- Department of Pharmacology, Kochi Medical School, Kochi University, Nankoku, Kochi, 783-8505, Japan
| | - Motoaki Saito
- Department of Pharmacology, Kochi Medical School, Kochi University, Nankoku, Kochi, 783-8505, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Graduate School of Medicine, Yokohama City University, Yokohama, 236-0004, Japan
| | - Takahisa Goto
- Department of Anesthesiology, Graduate School of Medicine, Yokohama City University, Yokohama, 236-0004, Japan
| | - Yoshio Goshima
- Department of Molecular Pharmacology and Neurobiology, Graduate School of Medicine, Yokohama City University, Yokohama, 236-0004, Japan.
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13
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Bandyopadhyay D, Lai C, Pulido JN, Restrepo-Jaramillo R, Tonelli AR, Humbert M. Perioperative approach to precapillary pulmonary hypertension in non-cardiac non-obstetric surgery. Eur Respir Rev 2021; 30:30/162/210166. [PMID: 34937705 DOI: 10.1183/16000617.0166-2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 08/12/2021] [Indexed: 01/02/2023] Open
Abstract
Pulmonary hypertension (PH) confers a significant challenge in perioperative care. It is associated with substantial morbidity and mortality. A considerable amount of information about management of patients with PH has emerged over the past decade. However, there is still a paucity of information to guide perioperative evaluation and management of these patients. Yet, a satisfactory outcome is feasible by focusing on elaborate disease-adapted anaesthetic management of this complex disease with a multidisciplinary approach. The cornerstone of the peri-anaesthetic management of patients with PH is preservation of right ventricular (RV) function with attention on maintaining RV preload, contractility and limiting increase in RV afterload at each stage of the patient's perioperative care. Pre-anaesthetic evaluation, choice of anaesthetic agents, proper fluid management, appropriate ventilation, correction of hypoxia, hypercarbia, acid-base balance and pain control are paramount in this regard. Essentially, the perioperative management of PH patients is intricate and multifaceted. Unfortunately, a comprehensive evidence-based guideline is lacking to navigate us through this complex process. We conducted a literature review on patients with PH with a focus on the perioperative evaluation and suggest management algorithms for these patients during non-cardiac, non-obstetric surgery.
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Affiliation(s)
- Debabrata Bandyopadhyay
- Center for Advanced Lung Disease and Lung Transplant, University of South Florida - Tampa General Hospital, Tampa, FL, USA
| | - Christopher Lai
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France.,Assistance Publique Hôpitaux de Paris, Service de médecine intensive - réanimation, Hôpital Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de recherche clinique CARMAS, Le Kremlin-Bicêtre, France.,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Juan N Pulido
- Dept of Anesthesiology and Critical Care Medicine, Swedish Medical Center, Seattle, WA, USA and US Anesthesia Partners - Washington, Seattle, WA, USA
| | - Ricardo Restrepo-Jaramillo
- Center for Advanced Lung Disease and Lung Transplant, University of South Florida - Tampa General Hospital, Tampa, FL, USA
| | - Adriano R Tonelli
- Dept of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.,Pathobiology Division, Lerner Research Institute, Cleveland Clinic, OH, USA
| | - Marc Humbert
- Assistance Publique Hôpitaux de Paris, Service de médecine intensive - réanimation, Hôpital Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de recherche clinique CARMAS, Le Kremlin-Bicêtre, France .,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France.,Assistance Publique Hôpitaux de Paris, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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14
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Proczka M, Przybylski J, Cudnoch-Jędrzejewska A, Szczepańska-Sadowska E, Żera T. Vasopressin and Breathing: Review of Evidence for Respiratory Effects of the Antidiuretic Hormone. Front Physiol 2021; 12:744177. [PMID: 34867449 PMCID: PMC8637824 DOI: 10.3389/fphys.2021.744177] [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: 07/19/2021] [Accepted: 09/27/2021] [Indexed: 12/17/2022] Open
Abstract
Vasopressin (AVP) is a key neurohormone involved in the regulation of body functions. Due to its urine-concentrating effect in the kidneys, it is often referred to as antidiuretic hormone. Besides its antidiuretic renal effects, AVP is a potent neurohormone involved in the regulation of arterial blood pressure, sympathetic activity, baroreflex sensitivity, glucose homeostasis, release of glucocorticoids and catecholamines, stress response, anxiety, memory, and behavior. Vasopressin is synthesized in the paraventricular (PVN) and supraoptic nuclei (SON) of the hypothalamus and released into the circulation from the posterior lobe of the pituitary gland together with a C-terminal fragment of pro-vasopressin, known as copeptin. Additionally, vasopressinergic neurons project from the hypothalamus to the brainstem nuclei. Increased release of AVP into the circulation and elevated levels of its surrogate marker copeptin are found in pulmonary diseases, arterial hypertension, heart failure, obstructive sleep apnoea, severe infections, COVID-19 due to SARS-CoV-2 infection, and brain injuries. All these conditions are usually accompanied by respiratory disturbances. The main stimuli that trigger AVP release include hyperosmolality, hypovolemia, hypotension, hypoxia, hypoglycemia, strenuous exercise, and angiotensin II (Ang II) and the same stimuli are known to affect pulmonary ventilation. In this light, we hypothesize that increased AVP release and changes in ventilation are not coincidental, but that the neurohormone contributes to the regulation of the respiratory system by fine-tuning of breathing in order to restore homeostasis. We discuss evidence in support of this presumption. Specifically, vasopressinergic neurons innervate the brainstem nuclei involved in the control of respiration. Moreover, vasopressin V1a receptors (V1aRs) are expressed on neurons in the respiratory centers of the brainstem, in the circumventricular organs (CVOs) that lack a blood-brain barrier, and on the chemosensitive type I cells in the carotid bodies. Finally, peripheral and central administrations of AVP or antagonists of V1aRs increase/decrease phrenic nerve activity and pulmonary ventilation in a site-specific manner. Altogether, the findings discussed in this review strongly argue for the hypothesis that vasopressin affects ventilation both as a blood-borne neurohormone and as a neurotransmitter within the central nervous system.
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Affiliation(s)
- Michał Proczka
- Department of Experimental and Clinical Physiology, Doctoral School, Medical University of Warsaw, Warsaw, Poland
| | - Jacek Przybylski
- Department of Biophysics, Physiology, and Pathophysiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Agnieszka Cudnoch-Jędrzejewska
- Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Ewa Szczepańska-Sadowska
- Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Tymoteusz Żera
- Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
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15
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Liao LM, Zhou L, Wang CR, Hu JY, Lu YJ, Huang S. Opposing responses of the rat pulmonary artery and vein to phenylephrine and other agents in vitro. BMC Pulm Med 2021; 21:189. [PMID: 34090386 PMCID: PMC8180060 DOI: 10.1186/s12890-021-01558-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 05/27/2021] [Indexed: 11/10/2022] Open
Abstract
Background Different from current cognition, our study demonstrated that adrenergic receptors agonist phenylephrine significantly relaxed isolated pulmonary artery but constricted pulmonary veins. Through comparing differences in the effects of commonly used vasoactive drugs on pulmonary artery and veins, the study aimed to improve efficiency and accuracy of isolated pulmonary vascular experiments, and to provide experimental basis for clinical drug use. Methods The contractile responses of pulmonary arteries and veins from twelve-week-old Male Sprague-Dawley rats to phenylephrine, arginine vasopressin (AVP), U46619, endothelin-1, and potassium chloride (KCl) were recorded, as well as the relaxation in response to phenylephrine, AVP, acetylcholine. To further explore the mechanism, some vessels was also pre-incubated with adrenergic receptors antagonists propranolol, prazosin and nitric oxide synthesis inhibitor N[gamma]-nitro-L-arginine methyl ester (L-NAME) before addition of the experimental drugs. Results Phenylephrine constricted pulmonary veins directly, but constricted pulmonary artery only after incubation with propranolol or/and L-NAME. The pulmonary artery exhibited significant relaxation to AVP with or without L-NAME incubation. AVP more clearly constricted the veins after incubation with L-NAME. Changes in vascular tension also varied from pulmonary artery to veins for KCl stimulation. Different from phenomena presented in veins, acetylcholine did not relax pulmonary artery preconstricted by KCl, U46619, and endothelin-1. Conclusions According to the results, phenylephrine, KCl, AVP, and acetylcholine could be used to distinguish pulmonary arteries and pulmonary veins in vitro. This also suggested that the pulmonary arteries and pulmonary veins have great differences in physiology and drug reactivity.
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Affiliation(s)
- Li-Mei Liao
- Department of Anaesthesia, Obstetrics and Gynecology Hospital, Fudan University, 128 Shenyang road, Shanghai, 200090, China.,Department of Anesthesiology and Perioperative Medicine, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, 9# Jinsui Road, Guangzhou, 510623, China
| | - Li Zhou
- Department of Physiology and Pathophysiology, School of Basic Medicine Science, Fudan University, 130 Dongan Road, Shanghai, 200032, China.
| | - Chen-Ran Wang
- Department of Anaesthesia, Obstetrics and Gynecology Hospital, Fudan University, 128 Shenyang road, Shanghai, 200090, China
| | - Jian-Ying Hu
- Department of Anaesthesia, Obstetrics and Gynecology Hospital, Fudan University, 128 Shenyang road, Shanghai, 200090, China
| | - Yao-Jun Lu
- Department of Anaesthesia, Obstetrics and Gynecology Hospital, Fudan University, 128 Shenyang road, Shanghai, 200090, China
| | - Shaoqiang Huang
- Department of Anaesthesia, Obstetrics and Gynecology Hospital, Fudan University, 128 Shenyang road, Shanghai, 200090, China.
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16
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Coleman RD, Chartan CA, Mourani PM. Intensive care management of right ventricular failure and pulmonary hypertension crises. Pediatr Pulmonol 2021; 56:636-648. [PMID: 33561307 DOI: 10.1002/ppul.24776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 04/03/2020] [Indexed: 01/22/2023]
Abstract
Pulmonary hypertension (PH), an often unrelenting disease that carries with it significant morbidity and mortality, affects not only the pulmonary vasculature but, in turn, the right ventricle as well. The survival of patients with PH is closely related to the right ventricular function. Therefore, having an understanding of how to manage right ventricular failure (RVF) and acute pulmonary hypertensive crises is imperative for clinicians who encounter these patients. This review addresses the management of these patients in detail, addressing: (a) the pathophysiology of RVF, (b) intensive care monitoring of these patients in the intensive care unit, (c) imaging of the right ventricle, (d) intubation and mechanical ventilation, (e) inotrope and vasopressor selection, (f) pulmonary vasodilator use, (g) interventional and surgical procedures for the acutely failing right ventricle, and (h) mechanical support for RVF.
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Affiliation(s)
- Ryan D Coleman
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Section of Pulmonary Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Corey A Chartan
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Section of Pulmonary Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Peter M Mourani
- Section of Critical Care Medicine and Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
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17
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Price LC, Martinez G, Brame A, Pickworth T, Samaranayake C, Alexander D, Garfield B, Aw TC, McCabe C, Mukherjee B, Harries C, Kempny A, Gatzoulis M, Marino P, Kiely DG, Condliffe R, Howard L, Davies R, Coghlan G, Schreiber BE, Lordan J, Taboada D, Gaine S, Johnson M, Church C, Kemp SV, Wong D, Curry A, Levett D, Price S, Ledot S, Reed A, Dimopoulos K, Wort SJ. Perioperative management of patients with pulmonary hypertension undergoing non-cardiothoracic, non-obstetric surgery: a systematic review and expert consensus statement. Br J Anaesth 2021; 126:774-790. [PMID: 33612249 DOI: 10.1016/j.bja.2021.01.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The risk of complications, including death, is substantially increased in patients with pulmonary hypertension (PH) undergoing anaesthesia for surgical procedures, especially in those with pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH). Sedation also poses a risk to patients with PH. Physiological changes including tachycardia, hypotension, fluid shifts, and an increase in pulmonary vascular resistance (PH crisis) can precipitate acute right ventricular decompensation and death. METHODS A systematic literature review was performed of studies in patients with PH undergoing non-cardiac and non-obstetric surgery. The management of patients with PH requiring sedation for endoscopy was also reviewed. Using a framework of relevant clinical questions, we review the available evidence guiding operative risk, risk assessment, preoperative optimisation, and perioperative management, and identifying areas for future research. RESULTS Reported 30 day mortality after non-cardiac and non-obstetric surgery ranges between 2% and 18% in patients with PH undergoing elective procedures, and increases to 15-50% for emergency surgery, with complications and death usually relating to acute right ventricular failure. Risk factors for mortality include procedure-specific and patient-related factors, especially markers of PH severity (e.g. pulmonary haemodynamics, poor exercise performance, and right ventricular dysfunction). Most studies highlight the importance of individualised preoperative risk assessment and optimisation and advanced perioperative planning. CONCLUSIONS With an increasing number of patients requiring surgery in specialist and non-specialist PH centres, a systematic, evidence-based, multidisciplinary approach is required to minimise complications. Adequate risk stratification and a tailored-individualised perioperative plan is paramount.
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Affiliation(s)
- Laura C Price
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK.
| | - Guillermo Martinez
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - Aimee Brame
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; Intensive Care unit and Pulmonary Hypertension Service, London, UK
| | | | | | - David Alexander
- Department of Anaesthesia, Royal Brompton Hospital, London, UK
| | - Benjamin Garfield
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Tuan-Chen Aw
- Department of Anaesthesia, Royal Brompton Hospital, London, UK
| | - Colm McCabe
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Bhashkar Mukherjee
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; Intensive Care unit and Pulmonary Hypertension Service, London, UK
| | - Carl Harries
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK
| | - Aleksander Kempny
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael Gatzoulis
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Philip Marino
- Intensive Care unit and Pulmonary Hypertension Service, London, UK
| | - David G Kiely
- Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - Robin Condliffe
- Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - Luke Howard
- National Pulmonary Hypertension Service, Hammersmith Hospital, London, UK
| | - Rachel Davies
- National Pulmonary Hypertension Service, Hammersmith Hospital, London, UK
| | - Gerry Coghlan
- National Pulmonary Hypertension Service, Royal Free Hospital, London, UK
| | | | - James Lordan
- National Pulmonary Hypertension Service, Freeman Hospital, Newcastle upon Tyne, UK
| | - Dolores Taboada
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - Sean Gaine
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Martin Johnson
- Scottish Pulmonary Vascular Unit, NHS Golden Jubilee, Clydebank, UK
| | - Colin Church
- Scottish Pulmonary Vascular Unit, NHS Golden Jubilee, Clydebank, UK
| | - Samuel V Kemp
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Davina Wong
- Intensive Care unit and Pulmonary Hypertension Service, London, UK
| | - Andrew Curry
- Cardiothoracic Anaesthesia, University Hospital Southampton, Southampton, Hampshire, UK
| | - Denny Levett
- Anaesthesia and Critical Care Research Area, Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Susanna Price
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Stephane Ledot
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Anna Reed
- National Heart and Lung Institute, Imperial College London, London, UK; Respiratory and Lung Transplantation, Harefield Hospital, Uxbridge, UK
| | - Konstantinos Dimopoulos
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Stephen John Wort
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
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19
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Szczepanska-Sadowska E, Cudnoch-Jedrzejewska A, Wsol A. The role of oxytocin and vasopressin in the pathophysiology of heart failure in pregnancy and in fetal and neonatal life. Am J Physiol Heart Circ Physiol 2020; 318:H639-H651. [PMID: 32056469 DOI: 10.1152/ajpheart.00484.2019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Pregnancy and early life create specific psychosomatic challenges for the mother and child, such as changes in hemodynamics, resetting of the water-electrolyte balance, hypoxia, pain, and stress, that all play an important role in the regulation of the release of oxytocin and vasopressin. Both of these hormones regulate the water-electrolyte balance and cardiovascular functions, maturation of the cardiovascular system, and cardiovascular responses to stress. These aspects may be of particular importance in a state of emergency, such as hypertension in the mother or severe heart failure in the child. In this review, we draw attention to a broad spectrum of actions exerted by oxytocin and vasopressin in the pregnant mother and the offspring during early life. To this end, we discuss the following topics: 1) regulation of the secretion of oxytocin and vasopressin and expression of their receptors in the pregnant mother and child, 2) direct and indirect effects of oxytocin and vasopressin on the cardiovascular system in the healthy mother and fetus, and 3) positive and negative consequences of altered secretion of oxytocin and vasopressin in the mother with cardiovascular pathology and in the progeny with heart failure. The present survey provides evidence that moderate stimulation of the oxytocin and vasopressin receptors plays a beneficial role in the healthy pregnant mother and fetus; however, under pathophysiological conditions the inappropriate action of these hormones exerts several negative effects on the cardiovascular system of the mother and progeny and may potentially contribute to the pathophysiology of heart failure in early life.
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Affiliation(s)
- E Szczepanska-Sadowska
- Department of Experimental and Clinical Physiology, Laboratory of Center for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - A Cudnoch-Jedrzejewska
- Department of Experimental and Clinical Physiology, Laboratory of Center for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - A Wsol
- Department of Experimental and Clinical Physiology, Laboratory of Center for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
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Francis L, Whitener S, McKinnon J, Whitener G. Pulmonary Hypertension and Thoracic Surgery: Impact and Treatment Options. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00360-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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21
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Belletti A, Landoni G, Lomivorotov VV, Oriani A, Ajello S. Adrenergic Downregulation in Critical Care: Molecular Mechanisms and Therapeutic Evidence. J Cardiothorac Vasc Anesth 2019; 34:1023-1041. [PMID: 31839459 DOI: 10.1053/j.jvca.2019.10.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 09/09/2019] [Accepted: 10/10/2019] [Indexed: 02/08/2023]
Abstract
Catecholamines remain the mainstay of therapy for acute cardiovascular dysfunction. However, adrenergic receptors quickly undergo desensitization and downregulation after prolonged stimulation. Moreover, prolonged exposure to high circulating catecholamines levels is associated with several adverse effects on different organ systems. Unfortunately, in critically ill patients, adrenergic downregulation translates into progressive reduction of cardiovascular response to exogenous catecholamine administration, leading to refractory shock. Accordingly, there has been a growing interest in recent years toward use of noncatecholaminergic inotropes and vasopressors. Several studies investigating a wide variety of catecholamine-sparing strategies (eg, levosimendan, vasopressin, β-blockers, steroids, and use of mechanical circulatory support) have been published recently. Use of these agents was associated with improvement in hemodynamics and decreased catecholamine use but without a clear beneficial effect on major clinical outcomes. Accordingly, additional research is needed to define the optimal management of catecholamine-resistant shock.
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Affiliation(s)
- Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Vladimir V Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia; Novosibirsk State University, Novosibirsk, Russia
| | - Alessandro Oriani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Ajello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
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