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Brennan KA, Bhutiani M, Kingeter MA, McEvoy MD. Updates in the Management of Perioperative Vasoplegic Syndrome. Adv Anesth 2022; 40:71-92. [PMID: 36333053 DOI: 10.1016/j.aan.2022.07.010] [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: 06/16/2023]
Abstract
Vasoplegic syndrome occurs relatively frequently in cardiac surgery, liver transplant, major noncardiac surgery, in post-return of spontaneous circulation situations, and in pateints with sepsis. It is paramount for the anesthesiologist to understand both the pathophysiology of vasoplegia and the different treatment strategies available for rescuing a patient from life-threatening hypotension.
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Affiliation(s)
- Kaitlyn A Brennan
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, MAB 422, Nashville, TN 37212, USA
| | - Monica Bhutiani
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, VUH 4107, Nashville, TN 37212, USA
| | - Meredith A Kingeter
- Anesthesia Residency, Vanderbilt University Medical Center, 1215 21st Avenue South, Suite 5160 MCE NT, Nashville, TN 37212, USA
| | - Matthew D McEvoy
- VUMC Enhanced Recovery Programs, Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN 37232, USA.
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Ziriat I, Le Thuaut A, Colin G, Merdji H, Grillet G, Girardie P, Souweine B, Dequin PF, Boulain T, Frat JP, Asfar P, Francois B, Landais M, Plantefeve G, Quenot JP, Chakarian JC, Sirodot M, Legriel S, Massart N, Thevenin D, Desachy A, Delahaye A, Botoc V, Vimeux S, Martino F, Reignier J, Cariou A, Lascarrou JB. Outcomes of mild-to-moderate postresuscitation shock after non-shockable cardiac arrest and association with temperature management: a post hoc analysis of HYPERION trial data. Ann Intensive Care 2022; 12:96. [PMID: 36251223 PMCID: PMC9576832 DOI: 10.1186/s13613-022-01071-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 10/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Outcomes of postresuscitation shock after cardiac arrest can be affected by targeted temperature management (TTM). A post hoc analysis of the "TTM1 trial" suggested higher mortality with hypothermia at 33 °C. We performed a post hoc analysis of HYPERION trial data to assess potential associations linking postresuscitation shock after non-shockable cardiac arrest to hypothermia at 33 °C on favourable functional outcome. METHODS We divided the patients into groups with vs. without postresuscitation (defined as the need for vasoactive drugs) shock then assessed the proportion of patients with a favourable functional outcome (day-90 Cerebral Performance Category [CPC] 1 or 2) after hypothermia (33 °C) vs. controlled normothermia (37 °C) in each group. Patients with norepinephrine or epinephrine > 1 µg/kg/min were not included. RESULTS Of the 581 patients included in 25 ICUs in France and who did not withdraw consent, 339 had a postresuscitation shock and 242 did not. In the postresuscitation-shock group, 159 received hypothermia, including 14 with a day-90 CPC of 1-2, and 180 normothermia, including 10 with a day-90 CPC of 1-2 (8.81% vs. 5.56%, respectively; P = 0.24). After adjustment, the proportion of patients with CPC 1-2 also did not differ significantly between the hypothermia and normothermia groups (adjusted hazards ratio, 1.99; 95% confidence interval, 0.72-5.50; P = 0.18). Day-90 mortality was comparable in these two groups (83% vs. 86%, respectively; P = 0.43). CONCLUSIONS After non-shockable cardiac arrest, mild-to-moderate postresuscitation shock at intensive-care-unit admission did not seem associated with day-90 functional outcome or survival. Therapeutic hypothermia at 33 °C was not associated with worse outcomes compared to controlled normothermia in patients with postresuscitation shock. Trial registration ClinicalTrials.gov, NCT01994772.
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Affiliation(s)
- Ines Ziriat
- Médecine Intensive Réanimation, University Hospital Centre, Nantes, France
| | - Aurélie Le Thuaut
- Direction de la Recherche Clinique et l'Innovation, Plateforme de Méthodologie et Biostatistique, University Hospital Centre, Nantes, France
| | - Gwenhael Colin
- Medecine Intensive Reanimation, District Hospital Center, La Roche-sur-Yon, France
- AfterROSC Network, Paris, France
| | - Hamid Merdji
- Université de Strasbourg (UNISTRA), Faculté de Médecine; Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Service de Médecine Intensive Réanimation, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Guillaume Grillet
- Medical Intensive Care Unit, South Brittany General Hospital Centre, Lorient, France
| | - Patrick Girardie
- Médecine Intensive Réanimation, CHU Lille, 59000, Lille, France
- Faculté de Médicine, Université de Lille, 59000, Lille, France
| | - Bertrand Souweine
- Medical Intensive Care Unit, University Hospital Centre, Clermond-Ferrand, France
| | - Pierre-François Dequin
- INSERM CIC1415, CHRU de Tours, Tours, France
- Medical Intensive Care Unit, University Hospital Centre, Tours, France
- Inserm UMR 1100 - Centre d'Étude des Pathologies Respiratoires, Tours University, Tours, France
| | - Thierry Boulain
- Medical Intensive Care Unit, Regional Hospital Centre, Orleans, France
| | - Jean-Pierre Frat
- Médecine Intensive Réanimation, CHU de Poitiers, Poitiers, France
- INSERM, CIC-1402, ALIVES, Poitiers, France
- Université de Poitiers, Faculté de Médecine et de Pharmacie de Poitiers, Poitiers, France
| | - Pierre Asfar
- Medical Intensive Care Unit, University Hospital Centre, Angers, France
| | - Bruno Francois
- Service de Réanimation Polyvalente, University Hospital Centre, Limoges, France
- INSERM CIC 1435 & UMR 1092, University Hospital Centre, Limoges, France
| | - Mickael Landais
- Medical-Surgical Intensive Care Unit, Community Hospital Centre, Le Mans, France
| | - Gaëtan Plantefeve
- Medical-Surgical Intensive Care Unit, Community Hospital Centre, Argenteuil, France
| | | | | | - Michel Sirodot
- Medical-Surgical Intensive Care Unit, Community Hospital Centre, Annecy, France
| | - Stéphane Legriel
- AfterROSC Network, Paris, France
- Medical-Surgical Intensive Care Unit, Versailles Hospital, Versailles, France
| | - Nicolas Massart
- Medical-Surgical Intensive Care Unit, Community Hospital Centre, Saint Brieuc, France
| | - Didier Thevenin
- Medical-Surgical Intensive Care Unit, Community Hospital Centre, Lens, France
| | - Arnaud Desachy
- Medical-Surgical Intensive Care Unit, Community Hospital Centre, Angoulême, France
| | - Arnaud Delahaye
- Medical-Surgical Intensive Care Unit, Community Hospital Centre, Rodez, France
| | - Vlad Botoc
- Medical-Surgical Intensive Care Unit, Community Hospital Centre, Saint Malo, France
| | - Sylvie Vimeux
- Medical-Surgical Intensive Care Unit, Community Hospital Centre, Montauban, France
| | - Frederic Martino
- Medical Intensive Care Unit, University Hospital Centre, Pointe-à-Pitre, France
| | - Jean Reignier
- Médecine Intensive Réanimation, University Hospital Centre, Nantes, France
| | - Alain Cariou
- AfterROSC Network, Paris, France
- Medical Intensive Care Unit, Cochin Hospital (APHP) and University of Paris, Paris, France
- Paris Cardiovascular Research Centre, INSERM U970, Paris, France
| | - Jean Baptiste Lascarrou
- Médecine Intensive Réanimation, University Hospital Centre, Nantes, France.
- AfterROSC Network, Paris, France.
- Paris Cardiovascular Research Centre, INSERM U970, Paris, France.
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire, 30 Boulevard Jean Monnet, 44093, Nantes Cedex 1, France.
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Petit M, Lascarrou JB, Colin G, Merdji H, Cariou A, Geri G. Hemodynamics and vasopressor support during targeted temperature management after cardiac arrest with non-shockable rhythm: A post hoc analysis of a randomized controlled trial. Resusc Plus 2022; 11:100271. [PMID: 35860752 PMCID: PMC9289859 DOI: 10.1016/j.resplu.2022.100271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/15/2022] [Accepted: 06/22/2022] [Indexed: 11/20/2022] Open
Abstract
Background Patients admitted after cardiac arrest with non-shockable rhythm frequently experience hemodynamic instability. This study assessed the hemodynamic consequences of TTM in this sub population. Methods This is a post hoc analysis of the HYPERION trial (NCT01994772), that randomized patients to either hypothermia or normothermia after non-shockable rhythm related cardiac arrest. Patients with no, moderate or severe circulatory failure were identified with cardiovascular Sequential Organ Failure Assessment at randomization. Primary outcome was the number of patients at day 7 with resolution of shock, accounting for the risk of death (competing risk analysis). Secondary endpoint included neurological outcome and death at day-90. Results 584 patients were included in the analysis: 195 (34%), 46 (8%) and 340 (59%) had no, moderate and severe circulatory failure, respectively. Resolution of circulatory failure at day 7 was more frequently observed in the normothermia group than in the TTM group (60% [95 %CI 54-66] versus 53% [95 %CI 46-60], Gray-test: p = 0.016). The severity of circulatory failure at randomization was associated with its less frequent resolution at day 7 accounting for the risk of death (76 % [62-86] versus 54% [49-59] for patients with moderate versus severe circulatory failure, Gray test, p < 0.001, respectively). At day 90, the proportion of patients with Cerebral Performance Category score of 1 or 2 was lower in patients presenting severe circulatory failure (p = 0.038). Conclusion Circulatory failure is frequent after CA with non-shockable rhythm. Its severity at admission and TTM were associated with delayed resolution of circulatory failure.
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Affiliation(s)
- Matthieu Petit
- Medical Intensive Care Unit, Ambroise Paré Hospital, APHP, Boulogne-Billancourt, France
- Paris-Saclay University, UVSQ, Inserm, CESP, 94807 Villejuif, France
| | - Jean-Baptiste Lascarrou
- Médecine Intensive Réanimation, University Hospital Center, Nantes, France
- Paris Cardiovascular Research Center, INSERM U970, Paris, France
- AfterROSC Network, France
| | - Gwenhael Colin
- Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France
| | - Hamid Merdji
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux universitaires de Strasbourg, Nouvel Hôpital Civil, Service de Médecine Intensive Réanimation, Strasbourg, France
- UMR 1260, Regenerative Nano Medecine, INSERM, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Alain Cariou
- Paris Cardiovascular Research Center, INSERM U970, Paris, France
- AfterROSC Network, France
- Medical Intensive Care Unit, Cochin University Hospital Center, Paris, France
| | - Guillaume Geri
- Medical and Surgical Intensive Care Unit, Ambroise Paré Clinic, Neuilly-sur-Seine, France
| | - HYPERION investigators1
- Medical Intensive Care Unit, Ambroise Paré Hospital, APHP, Boulogne-Billancourt, France
- Paris-Saclay University, UVSQ, Inserm, CESP, 94807 Villejuif, France
- Médecine Intensive Réanimation, University Hospital Center, Nantes, France
- Paris Cardiovascular Research Center, INSERM U970, Paris, France
- AfterROSC Network, France
- Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux universitaires de Strasbourg, Nouvel Hôpital Civil, Service de Médecine Intensive Réanimation, Strasbourg, France
- UMR 1260, Regenerative Nano Medecine, INSERM, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
- Medical Intensive Care Unit, Cochin University Hospital Center, Paris, France
- Medical and Surgical Intensive Care Unit, Ambroise Paré Clinic, Neuilly-sur-Seine, France
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