1
|
See EJ, Chaba A, Spano S, Maeda A, Clapham C, Burrell LM, Liu J, Khasin M, Liskaser G, Eastwood G, Bellomo R. Renin Levels and Angiotensin II Responsiveness in Vasopressor-Dependent Hypotension. Crit Care Med 2024; 52:1218-1227. [PMID: 38511994 DOI: 10.1097/ccm.0000000000006273] [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: 03/22/2024]
Abstract
OBJECTIVES The relationship between renin levels, exposure to renin-angiotensin system (RAS) inhibitors, angiotensin II (ANGII) responsiveness, and outcome in patients with vasopressor-dependent vasodilatory hypotension is unknown. DESIGN We conducted a single-center prospective observational study to explore whether recent RAS inhibitor exposure affected baseline renin levels, whether baseline renin levels predicted ANGII responsiveness, and whether renin levels at 24 hours were associated with clinical outcomes. SETTING An academic ICU in Melbourne, VIC, Australia. PATIENTS Forty critically ill adults who received ANGII as the primary agent for vasopressor-dependent vasodilatory hypotension who were included in the Acute Renal effects of Angiotensin II Management in Shock study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS After multivariable adjustment, recent exposure to a RAS inhibitor was independently associated with a relative increase in baseline renin levels by 198% (95% CI, 36-552%). The peak amount of ANGII required to achieve target mean arterial pressure was independently associated with baseline renin level (increase by 46% per ten-fold increase; 95% CI, 8-98%). Higher renin levels at 24 hours after ANGII initiation were independently associated with fewer days alive and free of continuous renal replacement therapy (CRRT) (-7 d per ten-fold increase; 95% CI, -12 to -1). CONCLUSIONS In patients with vasopressor-dependent vasodilatory hypotension, recent RAS inhibitor exposure was associated with higher baseline renin levels. Such higher renin levels were then associated with decreased ANGII responsiveness. Higher renin levels at 24 hours despite ANGII infusion were associated with fewer days alive and CRRT-free. These preliminary findings emphasize the importance of the RAS and the role of renin as a biomarker in patients with vasopressor-dependent vasodilatory hypotension.
Collapse
Affiliation(s)
- Emily J See
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Nephrology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
- Institute of Breathing and Sleep, Austin Health, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
| | - Anis Chaba
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Sofia Spano
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Akinori Maeda
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Caroline Clapham
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Louise M Burrell
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
- Institute of Breathing and Sleep, Austin Health, Melbourne, VIC, Australia
| | - Jasmine Liu
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Monique Khasin
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Grace Liskaser
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Rinaldo Bellomo
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
- Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
| |
Collapse
|
2
|
Russell JA. Vasopressor Responsiveness 101: Prediction of Responsiveness to Angiotensin II Infusion. Crit Care Med 2024; 52:1310-1313. [PMID: 39008548 DOI: 10.1097/ccm.0000000000006320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Affiliation(s)
- James A Russell
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, BC, Canada
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
3
|
Moll V, Khanna AK, Kurz A, Huang J, Smit M, Swaminathan M, Minear S, Parr KG, Prabhakar A, Zhao M, Malbrain MLNG. Optimization of kidney function in cardiac surgery patients with intra-abdominal hypertension: expert opinion. Perioper Med (Lond) 2024; 13:72. [PMID: 38997752 PMCID: PMC11245849 DOI: 10.1186/s13741-024-00416-5] [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: 12/28/2023] [Accepted: 06/09/2024] [Indexed: 07/14/2024] Open
Abstract
Cardiac surgery-associated acute kidney injury (CSA-AKI) affects up to 42% of cardiac surgery patients. CSA-AKI is multifactorial, with low abdominal perfusion pressure often overlooked. Abdominal perfusion pressure is calculated as mean arterial pressure minus intra-abdominal pressure (IAP). IAH decreases cardiac output and compresses the renal vasculature and renal parenchyma. Recent studies have highlighted the frequent occurrence of IAH in cardiac surgery patients and have linked the role of low perfusion pressure to the occurrence of AKI. This review and expert opinion illustrate current evidence on the pathophysiology, diagnosis, and therapy of IAH and ACS in the context of AKI.
Collapse
Affiliation(s)
- Vanessa Moll
- Department of Anesthesiology, Division of Critical Care Medicine, University of Minnesota, Minneapolis, MN, USA
- Department of Anesthesiology, Division of Critical Care Medicine, Emory School of Medicine, Atlanta, GA, USA
| | - Ashish K Khanna
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
- Departments of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Andrea Kurz
- Department of Anesthesiology, Emergency Medicine and Intensive Care Medicine, Medical University Graz, Graz, Austria
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA
| | - Jiapeng Huang
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Marije Smit
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Madhav Swaminathan
- Department of Anesthesiology, Cleveland Clinic Florida, Weston Hospital, Weston, FL, USA
| | - Steven Minear
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - K Gage Parr
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Amit Prabhakar
- Department of Anesthesiology, Division of Critical Care Medicine, Emory School of Medicine, Atlanta, GA, USA
| | - Manxu Zhao
- First Department of Anaesthesiology and Intensive Therapy, Medical University Lublin, Lublin, Poland
| | - Manu L N G Malbrain
- Medical Data Management, Medaman, Geel, Belgium.
- International Fluid Academy, Lovenjoel, Belgium.
| |
Collapse
|
4
|
Sadjadi M, von Groote T, Weiss R, Strauß C, Wempe C, Albert F, Langenkämper M, Landoni G, Bellomo R, Khanna AK, Coulson T, Meersch M, Zarbock A. A Pilot Study of Renin-Guided Angiotensin-II Infusion to Reduce Kidney Stress After Cardiac Surgery. Anesth Analg 2024; 139:165-173. [PMID: 38289858 DOI: 10.1213/ane.0000000000006839] [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: 02/01/2024]
Abstract
BACKGROUND Vasoplegia is common after cardiac surgery, is associated with hyperreninemia, and can lead to acute kidney stress. We aimed to conduct a pilot study to test the hypothesis that, in vasoplegic cardiac surgery patients, angiotensin-II (AT-II) may not increase kidney stress (measured by [TIMP-2]*[IGFBP7]). METHODS We randomly assigned patients with vasoplegia (cardiac index [CI] > 2.1l/min, postoperative hypotension requiring vasopressors) and Δ-renin (4-hour postoperative-preoperative value) ≥3.7 µU/mL, to AT-II or placebo targeting a mean arterial pressure ≥65 mm Hg for 12 hours. The primary end point was the incidence of kidney stress defined as the difference between baseline and 12 hours [TIMP-2]*[IGFBP7] levels. Secondary end points included serious adverse events (SAEs). RESULTS We randomized 64 patients. With 1 being excluded, 31 patients received AT-II, and 32 received placebo. No significant difference was observed between AT-II and placebo groups for kidney stress (Δ-[TIMP-2]*[IGFBP7] 0.06 [ng/mL] 2 /1000 [Q1-Q3, -0.24 to 0.28] vs -0.08 [ng/mL] 2 /1000 [Q1-Q3, -0.35 to 0.14]; P = .19; Hodges-Lehmann estimation of the location shift of 0.12 [ng/mL] 2 /1000 [95% confidence interval, CI, -0.1 to 0.36]). AT-II patients received less fluid during treatment than placebo patients (2946 vs 3341 mL, P = .03), and required lower doses of norepinephrine equivalent (0.19 mg vs 4.18mg, P < .001). SAEs were reported in 38.7% of patients in the AT-II group and in 46.9% of patients in the placebo group. CONCLUSIONS The infusion of AT-II for 12 hours appears feasible and did not lead to an increase in kidney stress in a high-risk cohort of cardiac surgery patients. These findings support the cautious continued investigation of AT-II as a vasopressor in hyperreninemic cardiac surgery patients.
Collapse
Affiliation(s)
- Mahan Sadjadi
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Thilo von Groote
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Raphael Weiss
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Christian Strauß
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Carola Wempe
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Felix Albert
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Marie Langenkämper
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Giovanni Landoni
- Department of Intensive Care and Anesthesia, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Anesthesia and Intensive Care, School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Rinaldo Bellomo
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Intensive Care, Austin Health, Heidelberg, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, School of Medicine, Wake Forest University, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
- Outcomes Research Consortium, Cleveland, Ohio
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, North Carolina
| | - Tim Coulson
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
- Department of Anesthesiology and Perioperative Medicine, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Melanie Meersch
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Alexander Zarbock
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
- Outcomes Research Consortium, Cleveland, Ohio
| |
Collapse
|
5
|
Scurt FG, Bose K, Mertens PR, Chatzikyrkou C, Herzog C. Cardiac Surgery-Associated Acute Kidney Injury. KIDNEY360 2024; 5:909-926. [PMID: 38689404 PMCID: PMC11219121 DOI: 10.34067/kid.0000000000000466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 04/26/2024] [Indexed: 05/02/2024]
Abstract
AKI is a common and serious complication of cardiac surgery that has a significant impact on patient morbidity and mortality. The Kidney Disease Improving Global Outcomes definition of AKI is widely used to classify and identify AKI associated with cardiac surgery (cardiac surgery-associated AKI [CSA-AKI]) on the basis of changes in serum creatinine and/or urine output. There are various preoperative, intraoperative, and postoperative risk factors for the development of CSA-AKI which should be recognized and addressed as early as possible to expedite its diagnosis, reduce its occurrence, and prevent or ameliorate its devastating complications. Crucial issues are the inaccuracy of serum creatinine as a surrogate parameter of kidney function in the perioperative setting of cardiothoracic surgery and the necessity to discover more representative markers of the pathophysiology of AKI. However, except for the tissue inhibitor of metalloproteinase-2 and insulin-like growth factor binding protein 7 ratio, other diagnostic biomarkers with an acceptable sensitivity and specificity are still lacking. This article provides a comprehensive review of various aspects of CSA-AKI, including pathogenesis, risk factors, diagnosis, biomarkers, classification, prevention, and treatment management.
Collapse
Affiliation(s)
- Florian G. Scurt
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Katrin Bose
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Magdeburg, Germany
| | - Peter R. Mertens
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Christos Chatzikyrkou
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Carolin Herzog
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| |
Collapse
|
6
|
Kotani Y, Chappell M, Landoni G, Zarbock A, Bellomo R, Khanna AK. Renin in critically ill patients. Ann Intensive Care 2024; 14:79. [PMID: 38775999 PMCID: PMC11111649 DOI: 10.1186/s13613-024-01304-3] [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: 03/14/2024] [Accepted: 04/28/2024] [Indexed: 05/25/2024] Open
Abstract
The renin-angiotensin system (RAS) constitutes one of the principal mechanisms to maintain hemodynamic and fluid homeostasis. However, most research until now on RAS primarily focuses on its relationship with hypertension and its role in critically ill hypotensive populations is not well understood. With the approval of angiotensin II (Ang II) in the United States and Europe, following a phase 3 randomized controlled trial showing efficacy in catecholamine-resistant vasodilatory shock, there is growing interest in RAS in critically ill patients. Among the fundamental components of RAS, renin acts as the initial stimulus for the entire system. In the context of hypotension, its release increases in response to low blood pressure sensed by renal baroreceptors and attenuated negative Ang II feedback loop. Thus, elevated renin could reflect disease severity and predict poor outcomes. Studies investigating this hypothesis have validated the prognostic accuracy of renin in various critically ill populations, with several reports indicating its superiority to lactate for mortality prediction. Accordingly, renin reduction has been used to assess the effectiveness of Ang II administration. Furthermore, renin holds potential to identify patients who might benefit from Ang II treatment, potentially paving the way for personalized vasopressor management. Despite these promising data, most available evidence is derived from retrospective analysis and necessitates prospective confirmation. The absence of a rapid, point-of-care and reliable renin assay presents another hurdle to its integration into routine clinical practice. This narrative review aims to describe the current understanding and future directions of renin as a biomarker during resuscitation of critically ill patients.
Collapse
Affiliation(s)
- Yuki Kotani
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Mark Chappell
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Ashish K Khanna
- Section On Critical Care Medicine, Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA.
- Perioperative Outcomes and Informatics Collaborative, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
- Outcomes Research Consortium, Cleveland, OH, 44195, USA.
| |
Collapse
|
7
|
Kotani Y, D'Andria Ursoleo J, Murru CP, Landoni G. Blood Pressure Management for Hypotensive Patients in Intensive Care and Perioperative Cardiovascular Settings. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00266-0. [PMID: 38918089 DOI: 10.1053/j.jvca.2024.04.010] [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: 01/06/2024] [Revised: 03/23/2024] [Accepted: 04/08/2024] [Indexed: 06/27/2024]
Abstract
Blood pressure is a critical physiological parameter, particularly in the context of cardiac intensive care and perioperative settings. As a primary indicator of organ perfusion, the maintenance of adequate blood pressure is imperative for the assurance of sufficient tissue oxygen delivery. Among critically ill and major surgery patients, the continuous monitoring of blood pressure is performed as a standard practice for patients. Nonetheless, uncertainties remain regarding blood pressure goals, and there is no consensus regarding blood pressure targets. This review describes the determinants of blood pressure, examine the influence of blood pressure on organ perfusion, and synthesize the current clinical evidence from various intensive care and perioperative settings to provide a concise guidance for daily clinical practice.
Collapse
Affiliation(s)
- Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Jacopo D'Andria Ursoleo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlotta Pia Murru
- 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; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
| |
Collapse
|
8
|
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.
Collapse
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.
| |
Collapse
|
9
|
Coloretti I, Genovese A, Teixeira JP, Cherian A, Ferrer R, Landoni G, Leone M, Girardis M, Nielsen ND. Angiotensin ii therapy in refractory septic shock: which patient can benefit most? A narrative review. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:13. [PMID: 38383521 PMCID: PMC10882873 DOI: 10.1186/s44158-024-00150-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 02/12/2024] [Indexed: 02/23/2024]
Abstract
Patients with septic shock who experience refractory hypotension despite adequate fluid resuscitation and high-dose noradrenaline have high mortality rates. To improve outcomes, evidence-based guidelines recommend starting a second vasopressor, such as vasopressin, if noradrenaline doses exceed 0.5 µg/kg/min. Recently, promising results have been observed in treating refractory hypotension with angiotensin II, which has been shown to increase mean arterial pressure and has been associated with improved outcomes. This narrative review aims to provide an overview of the pathophysiology of the renin-angiotensin system and the role of endogenous angiotensin II in vasodilatory shock with a focus on how angiotensin II treatment impacts clinical outcomes and on identifying the population that may benefit most from its use.
Collapse
Affiliation(s)
- Irene Coloretti
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Via del Pozzo, Modena, 71. 41124, Italy.
| | - Andrea Genovese
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Via del Pozzo, Modena, 71. 41124, Italy
| | - J Pedro Teixeira
- Divisions of Nephrology and Pulmonary, Critical Care, and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Anusha Cherian
- Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantri Nagar, Pondicherry, India
| | - Ricard Ferrer
- Intensive Care Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Giovanni Landoni
- Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marc Leone
- Anesthesia and Intensive Care Medicine, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Massimo Girardis
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Via del Pozzo, Modena, 71. 41124, Italy
| | - Nathan D Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine & Section of Transfusion Medicine and Therapeutic Pathology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| |
Collapse
|
10
|
von Groote T, Sadjadi M, Zarbock A. Acute kidney injury after cardiac surgery. Curr Opin Anaesthesiol 2024; 37:35-41. [PMID: 37865823 DOI: 10.1097/aco.0000000000001320] [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: 10/23/2023]
Abstract
PURPOSE OF REVIEW Patients undergoing cardiac surgery are at high risk to develop cardiac surgery-associated acute kidney injury (CS-AKI) postoperatively. CS-AKI is associated with an increased risk for persistent renal dysfunction, morbidity and mortality. This review summarizes the epidemiology and pathophysiology of CS-AKI, as well as current treatment and prevention strategies. RECENT FINDINGS As AKI is a syndrome with complex pathophysiology, no causative treatment strategies exist. Recent advances in the field of AKI biomarkers offer new perspectives on the issue and the implementation of biomarker-guided preventive strategies may reduce rates of CS-AKI. Finally, nephroprotective treatments and angiotensin II as a novel vasopressor may offer new opportunities for high-risk patients undergoing cardiac surgery. SUMMARY Based on the described novel approaches for early detection, prevention and management of CS-AKI, a precision-medicine approach should be implemented in order to prevent the development of AKI in patients undergoing cardiac surgery.
Collapse
Affiliation(s)
- Thilo von Groote
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | | | | |
Collapse
|
11
|
Bellomo R, Zarbock A, Landoni G. Angiotensin II. Intensive Care Med 2024; 50:279-282. [PMID: 38189932 DOI: 10.1007/s00134-023-07290-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024]
Affiliation(s)
- Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
- Department of Critical Care, University of Melbourne, Melbourne, Australia.
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Australia.
- Department of Intensive Care, Austin Hospital, Heidelberg, Melbourne, VIC, 3084, Australia.
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia.
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Giovanni Landoni
- Vita-Salute San Raffaele University, Milan, Italy
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| |
Collapse
|
12
|
See EJ, Chaba A, Spano S, Maeda A, Clapham C, Liu J, Khasin M, Liskaser G, Eastwood G, Bellomo R. Exploring the norepinephrine to angiotensin II conversion ratio in patients with vasodilatory hypotension: A post-hoc analysis of the ARAMIS trial. J Crit Care 2024; 79:154453. [PMID: 37890357 DOI: 10.1016/j.jcrc.2023.154453] [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: 09/24/2023] [Revised: 10/18/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023]
Abstract
PURPOSE Angiotensin II is approved for catecholamine-refractory vasodilatory shock but the conversion dose ratio from norepinephrine to angiotensin II remains unclear. METHODS We conducted a post-hoc analysis of the Acute Renal effects of Angiotensin II Management in Shock (ARAMIS) trial involving patients with vasodilatory hypotension. We determined the norepinephrine equivalent dose immediately prior to angiotensin II initiation and calculated the conversion dose ratio between norepinephrine and angiotensin II. We performed subgroup analyses based on recent exposure to angiotensin receptor blockers (ARBs) and renin levels at baseline. RESULTS In 37 patients, the median conversion dose ratio between norepinephrine equivalent and angiotensin II was to 10:1 for norepinephrine bitartrate (5:1 for norepinephrine base). The conversion ratio was not affected by the baseline renin, with a median ratio of 10 (7-21) in the high renin group versus 12 (5-22) in the low renin group. Finally, exposure to ARBs prior admission appeared to diminish the conversion ratio with a median ratio of 7 (4-13) in ARB patients vs. 12 (7-22) in non-ARB patients. CONCLUSIONS The norepinephrine to angiotensin II conversion dose ratio is 10:1 in a vasodilatory hypotension population. These findings can guide clinicians and researchers in the use, dosing, and study of angiotensin II in critical care.
Collapse
Affiliation(s)
- Emily J See
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Nephrology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Anis Chaba
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Sofia Spano
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Akinori Maeda
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Caroline Clapham
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Jasmine Liu
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Monique Khasin
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Grace Liskaser
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Australia.
| |
Collapse
|
13
|
Bokoch MP, Tran AT, Brinson EL, Marcus SG, Reddy M, Sun E, Roll GR, Pardo M, Fields S, Adelmann D, Kothari RP, Legrand M. Angiotensin II in liver transplantation (AngLT-1): protocol of a randomised, double-blind, placebo-controlled trial. BMJ Open 2023; 13:e078713. [PMID: 37984940 PMCID: PMC10660907 DOI: 10.1136/bmjopen-2023-078713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/24/2023] [Indexed: 11/22/2023] Open
Abstract
INTRODUCTION Catecholamine vasopressors such as norepinephrine are the standard drugs used to maintain mean arterial pressure during liver transplantation. At high doses, catecholamines may impair organ perfusion. Angiotensin II is a peptide vasoconstrictor that may improve renal perfusion pressure and glomerular filtration rate, a haemodynamic profile that could reduce acute kidney injury. Angiotensin II is approved for vasodilatory shock but has not been rigorously evaluated for treatment of hypotension during liver transplantation. The objective is to assess the efficacy of angiotensin II as a second-line vasopressor infusion during liver transplantation. This trial will establish the efficacy of angiotensin II in decreasing the dose of norepinephrine to maintain adequate blood pressure. Completion of this study will allow design of a follow-up, multicentre trial powered to detect a reduction of organ injury in liver transplantation. METHODS AND ANALYSIS This is a double-blind, randomised clinical trial. Eligible subjects are adults with a Model for End-Stage Liver Disease Sodium Score ≥25 undergoing deceased donor liver transplantation. Subjects are randomised 1:1 to receive angiotensin II or saline placebo as the second-line vasopressor infusion. The study drug infusion is initiated on reaching a norepinephrine dose of 0.05 µg kg-1 min-1 and titrated per protocol. The primary outcome is the dose of norepinephrine required to maintain a mean arterial pressure ≥65 mm Hg. Secondary outcomes include vasopressin or epinephrine requirement and duration of hypotension. Safety outcomes include incidence of thromboembolism within 48 hours of the end of surgery and severe hypertension. An intention-to-treat analysis will be performed for all randomised subjects receiving the study drug. The total dose of norepinephrine will be compared between the two arms by a one-tailed Mann-Whitney U test. ETHICS AND DISSEMINATION The trial protocol was approved by the local Institutional Review Board (#20-30948). Results will be posted on ClinicalTrials.gov and published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ClinicalTrials.govNCT04901169.
Collapse
Affiliation(s)
- Michael P Bokoch
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Amy T Tran
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Erika L Brinson
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Sivan G Marcus
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Meghana Reddy
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Elizabeth Sun
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Garrett R Roll
- Division of Transplant Surgery, University of California San Francisco, San Francisco, California, USA
| | - Manuel Pardo
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Scott Fields
- Investigational Drug Pharmacy, University of California San Francisco, San Francisco, California, USA
| | - Dieter Adelmann
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Rishi P Kothari
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
- Department of Anesthesiology and Perioperative Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Matthieu Legrand
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
14
|
Coulson TG, Miles LF, Zarbock A, Burrell LM, Patel SK, von Groote T, Pilcher D, Weinberg L, Landoni G, Bellomo R. Renin-angiotensin-aldosterone system dynamics after targeted blood pressure control using angiotensin II or norepinephrine in cardiac surgery: mechanistic randomised controlled trial. Br J Anaesth 2023; 131:664-672. [PMID: 37481435 DOI: 10.1016/j.bja.2023.06.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/06/2023] [Accepted: 06/10/2023] [Indexed: 07/24/2023] Open
Abstract
BACKGROUND The role of the renin-angiotensin-aldosterone axis in vasoplegia after cardiac surgery remains unclear. We tested the hypothesis that, compared with norepinephrine, infusion of angiotensin II titrated to achieve similar mean arterial pressure (MAP) would suppress plasma renin concentration (PRC) while maintaining aldosterone levels. METHODS In a double-blind, randomised controlled trial, subjects received either an infusion of angiotensin II or norepinephrine to maintain MAP 70-80 mm Hg from induction of anaesthesia. We compared PRC, aldosterone, dipeptidyl peptidase-3, and angiotensin-converting enzyme 2 activity between treatment groups, before surgery, on ICU admission, and 24 h after surgery. RESULTS In 60 patients (11.7% female; mean age 68 yr [11 yr]), norepinephrine increased median PRC at ICU admission (median difference [MD] 46 [inter-quartile range, IQR, 3-88] μU ml-1; P<0.001) but angiotensin II did not (MD -3 [IQR -62 to 35] μU ml-1; P=0.36). Aldosterone levels increased with both. The aldosterone:PRC ratio did not change with norepinephrine (MD -0.01 [IQR -0.14 to 0.03] μU ml-1 per ng dl-1, P=0.76) but increased with angiotensin II (MD 0.05 [IQR 0.004-0.26] μU ml-1 per ng dl-1, P<0.001). The upper quartile of PRC before surgery was associated with higher vasopressor requirements when norepinephrine was used to maintain MAP, but not angiotensin II. Dipeptidyl peptidase-3 levels and angiotensin-converting enzyme 2 activities were similar at all time points. CONCLUSIONS Angiotensin II suppressed renin release while maintaining aldosterone levels compared with norepinephrine. Higher plasma renin concentration before surgery was associated with greater vasopressor requirement for norepinephrine, but not angiotensin II. CLINICAL TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry-ACTRN12621000195853 23/02/2021.
Collapse
Affiliation(s)
- Tim G Coulson
- Department of Anaesthesiology and Perioperative Medicine, Alfred Health and Monash University, Melbourne, VIC, Australia; Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia.
| | - Lachlan F Miles
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia; Department of Anaesthesia and Pain Medicine, Austin Health, Melbourne, VIC, Australia
| | - Alex Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Munster, Germany
| | - Louise M Burrell
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, VIC, Australia; Department of Cardiology, Austin Health, Heidelberg, VIC, Australia; The Institute for Breathing and Sleep, Heidelberg, VIC, Australia
| | - Sheila K Patel
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, VIC, Australia
| | - Thilo von Groote
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Munster, Germany
| | - David Pilcher
- Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Laurence Weinberg
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia; Department of Anaesthesia and Pain Medicine, Austin Health, Melbourne, VIC, Australia
| | - Giovanni Landoni
- Department of Anaesthesia, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia; Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia; Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, VIC, Australia
| |
Collapse
|
15
|
Guerci P, Leone M, Lorne E, Mongardon N. Norepinephrine in cardiac surgery: The love-hate story. Anaesth Crit Care Pain Med 2023; 42:101210. [PMID: 36870666 DOI: 10.1016/j.accpm.2023.101210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 02/27/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023]
Affiliation(s)
- Philippe Guerci
- Department of Anesthesiology and Critical Care Medicine, Institut Lorrain du Coeur et des Vaisseaux, University Hospital of Nancy, F-54000 Vandoeuvre-les Nancy, France; INSERM U1116, DCAC, University of Lorraine, Nancy, France.
| | - Marc Leone
- Service d'Anesthésie et de Réanimation, Assistance Publique-Hôpitaux Universitaires de Marseille, Aix Marseille Université, Hôpital Nord, F-13015 Marseille, France
| | - Emmanuel Lorne
- Département d'Anesthésie-Réanimation (Akomé), Clinique du Millénaire, F-34000 Montpellier, France
| | - Nicolas Mongardon
- Service d'Anesthésie-Réanimation chirurgicale, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, F-94010 Créteil, France; Université Paris Est Créteil, Faculté de Santé, F-94010 Créteil, France; U955-IMRB, Equipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", Inserm, Univ Paris Est Créteil (UPEC)
| |
Collapse
|
16
|
Montgomery ML, Gross CR, Lin HM, Ouyang Y, Levin MA, Corkill HE, El-Eshmawi A, Adams DH, Weiner MM. Plasma Renin Activity Increases With Cardiopulmonary Bypass and is Associated With Vasoplegia After Cardiac Surgery. J Cardiothorac Vasc Anesth 2023; 37:367-373. [PMID: 36509636 DOI: 10.1053/j.jvca.2022.11.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 11/13/2022] [Accepted: 11/16/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To describe the trend in plasma renin activity over time in patients undergoing cardiac surgery on cardiopulmonary bypass, and to investigate if increased plasma renin activity is associated with postcardiopulmonary bypass vasoplegia. DESIGN A prospective cohort study. SETTING Patients were enrolled from June 2020 to May 2021 at a tertiary cardiac surgical institution. PATIENTS A cohort of 100 adult patients undergoing cardiac surgery on cardiopulmonary bypass. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Plasma renin activity was measured at 5 time points: baseline, postoperatively, and at midnight on postoperative days 1, 2, and 3. Plasma renin activity and delta plasma renin activity were correlated with the incidence of vasoplegia and clinical outcomes. The median plasma renin activity increased approximately 3 times from baseline immediately after cardiac surgery, remained elevated on postoperative days 0, 1, and 2, and began to downtrend on postoperative day 3. Plasma renin activity was approximately 3 times higher at all measured time points in patients who developed vasoplegia versus those who did not. CONCLUSIONS In patients undergoing cardiac surgery on cardiopulmonary bypass, plasma renin activity increased postoperatively and remained elevated through postoperative day 2. Additionally, patients with vasoplegic syndrome after cardiac surgery on cardiopulmonary bypass had more robust elevations in plasma renin activity than nonvasoplegic patients. These findings support the need for randomized controlled trials to determine if patients undergoing cardiac surgery with high plasma renin activity may benefit from targeted treatment with therapies such as synthetic angiotensin II.
Collapse
Affiliation(s)
- Morgan L Montgomery
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Caroline R Gross
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hung-Mo Lin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yuxia Ouyang
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Matthew A Levin
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Holly E Corkill
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ahmed El-Eshmawi
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David H Adams
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Menachem M Weiner
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| |
Collapse
|
17
|
Michálek P, Říha H, Pořízka M. Year 2022 in review - Cardiac anesthesia and postoperative care. ANESTEZIOLOGIE A INTENZIVNÍ MEDICÍNA 2022. [DOI: 10.36290/aim.2022.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
|
18
|
Hughes C, Djaiani G, Pungsornruk K, Agarwal S. Renal failure in cardiac surgery: in search of the magic bullet. Anaesthesia 2022; 77:1197-1201. [PMID: 36059270 DOI: 10.1111/anae.15857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 01/11/2023]
Affiliation(s)
- C Hughes
- Unit of Academic Anaesthesia, Critical Care and Peri-operative Medicine, University of Glasgow, Glasgow, UK
| | - G Djaiani
- Department of Anaesthesia and Pain Management, University Health Network, Toronto, ON, Canada.,University of Toronto, ON, Canada
| | - K Pungsornruk
- Department of Anaesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - S Agarwal
- Department of Cardiothoracic Anaesthesia, Manchester University Hospitals, Manchester, UK.,Manchester University, Manchester, UK
| |
Collapse
|
19
|
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.
Collapse
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
| |
Collapse
|