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Lam S, Mofidi S, Saddic L, Neelankavil J, Wingert T, Cheng D, Grogan T, Methangkool E. Incidence of Intraoperative Vasoplegic Syndrome in Lung Transplantation. J Cardiothorac Vasc Anesth 2023; 37:2531-2537. [PMID: 37775341 DOI: 10.1053/j.jvca.2023.08.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVES Severe hypotension and low systemic vascular resistance in the setting of adequate cardiac output, known as "vasoplegic syndrome" (VS), is a physiologic disturbance reported in 9% to 44% of cardiac surgery patients. Although this phenomenon is well-documented in cardiac surgery, there are few studies on its occurrence in lung transplantation. The goal of this study was to characterize the incidence of VS in lung transplantation, as well as identify associated risk factors and outcomes. DESIGN Retrospective study of single and bilateral lung transplants from April 2013 to September 2021. SETTING The study was conducted at an academic hospital. PARTICIPANTS Patients ≥18 years of age who underwent lung transplantation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The authors defined VS as mean arterial pressure <65 mmHg, cardiac index ≥2.2 L/min/m2, and ≥30 minutes of vasopressor administration after organ reperfusion. The association between VS and risk factors or outcomes was assessed using t tests, Mann-Whitney U, and chi-square tests. The authors ran multivariate logistic regression models to determine factors independently associated with VS. The incidence of VS was 13.9% (CI 10.4%-18.4%). In the multivariate model, male sex (odds ratio 2.85, CI 1.07-7.58, p = 0.04) and cystic fibrosis (odds ratio 5.76, CI 1.43-23.09, p = 0.01) were associated with VS. CONCLUSIONS The incidence of VS in lung transplantation is comparable to that of cardiac surgery. Interestingly, male sex and cystic fibrosis are strong risk factors. Identifying lung transplant recipients at increased risk of VS may be crucial to anticipating intraoperative complications.
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Affiliation(s)
- Stephanie Lam
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Sean Mofidi
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Louis Saddic
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Jacques Neelankavil
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Theodora Wingert
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Drew Cheng
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Tristan Grogan
- Department of Medicine Statistics Core, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Emily Methangkool
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA.
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Soetanto V, Grewal US, Mehta AC, Shah P, Varma M, Garg D, Majumdar T, Dangayach NS, Grewal HS. Early postoperative complications in lung transplant recipients. Indian J Thorac Cardiovasc Surg 2021; 38:260-270. [PMID: 34121821 PMCID: PMC8187456 DOI: 10.1007/s12055-021-01178-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 03/08/2021] [Accepted: 03/10/2021] [Indexed: 10/28/2022] Open
Abstract
Lung transplantation has become an established therapy for end-stage lung diseases. Early postoperative complications can impact immediate, mid-term, and long-term outcomes. Appropriate management, prevention, and early detection of these early postoperative complications can improve the overall transplant course. In this review, we highlight the incidence, detection, and management of these early postoperative complications in lung transplant recipients.
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Affiliation(s)
- Vanessa Soetanto
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ USA
| | - Udhayvir Singh Grewal
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA USA
| | - Atul C Mehta
- Respiratory Institute, Cleveland Clinic, Cleveland, OH USA
| | - Parth Shah
- Department of Medicine, Trumbull Regional Medical Center, Northeast Ohio Medical University, Warren, OH USA
| | - Manu Varma
- Division of Pediatric Cardiology, University of Texas Health Science Center at Houston, Houston, TX USA
| | - Delyse Garg
- Division of Pulmonary and Critical Care Medicine, Newark Beth Israel Medical Center, Newark, NJ USA
| | - Tilottama Majumdar
- Division of Pulmonary and Critical Care Medicine, Newark Beth Israel Medical Center, Newark, NJ USA
| | - Neha S Dangayach
- Department of Neurosurgery, Division of NeuroCritical Care, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Harpreet Singh Grewal
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine Lung Transplantation, NewYork-Presbyterian/Columbia University Medical Center, New York, NY USA
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Barnes TJ, Hockstein MA, Jabaley CS. Vasoplegia after cardiopulmonary bypass: A narrative review of pathophysiology and emerging targeted therapies. SAGE Open Med 2020; 8:2050312120935466. [PMID: 32647575 PMCID: PMC7328055 DOI: 10.1177/2050312120935466] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 05/21/2020] [Indexed: 12/29/2022] Open
Abstract
Cardiovascular disease remains the leading cause of death in the United States,
and cardiopulmonary bypass is a cornerstone in the surgical management of many
related disease states. Pathophysiologic changes associated both with
extracorporeal circulation and shock can beget a syndrome of low systemic
vascular resistance paired with relatively preserved cardiac output, termed
vasoplegia. While increased vasopressor requirements accompany vasoplegia,
related pathophysiologic mechanisms may also lead to true catecholamine
resistance, which is associated with further heightened mortality. The
introduction of a second non-catecholamine vasopressor, angiotensin II, and
non-specific nitric oxide scavengers offers potential means by which to manage
this challenging phenomenon. This narrative review addresses both the
definition, risk factors, and pathophysiology of vasoplegia and potential
therapeutic interventions.
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Affiliation(s)
- Theresa J Barnes
- Department of Anesthesiology, Emory University, Atlanta, GA, USA
| | | | - Craig S Jabaley
- Department of Anesthesiology, Emory University, Atlanta, GA, USA
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Miranda LE, Mente ED, Fernandes Molina CA, Sumarelli Albuquerque AA, Rubens de Nadai T, Arcêncio L, Basile-Filho A, Barbosa Evora PR. Methylene blue and the NO/cGMP pathway in solid organs transplants. Minerva Anestesiol 2020; 86:423-432. [PMID: 31994368 DOI: 10.23736/s0375-9393.20.13841-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The nitric oxide/cyclic guanosine monophosphate (NO/cGMP) pathway has a significative influence in hemodynamic changes that occur in transplants. Classically, the ischemia-reperfusion syndrome (IRS) is characterized by hypotension and low vascular resistance, when cGMP and nitric oxide (NO) are increased, contributing to oxidative stress, within an inflammatory context. These mechanisms occur in several types of transplants, such as liver, heart, lungs, kidney, which are a therapeutic choice in several clinical conditions when conventional treatments failed. It is well known the significant relation between graft dysfunction or rejection and ischemia-reperfusion injury that is linked to inflammatory response and NO/cGMP pathway activation. This review aims to study the NO/cGMP pathway in solid organ transplants. Finally, we inquire whether physicians do not underestimate the NO/cGMP pathway.
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Affiliation(s)
- Luiz E Miranda
- Division of Cardiothoracic Surgery, Department of Surgery and Anatomy, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Enio D Mente
- Division of Cardiothoracic Surgery, Department of Surgery and Anatomy, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Carlos A Fernandes Molina
- Division of Cardiothoracic Surgery, Department of Surgery and Anatomy, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Agnes A Sumarelli Albuquerque
- Division of Cardiothoracic Surgery, Department of Surgery and Anatomy, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Tales Rubens de Nadai
- Division of Cardiothoracic Surgery, Department of Surgery and Anatomy, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Livia Arcêncio
- Division of Cardiothoracic Surgery, Department of Surgery and Anatomy, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Anibal Basile-Filho
- Division of Cardiothoracic Surgery, Department of Surgery and Anatomy, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Paulo R Barbosa Evora
- Division of Cardiothoracic Surgery, Department of Surgery and Anatomy, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil -
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Ortoleva J, Shapeton A, Vanneman M, Dalia AA. Vasoplegia During Cardiopulmonary Bypass: Current Literature and Rescue Therapy Options. J Cardiothorac Vasc Anesth 2019; 34:2766-2775. [PMID: 31917073 DOI: 10.1053/j.jvca.2019.12.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/04/2019] [Accepted: 12/09/2019] [Indexed: 11/11/2022]
Abstract
Vasoplegia syndrome in the cardiac surgical intensive care unit and postoperative period has been an area of interest to clinicians because of its prevalence and effects on morbidity and mortality. However, there is a paucity of evidence regarding the treatment of vasoplegia syndrome during cardiopulmonary bypass (on-CPB VS). This review aims to detail the incidence, outcomes, and possible treatment options for patients who develop vasoplegia during bypass. The pharmacologic rescue agents discussed are used in cases in which vasoplegia during CPB is refractory to standard catecholamine agents, such as norepinephrine, epinephrine, and phenylephrine. Methods to improve vasoplegia during CPB can be both pharmacologic and nonpharmacologic. In particular, optimization of CPB parameters plays an important nonpharmacologic role in vasoplegia during CPB. Pharmacologic agents that have been demonstrated as being effective in vasoplegia include vasopressin, terlipressin, methylene blue, hydroxocobalamin, angiotensin II (Giapreza), vitamin C, flurbiprofen (Ropion), and hydrocortisone. Although these agents have not been specifically evaluated for vasoplegia during CPB, they have shown signs of effectiveness for vasoplegia postoperatively to varying degrees. Understanding the evidence for, dosing, and side effects of these agents is crucial for cardiac anesthesiologists when treating vasoplegia during CPB bypass.
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Affiliation(s)
- Jamel Ortoleva
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Alexander Shapeton
- Department of Anesthesia, Critical Care and Pain Medicine, Veterans Affairs Boston Healthcare System, Harvard Medical School, Boston, MA
| | - Mathew Vanneman
- Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Adam A Dalia
- Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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