The vasoactive-inotropic score and levosimendan: time for LVIS?

Vasoactive Management of Pulmonary Hypertension and Ventricular Dysfunction in Neonates Following Complicated Monochorionic Twin Pregnancies: A Single-Center Experience

OBJECTIVES

Twins resulting from a complicated monochorionic (MC) twin pregnancy are at risk for postnatal evolution of pulmonary hypertension (PH) and cardiac dysfunction (CD). Both pathologies are important contributors to short- and long-term morbidity in these infants. The aim of the present retrospective single-center cohort study was to evaluate the need for vasoactive treatment for PH and CD in these neonates.

METHODOLOGY

In-born neonates following a complicated MC twin pregnancy admitted to the department of neonatology of the University Children's Hospital Bonn (UKB) between October 2019 and December 2023 were screened for study inclusion. Finally, 70 neonates were included in the final analysis, with 37 neonates subclassified as recipient twins (group A) and 33 neonates as donor twins (group B).

RESULTS

The overall PH incidence at day of life (DOL) 1 was 17% and decreased to 6% at DOL 7 (p = 0.013), with no PH findings at DOL 28. The overall incidence of CD was 56% at DOL 1 and decreased strongly until DOL 7 (10%, p = 0.015), with no diagnosis of CD at DOL 28. The use of dobutamine, norepinephrine, and vasopressin at DOL 1 until DOL 7 did not differ between the subgroups, whereas the dosing of milrinone was significantly higher in Group B at DOL 1 (p = 0.043). Inhaled nitric oxide (iNO) was used in 16% of the cohort, and a levosimendan therapy was administered in 34% of the neonates. One-third of the cohort was treated with oral beta blockers, and in 10%, an intravenous beta blockade (landiolol) was administered. The maximum levosimendan vasoactive-inotropic score (LVISmax) increased from DOL 1 (12.4 [3/27]) to DOL 2 (14.6 [1/68], p = 0.777), with a significant decrease thereafter as measured at DOL 7 (9.5 [2/30], p = 0.011).

CONCLUSION

Early PH and CD are frequent diagnoses in neonates following a complicated MC twin pregnancy, and an individualized vasoactive treatment strategy is required in the management of these infants.

Evolution of Cardiogenic Shock Management and Development of a Multidisciplinary Team-Based Approach: Ten Years Experience of a Single Center

Background: The management of cardiogenic shock (CS) after ACS has evolved over time, and the development of a multidisciplinary team-based approach has been shown to improve outcomes, although mortality remains high. Methods: All consecutive patients with ACS-CS admitted at our CICU from March 2012 to July 2021 were included in this single-center retrospective study. In 2019, we established a "shock team" consisting of a cardiac intensivist, an interventional cardiologist, an anesthetist, and a cardiac surgeon. The primary outcome was in-hospital mortality. Results: We included 167 patients [males 67%; age 71 (61-80) years] with ischemic CS. The proportion of SCAI shock stages from A to E were 3.6%, 6.6%, 69.4%, 9.6%, and 10.8%, respectively, with a mean baseline serum lactate of 5.2 (3.1-8.8) mmol/L. Sixty-six percent of patients had severe LV dysfunction, and 76.1% needed ≥ 1 inotropic drug. Mechanical cardiac support (MCS) was pursued in 91.1% [65% IABP, 23% Impella CP, 4% VA-ECMO]. From March 2012 to July 2021, we observed a significative temporal trend in mortality reduction from 57% to 29% (OR = 0.90, p = 0.0015). Over time, CS management has changed, with a significant increase in Impella catheter use (p = 0.0005) and a greater use of dobutamine and levosimendan (p = 0.015 and p = 0.0001) as inotropic support. In-hospital mortality varied across SCAI shock stages, and the SCAI E profile was associated with a poor prognosis regardless of patient age (OR 28.50, p = 0.039). Conclusions: The temporal trend mortality reduction in CS patients is multifactorial, and it could be explained by the multidisciplinary care developed over the years.

Vasoactive-Inotropic Score as a Promising Predictor of Acute Kidney Injury in Adult Patients Requiring Extracorporeal Membrane Oxygenation

Acute kidney injury (AKI) is a common complication in patients supported by extracorporeal membrane oxygenation (ECMO). Vasoactive-Inotropic Score (VIS) serves as an indicator of the extent of cardiovascular drug support provided. Our objective is to assess the relationship between the VIS and ECMO-associated AKI (EAKI). This single-center retrospective study extracted adult patients treated with ECMO between August 2016 and September 2022 from an intensive care unit (ICU) in a university hospital. A total of 126 patients requiring ECMO support were included in the study, of which 76% developed AKI. Multivariate logistic regression analysis identified VIS-max Day1 (odds ratio [OR]: 1.025, 95% confidence interval [CI]: 1.007-1.044, p = 0.006), VIS-max Day2 (OR: 1.038, 95% CI: 1.007-1.069, p = 0.015), VIS-mean Day1 (OR: 1.048, 95% CI: 1.013-1.084, p = 0.007), and VIS-mean Day2 (OR: 1.059, 95% CI: 1.014-1.107, p = 0.010) as independent risk factors for EAKI. VIS-max Day1 showing the best predictive effect (Area under the receiver operating characteristic curve (AUROC): 0.80, sensitivity: 71.87%, specificity: 80.00%) for EAKI with a cutoff value of 33.33. Surprisingly, VIS-mean Day2 was also excellent at predicting 7 day mortality (AUROC: 0.77, sensitivity: 87.50%, specificity: 56.38%) with a cutoff value of 8.67. In conclusion, VIS could independently predict EAKI and 7 day mortality in patients with ECMO implantation, which may help clinicians to recognize the poor prognosis in time for early intervention.

Hemodynamic failure and graft dysfunction after lung transplant: A possible clinical continuum with immediate and long-term consequences

INTRODUCTION

The postoperative hemodynamic management after lung transplant (LUTX) is guided by limited evidence. We aimed to describe and evaluate risk factors and outcomes of postoperative vasoactive support of LUTX recipients.

METHODS

In a single-center retrospective analysis of consecutive adult LUTX, two cohorts were identified: (1) patients needing prolonged vasoactive support (>12 h from ICU admission) (VASO+); (2) or not (VASO-). Postoperative hemodynamic characteristics were thoroughly analyzed. Risk factors and outcomes of VASO+ versus VASO- cohorts were assessed by multivariate logistic regression and propensity score matching.

RESULTS

One hundred and thirty-eight patients were included (86 (62%) VASO+ versus 52 (38%) VASO-). Vasopressors (epinephrine, norepinephrine, dopamine) were used in the first postoperative days (vasoactive inotropic score at 12 h: 6 [4-12]), while inodilators (dobutamine, levosimendan) later. Length of vasoactive support was 3 [2-4] days. Independent predictors of vasoactive use were: LUTX indication different from cystic fibrosis (p = .003), higher Oto score (p = .020), longer cold ischemia time (p = .031), but not preoperative cardiac catheterization. VASO+ patients showed concomitant hemodynamic and graft impairment, with longer mechanical ventilation (p = .010), higher primary graft dysfunction (PGD) grade at 72 h (PGD grade > 0 65% vs. 31%, p = .004, OR 4.2 [1.54-11.2]), longer ICU (p < .001) and hospital stay (p = .013). Levosimendan as a second-line inodilator appeared safe.

CONCLUSIONS

Vasoactive support is frequently necessary after LUTX, especially in recipients of grafts of lesser quality. Postoperative hemodynamic dysfunction requiring vasopressor support and graft dysfunction may represent a clinical continuum with immediate and long-term consequences. Further studies may elucidate if this represents a possible treatable condition.

Extracorporeal Membrane Oxygenation for Septic Shock in Adults and Children: A Narrative Review

Refractory septic shock is associated with a high risk of death. Circulatory support in the form of veno-arterial extracorporeal membrane oxygenation (VA ECMO) may function as a bridge to recovery, allowing for the treatment of the source of the sepsis. Whilst VA ECMO has been accepted as the means of hemodynamic support for children, in adults, single center observational studies show survival rates of only 70-90% for hypodynamic septic shock. The use of VA ECMO for circulatory support in hyperdynamic septic shock with preserved cardiac output or when applied late during cardio-pulmonary resuscitation is not recommended. With unresolving septic shock and a loss of ventriculo-arterial coupling, stress cardiomyopathy often develops. If the cardiac index (CI) approaches subnormal levels (CI < 2.5 L/min m-2) that do not match low systemic vascular resistance with a resulting loss of vital systemic perfusion pressure, VA ECMO support should be considered. A further decrease to the level of cardiogenic shock (CI < 1.8 L/min m-2) should be regarded as an indication for VA ECMO insertion. For patients who maintain a normal-to-high CI as part of their refractory vasoparalysis, VA ECMO support is justified in children and possibly in patients with a low body mass index. Extracorporeal support for septic shock should be limited to high-volume ECMO centers.

Incorporating intraoperative blood pressure time-series variables to assist in prediction of acute kidney injury after type a acute aortic dissection repair: an interpretable machine learning model

BACKGROUND

Acute kidney injury (AKI) is a common and serious complication after the repair of Type A acute aortic dissection (TA-AAD). However, previous models have failed to account for the impact of blood pressure fluctuations on predictive performance. This study aims to develop machine learning (ML) models combined with intraoperative medicine and blood pressure time-series data to improve the accuracy of early prediction for postoperative AKI risk.

METHODS

Indicators reflecting the duration and depth of hypotension were obtained by analyzing continuous mean arterial pressure (MAP) monitored intraoperatively with multiple thresholds (<65, 60, 55, 50) set in the study. The predictive features were selected by logistic regression and the least absolute shrinkage and selection operator (LASSO), and 4 ML models were built based on the above features. The performance of the models was evaluated by area under receiver operating characteristic curve (AUROC), calibration curve and decision curve analysis (DCA). Shapley additive interpretation (SHAP) was used to explain the prediction models.

RESULTS

Among the indicators reflecting intraoperative hypotension, 65 mmHg showed a statistically superior difference to other thresholds in patients with or without AKI (p < .001). Among 4 models, the extreme gradient boosting (XGBoost) model demonstrated the highest AUROC: 0.800 (95% 0.683-0.917) and sensitivity: 0.717 in the testing set and was verified the best-performing model. The SHAP summary plot indicated that intraoperative urine output, cumulative time of mean arterial pressure lower than 65 mmHg outside cardiopulmonary bypass (OUT_CPB_MAP_65 time), autologous blood transfusion, and smoking were the top 4 features that contributed to the prediction model.

CONCLUSION

With the introduction of intraoperative blood pressure time-series variables, we have developed an interpretable XGBoost model that successfully achieve high accuracy in predicting the risk of AKI after TA-AAD repair, which might aid in the perioperative management of high-risk patients, particularly for intraoperative hemodynamic regulation.

Vasoactive Inotropic Score compared to the sequential organ failure assessment cardiovascular score in intensive care

BACKGROUND

The cardiovascular component of the sequential organ failure assessment (cvSOFA) score may be outdated because of changes in intensive care. Vasoactive Inotropic Score (VIS) represents the weighted sum of vasoactive and inotropic drugs. We investigated the association of VIS with mortality in the general intensive care unit (ICU) population and studied whether replacing cvSOFA with a VIS-based score improves the accuracy of the SOFA score as a predictor of mortality.

METHODS

We studied the association of VIS during the first 24 h after ICU admission with 30-day mortality in a retrospective study on adult medical and non-cardiac emergency surgical patients admitted to Kuopio University Hospital ICU, Finland, in 2013-2019. We determined the area under the receiver operating characteristic curve (AUROC) for the original SOFA and for SOFAVISmax , where cvSOFA was replaced with maximum VIS (VISmax ) categories.

RESULTS

Of 8079 patients, 1107 (13%) died within 30 days. Mortality increased with increasing VISmax . AUROC was 0.813 (95% confidence interval [CI], 0.800-0.825) for original SOFA and 0.822 (95% CI: 0.810-0.834) for SOFAVISmax , p < .001.

CONCLUSION

Mortality increased consistently with increasing VISmax . Replacing cvSOFA with VISmax improved the predictive accuracy of the SOFA score.

Impact of mean perfusion pressure and vasoactive drugs on occurrence and reversal of cardiac surgery-associate acute kidney injury: A cohort study

PURPOSE

Low cardiac output and kidney congestion are associated with acute kidney injury after cardiac surgery (CSA-AKI). This study investigates hemodynamics on CSA-AKI development and reversal.

MATERIALS AND METHODS

Adult patients undergoing cardiac surgery were retrospectively included. Hemodynamic support was quantified using a new time-weighted vaso-inotropic score (VIS_AUC), and hemodynamic variables expressed by mean perfusion pressure and its components. The primary outcome was AKI stage ≥2 (CSA-AKI ≥2) and secondary outcome full AKI reversal before ICU discharge.

RESULTS

3415 patients were included. CSA-AKI ≥2 occurred in 37.4%. Mean perfusion pressure (MPP) (OR 0.95,95%CI 0.94-0.96, p < 0.001); and central venous pressure (CVP) (OR 1.17, 95%CI 1.13-1.22, p < 0.001) are associated with CSA-AKI ≥2 development, while VIS_AUC/h was not (p = 0.104). Out of 1085 CSA-AKI ≥2 patients not requiring kidney replacement therapy, 76.3% fully recovered of AKI. Full CSA-AKI reversal was associated with MPP (OR 1.02 per mmHg (95%CI 1.01-1.03, p = 0.003), and MAP (OR = 1.01 per mmHg (95%CI 1.00-1.02), p = 0.047), but not with VIS_AUC/h (p = 0.461).

CONCLUSION

Development and full recovery of CSA-AKI ≥2 are affected by mean perfusion pressure, independent of vaso-inotropic use. CVP had a significant effect on AKI development, while MAP on full AKI reversal.

Persistent Liver Dysfunction in Pediatric Patients After Total Cavopulmonary Connection Surgery

Background

Studies have reported early liver dysfunction (LD) after cardiac surgery is associated with short and long-term mortality. In this study, we aimed to investigate risk factors for persistent LD after total cavopulmonary connection (TCPC) surgery.

Methods

This is a retrospective case-control study. We defined persistent LD as LDs occurring between postoperative day 1 (POD1) and POD7 and sustaining at least on POD7, while transient LD as LDs occurring between POD1 and POD7 and recovering at least on POD7. Multivariable logistic regression analysis was applied and central venous pressure (CVP) was considered continuously or in quantiles.

Results

Postoperative LD occurred in 111 (27.1%) patients. Transient and persistent LD occurred in 65 (15.9%) and 46 (11.2%) patients, respectively. Aortic cross-clamping (ACC) (odds ratio [OR] 2.55, 95% CI 1.26–5.14) and postoperative CVP (OR 1.34, 95% CI 1.18–1.51) were risk factors for persistent LD, also identified for postoperative any LD and transient LD. Adding postoperative CVP to the model only including ACC significantly improved persistent LD prediction (△AUC 0.15, p = 0.002). Compared with CVP ≤ 14 mmHg, adjusted ORs and 95% CI of persistent LD for CVP of 14–16 and >16 mmHg were 3.11 (1.24, 7.81) and 10.55 (3.72, 29.93), respectively. Patients with persistent LD might have a longer length of mechanical ventilation (mean difference, 13.5 h) and postoperative hospital stay (mean difference, 7 days), and higher postoperative costs (mean difference, 6.7 thousand dollars) compared to those with transient LD.

Conclusions

Intra-operative application of ACC and postoperative elevated CVP were independent risk factors for persistent LD in pediatric patients following TCPC surgery. Compared to patients with transient LD, patients with persistent LD might have a longer length of mechanical ventilation and postoperative hospital stay, and higher postoperative costs. We should pay more attention to patients with high postoperative CVP to prevent their persistent LD occurrence.

Vasoactive Inotropic Score as a Prognostic Factor during (Cardio-) Respiratory ECMO

The vasoactive inotropic score (VIS) is calculated as a weighted sum of all administered vasopressor and inotropic medications and quantifies the amount of pharmacological cardiovascular support in patients with the most severe combined cardiopulmonary failure supported with extracorporeal membrane oxygenation (ECMO). This study evaluated (1) whether VIS prior to the initiation of ECMO is an independent predictor of survival in these patients and (2) whether VIS might guide the selection of the appropriate extracorporeal cannulation modality (Veno-Venous ‘V-V’ or Veno-VenoArterial ‘V-VA’). In this study, 39 V-VA and 182 V-V ECMO runs were retrospectively analyzed. VIS immediately prior to ECMO initiation (pre-ECMO) was 40 (10/113) in all patients, 30 (10/80) in patients with V-V ECMO and 207 (60/328) in patients with V-VA ECMO. Pre-ECMO VIS was an independent predictor of survival in univariate (AUC = 0.68, p = 0.001) and multi-variable analyses (p = 0.02). Pre-ECMO VIS was clearly associated with mortality (p = 0.001) in V-V ECMO group; however, V-VA ECMO disrupted this association (p = 0.18). Therefore, in conjunction with echocardiography, VIS might assist in selecting the appropriate ECMO cannulation strategy as patients with a pre-ECMO VIS ≥ 61.4 had significantly lower odds of survival compared to those with lower VIS.

Clinical efficacy of levosimendan vs milrinone in preventing low cardiac output syndrome following pediatric cardiac surgery

Background:

Prophylactic milrinone is commonly used to prevent Low Cardiac Output Syndrome (LCOS) after pediatric cardiac surgery. This study compares the use of levosimendan with milrinone when used as the primary inotrope following pediatric cardiac surgery.

Subjects and Methods:

Forty infants undergoing corrective surgery for congenital heart disease were recruited during the study and randomized into two groups (group L and group M). During rewarming, a loading dose of levosimendan or milrinone was administered followed by a 24-hour infusion of the chosen inotrope. Echocardiographic variables were measured postoperatively. Statistical analysis was done with SPSS-20 computer package. Association between the variables was found by independent t test. P < 0.05 was considered statistically significant.

Results:

Mean age and weight of the patient in Group L was 8.55 ± 5.83 months and 6.05 ± 2.09 kgs, while that in group M was 6.85 ± 3.57 months and 5.26 ± 2.11 kgs. 4 patients (20%) treated with levosimendan had LCOS in comparison with 6 (30%) patients in those treated with milrinone. Echocardiographic parameters in both groups L and M were comparable (cardiac index 3.47 ± 0.76 vs 3.72 ± 1.05 L/min/m², EF 66.10 ± 7.82% vs 59.34 ± 10.74%, stroke volume index 25.4 ± 6.3 vs 27.74 ± 10.35 mL/m²). The duration of ventilation, ICU stay and hospital stay were lesser in group L (12.75 ± 9.69, 35.95 ± 12.11, 119.10 ± 46.397 vs 23.60 ± 22.03, 51.20 ± 29.92, 140.20 ± 52.65 hours).

Conclusions:

The incidence of LCOS was lesser in those patients treated with levosimendan, when compared with those treated with milrinone. Cardiac index and stroke volume index were comparable between the two groups. Thus, levosimendan provides a non-inferior alternative to milrinone when used as the primary inotrope following pediatric cardiac surgery.

Vasoactive-inotropic score and the prediction of morbidity and mortality after cardiac surgery

BACKGROUND

The vasoactive-inotropic score (VIS) predicts mortality and morbidity after paediatric cardiac surgery. Here we examined whether VIS also predicted outcome in adults after cardiac surgery, and compared predictive capability between VIS and three widely used scoring systems.

METHODS

This single-centre retrospective cohort study included 3213 cardiac surgery patients. Maximal VIS (VIS_max) was calculated using the highest doses of vasoactive and inotropic medications administered during the first 24 h post-surgery. We established five VIS_max categories: 0-5, >5-15, >15-30, >30-45, and >45 points. The predictive accuracy of VIS_max was evaluated for a composite outcome, which included 30-day mortality, mediastinitis, stroke, acute kidney injury, and myocardial infarction.

RESULTS

VIS_max showed good prediction accuracy for the composite outcome [area under the curve (AUC), 0.72; 95% confidence interval (CI), 0.69-0.75]. The incidence of the composite outcome was 9.6% overall and 43% in the highest VIS_max group (>45). VIS_max predicted 30-day mortality (AUC, 0.76; 95% CI, 0.69-0.83) and 1-yr mortality (AUC, 0.70; 95% CI, 0.65-0.74). Prediction accuracy for unfavourable outcome was significantly better with VIS_max than with Acute Physiology and Chronic Health Evaluation II (P=0.01) and Simplified Acute Physiological Score II (P=0.048), but not with the Sequential Organ Failure Assessment score (P=0.32).

CONCLUSIONS

In adults after cardiac surgery, VIS_max predicted a composite of unfavourable outcomes and predicted mortality up to 1 yr after surgery.

Pressure recording analytical method and bioreactance for stroke volume index monitoring during pediatric cardiac surgery

BACKGROUND

It is currently uncertain which hemodynamic monitoring device reliably measures stroke volume and tracks cardiac output changes in pediatric cardiac surgery patients.

OBJECTIVE

To evaluate the difference between stroke volume index (SVI) measured by pressure recording analytical method (PRAM) and bioreactance and their ability to track changes after a therapeutic intervention.

METHODS

A single-center prospective observational cohort study in children undergoing cardiac surgery with cardiopulmonary bypass (CPB) was conducted. Twenty children below 20 kg with median (interquartile range) weight of 5.3 kg (4.1-7.8) and age of 6 months (3-20) were enrolled. Data were collected after anesthesia induction, at the end of CPB, before fluid administration and after fluid administration. Overall, median-IQR PRAM SVI values (23 ml·m(-2), 19-27) were significantly higher than bioreactance SVI (15 ml·m(-2), 12-25, P = 0.0001). Correlation (r(2) ) between the two methods was 0.15 (P = 0.0003). The mean difference between the measurements (bias) was 5.7 ml·m(-2) with a standard deviation of 9.6 (95% limits of agreement ranged from -13 to 24 ml·m(-2)). Percentage error was 91.7%. Baseline SVI appeared to be similar, but PRAM SVI was systematically greater than bioreactance thereafter, with the highest gap after the fluid loading phase: 13 (12-18) ml·m(-2) vs. 23 (19-25) ml·m(-2), respectively, P = 0.0013. A multivariable regression model showed that a significant independent inverse correlation with patients' body weight predicted the CI difference between the two methods after fluid challenge (β coefficient -0.12, P = 0.013).

CONCLUSIONS

Pressure recording analytical method and bioreactance provided similar SVI estimation at stable hemodynamic conditions, while bioreactance SVI values appeared significantly lower than PRAM at the end of CPB and after fluid replacement.

Vasoactive Inotrope Score as a tool for clinical care in children post cardiac surgery

BACKGROUND

Neonates and infants undergoing heart surgery on cardiopulmonary bypass (CPB) are at high risk for significant post-operative morbidity and mortality. Hence, there is a need to identify and quantify clinical factors during the early post-operative period that are indicative of short-term as well as long-term outcomes. Multiple inotrope scores have been used in practice to quantify the amount of cardiovascular support received by neonates.

AIMS

The goal of this study was to determine the association between inotropic/vasoactive support and clinical outcomes in children after open cardiac surgery.

MATERIALS AND METHODS

This is a retrospective analysis of the 208 patients who underwent cardiac surgery for congenital heart disease at a tertiary pediatric cardiac surgery Intensive Care Unit (ICU) from January 2012 to March 2013. Multiple demographic, intra-operative and post-operative variables were recorded, including the Vasoactive Inotrope Score (VIS).

RESULTS

A total of 208 patients underwent cardiac surgery for congenital heart disease in the study period. The mean age and weight in the study were 66.94 months and 16.31 kg, respectively. Statistically significant associations were found in the various variables and VIS, including infancy, weight < 10 kg, CPB time, pump failure and post-operative variables like sepsis, hematological complications, hepatic dysfunction, acute kidney injury during admission, mortality, prolonged ventilator requirement, CPB time (in min) and hospital stay.

CONCLUSIONS

Inotrope score and its adaptations are an excellent tool to measure illness severity, deciding interventions and during parental counseling in the pediatric cardiac surgery ICUs.