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Zimmerman JT, Hanson C, Iardino A. Haemophagocytic lymphohistiocytosis (HLH) secondary to disseminated histoplasmosis infection in a patient with HIV. BMJ Case Rep 2024; 17:e259484. [PMID: 39159978 DOI: 10.1136/bcr-2023-259484] [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: 08/21/2024] Open
Abstract
A male in his 30s who was recently diagnosed with HIV arrived at the emergency department exhibiting an altered mental state and acute respiratory distress. Initial laboratory tests revealed a high anion gap metabolic acidosis, elevated liver enzyme levels and bicytopenia. A CT scan identified a miliary pattern. Bronchoscopy with bronchoalveolar lavage displayed epithelial and inflammatory cells. However, subsequent tests ruled out the presence of fungi, Pneumocystis organisms, malignancies, granulomas and viral inclusions. Broad-spectrum antibiotics with emphasis on Mycobacterium tuberculosis and antifungal treatments were administered. The regimen was adjusted after a positive urine test for the Histoplasma antigen.The patient later manifested signs and symptoms, including increased ferritin level, fever, splenomegaly, diminished natural killer cell function and heightened interleukin-2 receptor levels, confirming haemophagocytic lymphohistiocytosis. Given the patient's gravely decompensated state, the treatment incorporated dexamethasone, and the patient's vasopressor-resistant septic shock was addressed with methylene blue.
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Affiliation(s)
- Joel Thomas Zimmerman
- Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota, USA
| | - Courtney Hanson
- Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota, USA
| | - Alfredo Iardino
- Critical Care, Pulmonology, CHI St Alexius Health Bismarck Medical Center, Bismarck, North Dakota, USA
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2
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Pouessel G, Dribin TE, Tacquard C, Tanno LK, Cardona V, Worm M, Deschildre A, Muraro A, Garvey LH, Turner PJ. Management of Refractory Anaphylaxis: An Overview of Current Guidelines. Clin Exp Allergy 2024; 54:470-488. [PMID: 38866583 DOI: 10.1111/cea.14514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/21/2024] [Accepted: 05/23/2024] [Indexed: 06/14/2024]
Abstract
In this review, we compare different refractory anaphylaxis (RA) management guidelines focusing on cardiovascular involvement and best practice recommendations, discuss postulated pathogenic mechanisms underlining RA and highlight knowledge gaps and research priorities. There is a paucity of data supporting existing management guidelines. Therapeutic recommendations include the need for the timely administration of appropriate doses of aggressive fluid resuscitation and intravenous (IV) adrenaline in RA. The preferred second-line vasopressor (noradrenaline, vasopressin, metaraminol and dopamine) is unknown. Most guidelines recommend IV glucagon for patients on beta-blockers, despite a lack of evidence. The use of methylene blue or extracorporeal life support (ECLS) is also suggested as rescue therapy. Despite recent advances in understanding the pathogenesis of anaphylaxis, the factors that lead to a lack of response to the initial adrenaline and thus RA are unclear. Genetic factors, such as deficiency in platelet activating factor-acetyl hydrolase or hereditary alpha-tryptasaemia, mastocytosis may modulate reaction severity or response to treatment. Further research into the underlying pathophysiology of RA may help define potential new therapeutic approaches and reduce the morbidity and mortality of anaphylaxis.
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Affiliation(s)
- Guillaume Pouessel
- Department of Paediatrics, Children's Hospital, Roubaix, France
- Paediatric Pulmonology and Allergy Department, Jeanne de Flandre Hospital, CHU Lille, Lille, France
- Univ Lille, ULR 2694: METRICS, Lille, France
| | - Timothy E Dribin
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Charles Tacquard
- Department of Anaesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Luciana Kase Tanno
- University Hospital of Montpellier, Montpellier, France
- Desbrest Institute of Epidemiology and Public Health, University of Montpellier - INSERM, Montpellier, France
- WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
| | - Victoria Cardona
- Department of Allergy, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Margitta Worm
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergology, Charité-Universitätsmedizin Berlin, Berlin Institute of Health, Berlin, Germany
| | - Antoine Deschildre
- Paediatric Pulmonology and Allergy Department, Jeanne de Flandre Hospital, CHU Lille, Lille, France
| | - Antonella Muraro
- Food Allergy Referral Centres, Padua University Hospital, Padua, Italy
| | - Lene H Garvey
- Department of Dermatology and Allergy, Danish Anaesthesia Allergy Centre, Allergy Clinic, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Paul J Turner
- National Heart & Lung Institute, Imperial College London, London, UK
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Pai SL, Torp KD, Insignares VC, DeMaria S, Giordano CR, Logvinov II, Li Z, Chadha R, Aniskevich S. Use of hydroxocobalamin to treat intraoperative vasoplegic syndrome refractory to vasopressors and methylene blue during liver transplantation. Clin Transplant 2024; 38:e15271. [PMID: 38485687 DOI: 10.1111/ctr.15271] [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: 09/14/2023] [Revised: 01/16/2024] [Accepted: 02/11/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION For patients with catecholamine-resistant vasoplegic syndrome (VS) during liver transplantation (LT), treatment with methylene blue (MB) and/or hydroxocobalamin (B12) has been an acceptable therapy. However, data on the effectiveness of B12 is limited to case reports and case series. METHODS We retrospectively reviewed records of patients undergoing LT from January 2016 through March 2022. We identified patients with VS treated with vasopressors and MB, and abstracted hemodynamic parameters, vasopressor requirements, and B12 administration from the records. The primary aim was to describe the treatment efficacy of B12 for VS refractory to vasopressors and MB, measured as no vasopressor requirement at the conclusion of the surgery. RESULTS One hundred one patients received intraoperative VS treatment. For the 35 (34.7%) patients with successful VS treatment, 14 received MB only and 21 received both MB and B12. Of the 21 patients with VS resolution after receiving both MB and B12, 17 (89.5%) showed immediate, but transient, hemodynamic improvements at the time of MB administration and later showed sustained response to B12. CONCLUSION Immediate but transient hemodynamic response to MB in VS patients during LT supports the diagnosis of VS and should prompt B12 administration for sustained treatment response.
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Affiliation(s)
- Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Klaus D Torp
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Vianca C Insignares
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Samuel DeMaria
- Department of Anesthesiology, Perioperative and Pain Medicine, The Mount Sinai Hospital, New York, New York, USA
| | - Chris R Giordano
- Department of Anesthesiology, University of Florida Health, Gainesville, Florida, USA
| | - Ilana I Logvinov
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Zhuo Li
- Department of Quantitative Health Science, Mayo Clinic, Jacksonville, Florida, USA
| | - Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Stephen Aniskevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Pouessel G, Tacquard C, Tanno LK, Mertes PM, Lezmi G. Anaphylaxis mortality in the perioperative setting: Epidemiology, elicitors, risk factors and knowledge gaps. Clin Exp Allergy 2024; 54:11-20. [PMID: 38168878 DOI: 10.1111/cea.14434] [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: 07/03/2023] [Revised: 11/09/2023] [Accepted: 11/09/2023] [Indexed: 01/05/2024]
Abstract
Perioperative anaphylaxis (PA) is a severe condition that can be fatal, but data on PA mortality are scarce. The aim of this article is to review the epidemiology, elicitors and risk factors for PA mortality and identify knowledge gaps and areas for improvement regarding the management of severe PA. PA affects about 100 cases per million procedures. Mortality is rare, estimated at 3 to 5 cases per million procedures, but the PA mortality rate is higher than for other anaphylaxis aetiologies, at 1.4% to 4.8%. However, the data are incomplete. Published data mention neuromuscular blocking agents and antibiotics, mainly penicillin and cefazolin, as the main causes of fatal PA. Reported risk factors for fatal PA vary in different countries. Most frequently occurring comorbidities are obesity, male gender, cardiovascular diseases and ongoing treatment with beta-blockers. However, there are no clues about how these factors interact and the impact of individual risk factors. The pathophysiology of fatal PA is still not completely known. Genetic factors such as deficiency in PAF-acetyl hydrolase and hereditary alpha-tryptasemia, have been reported as modulators of severe anaphylaxis and possible targets for specific treatments. Our review underlines unmet needs in the field of fatal PA. Although we confirmed the need for timely administration of an adequate dose of adrenaline and the proper infusion of fluids, there is no evidence-based data on the proper dose of intravenous titrated adrenaline and which clinical manifestations would flag the need for fluid therapy. There are no large clinical studies supporting the administration of alternative vasopressors, such as glucagon and methylene blue. Further research on pathophysiological mechanisms of PA and its severity may address these issues and help clinicians to define new therapeutic approaches.
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Affiliation(s)
- Guillaume Pouessel
- Department of Pediatrics, Children's Hospital, CH Roubaix, Roubaix, France
- Pediatric Pulmonology and Allergy Department, Pôle enfant, Hôpital Jeanne de Flandre, CHU Lille, Lille, France
- ULR 2694: METRICS, Univ Lille, Lille, France
| | - Charles Tacquard
- Department of Anaesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Luciana Kase Tanno
- Division of Allergy, Department of Pulmonology, Allergy and Thoracic Oncology, University Hospital of Montpellier, Montpellier, France
- Desbrest Institute of Epidemiology and Public Health, UMR UA11 University of Montpellier - INSERM, Montpellier, France
- WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
| | - Paul Michel Mertes
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Guillaume Lezmi
- Paediatric Pneumology and Allergology Unit, Children's Hospital Necker, Paris, France
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Johannsen CM, Nørholt C, Baltsen C, Eggertsen MA, Magnussen A, Vormfenne L, Mortensen SØ, Hansen ESS, Vammen L, Andersen LW, Granfeldt A. The effects of methylene blue during and after cardiac arrest in a porcine model; a randomized, blinded, placebo-controlled study. Am J Emerg Med 2023; 73:145-153. [PMID: 37659143 DOI: 10.1016/j.ajem.2023.08.041] [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: 03/29/2023] [Revised: 07/04/2023] [Accepted: 08/22/2023] [Indexed: 09/04/2023] Open
Abstract
PURPOSE To evaluate the effect of methylene blue administered as a bolus on return of spontaneous circulation (ROSC), lactate levels, vasopressor requirements, and markers of neurological injury in a clinically relevant pig model of cardiac arrest. MATERIALS AND METHODS 40 anesthetized pigs were subjected to acute myocardial infarction and 7 min of untreated cardiac arrest. Animals were randomized into three groups: one group received saline only (controls), one group received 2 mg/kg methylene blue and saline (MB + saline), and one group received two doses of 2 mg/kg methylene blue (MB + MB). The first intervention was given after the 3rd rhythm analysis, while the second dose was administered one hour after achieving ROSC. Animals underwent intensive care and observation for six hours, followed by cerebral magnetic resonance imaging (MRI). The primary outcome for this study was development in lactate levels after cardiac arrest. Categorical data were compared using Fisher's exact test and pointwise data were analyzed using one-way analysis of variance (ANOVA) or equivalent non-parametric test. Continuous data collected over time were analyzed using a linear mixed effects model. A value of p < .05 was considered statistically significant. RESULTS Lactate levels increased in all groups after cardiac arrest and resuscitation, however lactate levels in the MB + MB group decreased significantly faster compared with the control group (p = .007) and the MB + saline group (p = .02). The proportion of animals achieving initial ROSC was similar across groups: 11/13 (85%) in the control group, 10/13 (77%) in the MB + saline group, and 12/14 (86%) in the MB + MB group (p = .81). Time to ROSC did not differ between groups (p = .67). There was no significant difference in accumulated norepinephrine dose between groups (p = .15). Cerebral glycerol levels were significantly lower in the MB + MB group after resuscitation compared with control group (p = .03). However, MRI data revealed no difference in apparent diffusion coefficient, cerebral blood flow, or dynamic contrast enhanced MR perfusion between groups. CONCLUSION Treatment with a bolus of methylene blue during cardiac arrest and after resuscitation did not significantly improve hemodynamic function. A bolus of methylene blue did not yield the neuroprotective effects that have previously been described in animals receiving methylene blue as an infusion.
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Affiliation(s)
- Cecilie Munch Johannsen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Casper Nørholt
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Cecilie Baltsen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Mark A Eggertsen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | | | | | | | - Esben Søvsø Szocska Hansen
- Department of Clinical Medicine, Aarhus University, Denmark; MR Research Centre, Aarhus University, Denmark
| | - Lauge Vammen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Lars W Andersen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark; Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
| | - Asger Granfeldt
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark.
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Asthma and Anaphylaxis—interconnected entities. CURRENT TREATMENT OPTIONS IN ALLERGY 2022. [DOI: 10.1007/s40521-022-00324-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Zhao CC, Zhai YJ, Hu ZJ, Huo Y, Li ZQ, Zhu GJ. Efficacy and safety of methylene blue in patients with vasodilatory shock: A systematic review and meta-analysis. Front Med (Lausanne) 2022; 9:950596. [PMID: 36237547 PMCID: PMC9552293 DOI: 10.3389/fmed.2022.950596] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/01/2022] [Indexed: 12/03/2022] Open
Abstract
Background The role of methylene blue (MB) in patients with vasodilatory shock is unclear. The purpose of this systematic review and meta-analysis was to evaluate the efficacy and safety of MB in patients with vasodilatory shock. Methods We searched MEDLINE at PubMed, Embase, Web of Science, Cochrane, CNKI, CBM and Wanfang Medical databases for all observational and intervention studies comparing the effect of MB vs. control in vasodilatory shock patients. This study was performed in accordance with the PRISMA statement. There were no language restrictions for inclusion. Results A total of 15 studies with 832 patients were included. Pooled data demonstrated that administration of MB along with vasopressors significantly reduced mortality [odds ratio (OR) 0.54, 95% confidence interval (CI) 0.34 to 0.85, P = 0.008; I 2 = 7%]. This benefit in mortality rate was also seen in a subgroup analysis including randomized controlled trials and quasi-randomized controlled trials. In addition, the vasopressor requirement was reduced in the MB group [mean difference (MD) -0.77, 95%CI -1.26 to -0.28, P = 0.002; I 2 = 80%]. Regarding hemodynamics, MB increased the mean arterial pressure, heart rate and peripheral vascular resistance. In respect to organ function, MB was associated with a lower incidence of renal failure, while in regards to oxygen metabolism, it was linked to reduced lactate levels. MB had no effect on the other outcomes and no serious side effects. Conclusions Concomitant administration of MB and vasopressors improved hemodynamics, decreased vasopressor requirements, reduced lactate levels, and improved survival in patients with vasodilatory shock. However, further studies are required to confirm these findings. Systematic review registration Identifier: CRD42021281847.
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Affiliation(s)
- Cong-Cong Zhao
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yu-Jia Zhai
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhen-Jie Hu
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yan Huo
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhi-Qiang Li
- Department of Intensive Care Unit, Affiliated Hospital of North China University of Science and Technology, Tangshan, China
| | - Gui-Jun Zhu
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
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Mo S, He Y, Zhu G, Su H, Han C, Ye X, Liao X, Yang C, Liang T, Chen Z, Wei Y, Wei Z, Luo J, Nong J, Lau WY, Peng T. A novel Peng’s test in reducing bile leakage after partial hepatectomy for hepatocellular carcinoma: From an animal study to a clinical cohort Propensity score matching comparative study. Int J Surg 2022; 104:106748. [DOI: 10.1016/j.ijsu.2022.106748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/25/2022] [Accepted: 06/24/2022] [Indexed: 02/07/2023]
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Nuñez-Borque E, Fernandez-Bravo S, Yuste-Montalvo A, Esteban V. Pathophysiological, Cellular, and Molecular Events of the Vascular System in Anaphylaxis. Front Immunol 2022; 13:836222. [PMID: 35371072 PMCID: PMC8965328 DOI: 10.3389/fimmu.2022.836222] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/07/2022] [Indexed: 01/10/2023] Open
Abstract
Anaphylaxis is a systemic hypersensitivity reaction that can be life threatening. Mechanistically, it results from the immune activation and release of a variety of mediators that give rise to the signs and symptoms of this pathological event. For years, most of the research in anaphylaxis has focused on the contribution of the immune component. However, approaches that shed light on the participation of other cellular and molecular agents are necessary. Among them, the vascular niche receives the various signals (e.g., histamine) that elicit the range of anaphylactic events. Cardiovascular manifestations such as increased vascular permeability, vasodilation, hypotension, vasoconstriction, and cardiac alterations are crucial in the pathophysiology of anaphylaxis and are highly involved to the development of the most severe cases. Specifically, the endothelium, vascular smooth muscle cells, and their molecular signaling outcomes play an essential role downstream of the immune reaction. Therefore, in this review, we synthesized the vascular changes observed during anaphylaxis as well as its cellular and molecular components. As the risk of anaphylaxis exists both in clinical procedures and in routine life, increasing our knowledge of the vascular physiology and their molecular mechanism will enable us to improve the clinical management and how to treat or prevent anaphylaxis. Key Message Anaphylaxis, the most severe allergic reaction, involves a variety of immune and non-immune molecular signals that give rise to its pathophysiological manifestations. Importantly, the vascular system is engaged in processes relevant to anaphylactic events such as increased vascular permeability, vasodilation, hypotension, vasoconstriction, and decreased cardiac output. The novelty of this review focuses on the fact that new studies will greatly improve the understanding of anaphylaxis when viewed from a vascular molecular angle and specifically from the endothelium. This knowledge will improve therapeutic options to treat or prevent anaphylaxis.
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Affiliation(s)
- Emilio Nuñez-Borque
- Department of Allergy and Immunology, Instituto en Investigación Sanitaria - Fundación Jiménez Díaz (IIS-FJD), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Sergio Fernandez-Bravo
- Department of Allergy and Immunology, Instituto en Investigación Sanitaria - Fundación Jiménez Díaz (IIS-FJD), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Alma Yuste-Montalvo
- Department of Allergy and Immunology, Instituto en Investigación Sanitaria - Fundación Jiménez Díaz (IIS-FJD), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Vanesa Esteban
- Department of Allergy and Immunology, Instituto en Investigación Sanitaria - Fundación Jiménez Díaz (IIS-FJD), Universidad Autónoma de Madrid (UAM), Madrid, Spain.,Faculty of Medicine and Biomedicine, Alfonso X El Sabio University, Madrid, Spain
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Belletti A, Lerose CC, Zangrillo A, Landoni G. Vasoactive-Inotropic Score: Evolution, Clinical Utility, and Pitfalls. J Cardiothorac Vasc Anesth 2021; 35:3067-3077. [DOI: 10.1053/j.jvca.2020.09.117] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/16/2020] [Accepted: 09/18/2020] [Indexed: 02/06/2023]
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Bezinover D, Mukhtar A, Wagener G, Wray C, Blasi A, Kronish K, Zerillo J, Tomescu D, Pustavoitau A, Gitman M, Singh A, Saner FH. Hemodynamic Instability During Liver Transplantation in Patients With End-stage Liver Disease: A Consensus Document from ILTS, LICAGE, and SATA. Transplantation 2021; 105:2184-2200. [PMID: 33534523 DOI: 10.1097/tp.0000000000003642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hemodynamic instability (HDI) during liver transplantation (LT) can be difficult to manage and increases postoperative morbidity and mortality. In addition to surgical causes of HDI, patient- and graft-related factors are also important. Nitric oxide-mediated vasodilatation is a common denominator associated with end-stage liver disease related to HDI. Despite intense investigation, optimal management strategies remain elusive. In this consensus article, experts from the International Liver Transplantation Society, the Liver Intensive Care Group of Europe, and the Society for the Advancement of Transplant Anesthesia performed a rigorous review of the most current literature regarding the epidemiology, causes, and management of HDI during LT. Special attention has been paid to unique LT-associated conditions including the causes and management of vasoplegic syndrome, cardiomyopathies, LT-related arrhythmias, right and left ventricular dysfunction, and the specifics of medical and fluid management in end-stage liver disease as well as problems specifically related to portal circulation. When possible, management recommendations are made.
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Affiliation(s)
- Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Pennsylvania State University, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA. Represents ILTS and LICAGE
| | - Ahmed Mukhtar
- Department of Anesthesia and Surgical Intensive Care, Cairo University, Almanyal, Cairo, Egypt. Represents LICAGE
| | - Gebhard Wagener
- Department of Anesthesiology, Columbia University Medical Center, New York, NY. Represents SATA and ILTS
| | - Christopher Wray
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA. Represents SATA
| | - Annabel Blasi
- Department of Anesthesia, IDIBAPS (Institut d´investigació biomèdica Agustí Pi i Sunyé) Hospital Clinic, Villaroel, Barcelona, Spain. Represents LICAGE and ILTS
| | - Kate Kronish
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA. Represents SATA
| | - Jeron Zerillo
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY. Represents SATA and ILTS
| | - Dana Tomescu
- Department of Anesthesiology and Intensive Care, Carol Davila University of Medicine and Pharmacy, Fundeni Clinical Institute, Bucharest, Romania. Represents LICAGE
| | - Aliaksei Pustavoitau
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Johns Hopkins School of Medicine, Baltimore, MD. Represents ILTS
| | - Marina Gitman
- Department of Anesthesiology, University of Illinois Hospital, Chicago, IL. Represents SATA and ILTS
| | - Anil Singh
- Department of Liver Transplant and GI Critical Care, Sir HN Reliance Foundation Hospital, Cirgaon, Mumbai, India. Represents ILTS
| | - Fuat H Saner
- Department of General, Visceral and Transplant Surgery, Essen University Medical Center, Essen, Germany. Represents LICAGE
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Abstract
ABSTRACT Methylene blue has been in medicinal use for centuries and is best known as an antidotal treatment for acquired methemoglobinemia (MetHB). More recently, methylene blue has gained recognition for its efficacious use in the treatment of ifosfamide neurotoxicity and refractory vasoplegic shock in both the pediatric and adult critical care literature, extending its use beyond MetHB. Methylene blue's mechanism of action is somewhat complex and based partly on its oxidizing capabilities, ironically the same mechanism that causes MetHB. This review will examine methylene blue's use in the treatment of acquired MetHB and ifosfamide neurotoxicity and review the current literature regarding its role in critically ill pediatric and adult patients with refractory vasoplegic shock. Methylene blue's pharmacologic actions, dosing, and adverse effects will also be discussed.
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Affiliation(s)
- Renita S Pushparajah Mak
- From the Assistant Professor of Pediatrics (Pushparajah Mak) and Professor of Pediatrics (Liebelt), University of Arkansas for Medical Sciences
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Kram SJ, Kram BL, Cook JC, Ohman KL, Ghadimi K. Hydroxocobalamin or Methylene Blue for Vasoplegic Syndrome in Adult Cardiothoracic Surgery. J Cardiothorac Vasc Anesth 2021; 36:469-476. [PMID: 34176677 DOI: 10.1053/j.jvca.2021.05.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/15/2021] [Accepted: 05/19/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare hydroxocobalamin and methylene blue for the treatment of vasopressor-refractory vasoplegic syndrome (VS) after adult cardiac surgery with cardiopulmonary bypass (CPB). DESIGN A retrospective, propensity-matched, cohort study was performed. The primary endpoints were the percentage change in vasopressor use at 30, 60, and 120 minutes, characterized as both norepinephrine equivalents and vasoactive inotropic score. Eligible patients who received methylene blue were matched 3:1 with patients who received hydroxocobalamin based on sequential organ failure assessment score, preoperative mechanical circulatory support, CPB duration, and use of pre-CPB vasopressors, angiotensin-converting enzyme inhibitors, or beta-blockers. SETTING A quaternary care academic medical center. PARTICIPANTS Adult patients who underwent cardiac surgery with CPB from July 2013 to June 2019. INTERVENTIONS Patients were included who received either hydroxocobalamin (5,000 mg) or methylene blue (median 1.2 mg/kg) for VS in the operating room during the index surgery or in the intensive care unit up to 24 hours after CPB separation. MEASUREMENTS AND MAIN RESULTS Of the 142 included patients, 120 received methylene blue and 22 received hydroxocobalamin. After matching, 66 patients in the methylene blue group were included in the analysis. Baseline demographics, surgical characteristics, and vasoactive medications were similar between groups. There were no significant between-group differences in percentage change in norepinephrine equivalents or vasoactive inotropic score at each timepoint. CONCLUSIONS In adult patients undergoing cardiothoracic surgery using CPB with VS, the ability to reduce vasopressor use was similar with hydroxocobalamin compared with methylene blue.
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Affiliation(s)
- Shawn J Kram
- Department of Pharmacy, Duke University Hospital, Durham, NC.
| | | | - Jennifer C Cook
- Department of Pharmacy, Duke University Hospital, Durham, NC
| | - Kelsey L Ohman
- Department of Pharmacy, Duke University Hospital, Durham, NC
| | - Kamrouz Ghadimi
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, NC
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14
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Defining Vasoplegia Following Durable, Continuous Flow Left Ventricular Assist Device Implantation. ASAIO J 2021; 68:46-55. [PMID: 34227791 DOI: 10.1097/mat.0000000000001419] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This study aimed to develop a definition of vasoplegia that reliably predicts clinical outcomes. Vasoplegia was evaluated using data from the electronic health record for each 15-minute interval for 72 hours following cardiopulmonary bypass. Standardized definitions considered clinical features (systemic vascular resistance [SVR], mean arterial pressure [MAP], cardiac index [CI], norepinephrine equivalents [NEE]), threshold strategy (criteria occurring in any versus all measurements in an interval), and duration (criteria occurring over multiple consecutive versus separated intervals). Minor vasoplegia was MAP < 60 mm Hg or SVR < 800 dynes⋅sec⋅cm with CI > 2.2 L/min/m and NEE ≥ 0.1 µg/kg/min. Major vasoplegia was MAP < 60 mm Hg or SVR < 700 dynes⋅sec⋅cm with CI > 2.5 L/min/m and NEE ≥ 0.2 µg/kg/min. The primary outcome was incidence of vasoplegia for eight definitions developed utilizing combinations of these criteria. Secondary outcomes were associations between vasoplegia definitions and three clinical outcomes: time to extubation, time to intensive care unit discharge, and nonfavorable discharge. Minor vasoplegia detected anytime within a 15-minute period (MINOR_ANY_15) predicted the highest incidence of vasoplegia (61%) and was associated with two of three clinical outcomes: 1 day delay to first extubation (95% CI: 0.2 to 2) and 7 day delay to first intensive care unit discharge (95% CI: 1 to 13). The MINOR_ANY_15 definition should be externally validated as an optimal definition of vasoplegia.
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15
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Perdhana F, Kloping NA, Witarto AP, Nugraha D, Yogiswara N, Luke K, Kloping YP, Rehatta NM. Methylene blue for vasoplegic syndrome in cardiopulmonary bypass surgery: A systematic review and meta-analysis. Asian Cardiovasc Thorac Ann 2021; 29:717-728. [PMID: 33653154 DOI: 10.1177/0218492321998523] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND To evaluate the benefit of methylene blue as an adjunct treatment by assessing hemodynamic, morbidity rate, intensive care unit length of stay, and mortality rate outcomes in adult patients with vasoplegic syndrome. METHODS A systematic search through electronic databases including Pubmed, Embase, Scopus, and Medline for studies assessing the use of methylene blue in patients with vasoplegic syndrome compared to control treatments. The Newcastle-Ottawa Scale tool was used for observational studies, and Jadad Scale was used for controlled trials to assess the risk of bias. RESULTS This systematic review included six studies for qualitative synthesis and five studies for quantitative synthesis. Pooled analysis revealed that mean arterial pressure, systemic vascular resistance, heart rate, and hospital stay were not statistically significant in methylene blue administration compared to control. However, administration of methylene blue in vasoplegic syndrome patients significantly reduces renal failure (OR = 0.25; 95% CI = 0.08-0.75), development of multiple organ failure (OR = 0.09; 95% CI = 0.02-0.51), and mortality rate (OR = 0.12; 95% CI = 0.03-0.46). CONCLUSION Adjunct administration of methylene blue for vasoplegic syndrome patients significantly reduces renal failure, multiple organ failure, and mortality.
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Affiliation(s)
- Fajar Perdhana
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Universitas Airlangga - Dr Soetomo General Hospital, Surabaya, Indonesia
| | | | - Andro P Witarto
- Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - David Nugraha
- Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | | | - Kevin Luke
- Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | | | - Nancy M Rehatta
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Universitas Airlangga - Dr Soetomo General Hospital, Surabaya, Indonesia
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16
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Weinberg D, Running K, Kalarickal PL, Patel GP. Use of Intravenous Hydroxocobalamin for Vasoplegic Syndrome in Simultaneous Liver-Kidney Transplant: A Case Report. Transplant Proc 2020; 53:1300-1302. [PMID: 33246585 DOI: 10.1016/j.transproceed.2020.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/09/2020] [Accepted: 09/21/2020] [Indexed: 11/28/2022]
Abstract
Vasoplegic syndrome can occur after reperfusion in liver transplantation. Generally, vasopressor infusions along with volume resuscitation are used to combat this process. There are case reports of the use of hydroxocobalamin to improve vasoplegia in liver transplant and cardiac surgery. In this case report, we describe a patient who received hydroxocobalamin for a simultaneous liver-kidney transplant. Use of this medication facilitated a prompt decrease of very high-dose vasopressor infusions and allowed completion of the kidney transplantation portion of this case. To our knowledge, use in combined liver-kidney transplant has not been described. In light of the dearth of medications to improve vasoplegia outside of vasopressor infusions, the use of hydroxocobalamin as a therapeutic intervention may gain importance.
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Affiliation(s)
- Devin Weinberg
- Department of Anesthesiology, Emory University, Atlanta, Georgia
| | - Kati Running
- Department of Anesthesiology, Emory University, Atlanta, Georgia
| | | | - Gaurav P Patel
- Department of Anesthesiology, Emory University, Atlanta, Georgia.
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17
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Guarracino F, Habicher M, Treskatsch S, Sander M, Szekely A, Paternoster G, Salvi L, Lysenko L, Gaudard P, Giannakopoulos P, Kilger E, Rompola A, Häberle H, Knotzer J, Schirmer U, Fellahi JL, Hajjar LA, Kettner S, Groesdonk HV, Heringlake M. Vasopressor Therapy in Cardiac Surgery-An Experts' Consensus Statement. J Cardiothorac Vasc Anesth 2020; 35:1018-1029. [PMID: 33334651 DOI: 10.1053/j.jvca.2020.11.032] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 11/09/2020] [Accepted: 11/13/2020] [Indexed: 12/17/2022]
Abstract
Hemodynamic conditions with reduced systemic vascular resistance commonly are observed in patients undergoing cardiac surgery and may range from moderate reductions in vascular tone, as a side effect of general anesthetics, to a profound vasodilatory syndrome, often referred to as vasoplegic shock. Therapy with vasopressors is an important pillar in the treatment of these conditions. There is limited guidance on the appropriate choice of vasopressors to restore and optimize systemic vascular tone in patients undergoing cardiac surgery. A panel of experts in the field convened to develop statements and evidence-based recommendations on clinically relevant questions on the use of vasopressors in cardiac surgical patients, using a critical appraisal of the literature following the GRADE system and a modified Delphi process. The authors unanimously and strongly recommend the use of norepinephrine and/or vasopressin for restoration and maintenance of systemic perfusion pressure in cardiac surgical patients; despite that, the authors cannot recommend either of these drugs with respect to the risk of ischemic complications. The authors unanimously and strongly recommend against using dopamine for treating post-cardiac surgery vasoplegic shock and against using methylene blue for purposes other than a rescue therapy. The authors unanimously and weakly recommend that clinicians consider early addition of a second vasopressor (norepinephrine or vasopressin) if adequate vascular tone cannot be restored by a monotherapy with either norepinephrine or vasopressin and to consider using vasopressin as a first-line vasopressor or to add vasopressin to norepinephrine in cardiac surgical patients with pulmonary hypertension or right-sided heart dysfunction.
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Affiliation(s)
- Fabio Guarracino
- Department of Anesthesia and Intensive Care Medicine, University Hospital of Pisa, Pisa, Italy
| | - Marit Habicher
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Gieβen, Justus-Liebig University Gieβen, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Operative Intensive Care Medicine Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany
| | - Michael Sander
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Gieβen, Justus-Liebig University Gieβen, Germany
| | - Andrea Szekely
- Department of Anesthesia, Semmelweis University Budapest, Budapest, Hungary
| | - Gianluca Paternoster
- Division of Cardiac Resuscitation, Cardiovascular Anesthesia and Intensive Care, San Carlo Hospital, Potenza, Italy
| | - Luca Salvi
- IRCCS Centro Cardiologico Monzino, Milano, Italy
| | - Lidia Lysenko
- Department of Anesthesiology and Intensive Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Phillipe Gaudard
- Department of Anaesthesiology and Critical Care Medicine Arnaud de Villeneuve, CHU Montpellier, University of Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France
| | | | - Erich Kilger
- Department of Anesthesiology, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Amalia Rompola
- Department of Cardiac Surgery Intensive Care, Onassis Cardiac Center, Kallithea Athens, Greece
| | - Helene Häberle
- Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany
| | - Johann Knotzer
- Department of Anaesthesiology and Critical Care Medicine, County Hospital Wels, Wels, Austria
| | - Uwe Schirmer
- Institute for Anesthesiology, Heart, and Diabetes Center, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Jean-Luc Fellahi
- Department of Anesthesiology and Critical Care, Hôpital Cardiologique Louis Pradel, Lyon, France
| | - Ludhmila Abrahao Hajjar
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clínicas, Sao Paulo, Brazil
| | - Stephan Kettner
- Department of Anesthesiology and Intensive Care, Vienna Hospital Association, Vienna, Austria
| | | | - Matthias Heringlake
- Department of Anesthesiology and Intensive Care, Heart- and Diabetes Center Mecklenburg - Western Pomerania, Karlsburg, Germany.
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18
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Chen L, Ge M. [Advances in Identification of Intersegmental Plane during Pulmonary Segmentectomy]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2020; 23:818-823. [PMID: 32773009 PMCID: PMC7519953 DOI: 10.3779/j.issn.1009-3419.2020.101.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
With the popularity of computed tomography (CT) scan in recent years, early stage lung cancer has been discovered in large numbers of patients and pulmonary segmentectomy has been widely used clinically. Identification of the intersegmental plane is one of the key steps in pulmonary segmentectomy, and current methods for identifying the intersegmental plane are numerous and have their own advantages and disadvantages. We will review relevant methods to help the clinical practice.
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Affiliation(s)
- Liang Chen
- Department of Thoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Mingjian Ge
- Department of Thoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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19
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Puntillo F, Giglio M, Pasqualucci A, Brienza N, Paladini A, Varrassi G. Vasopressor-Sparing Action of Methylene Blue in Severe Sepsis and Shock: A Narrative Review. Adv Ther 2020; 37:3692-3706. [PMID: 32705530 PMCID: PMC7444404 DOI: 10.1007/s12325-020-01422-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Indexed: 12/15/2022]
Abstract
Shock is a serious acute circulatory failure leading to inadequate oxygen delivery to the cells. Its treatment is mainly based on circulating fluid optimization, and vasopressors to provide an adequate mean arterial pressure and microcirculatory flow. Norepinephrine is the drug of choice, but high dosages may be responsible for several side effects, including increased myocardial oxygen consumption, dysrhythmias, and peripheral and organ ischemia. Moreover, some patients are “non-responders” to first-line norepinephrine treatment. Hence, other drugs have been proposed to reach and maintain the hemodynamic target. In general, they are described as catecholamine-sparing agents. Among others, the most used are vasopressin, corticosteroids, and angiotensin II. Methylene blue (MB) represents a further option, even though its use is still a topic of controversy. This review article tries to summarize what is known and unknown about the actions of MB in patients in shock. It reduces excessive production of nitric oxide via blockade of guanylate cyclase in shock states. At present, it appears the MB provides positive results in septic shock, if administered early. Further randomized controlled trials are warranted regarding its use to provide more precise indications to physicians involved in the treatment of such patients.
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Affiliation(s)
- Filomena Puntillo
- Department of Interdisciplinary Medicine, University of Bari "Aldo Moro", 70124, Bari, Italy
| | - Mariateresa Giglio
- Anesthesia, Intensive Care and Pain Unit, Policlinico Hospital, 70124, Bari, Italy
| | - Alberto Pasqualucci
- Department of Surgical and Biomedical Science, University of Perugia, 06100, Perugia, Italy
- Rashid Hospital, Trauma and Emergency Center, Dubai Health Authority, Dubai, UAE
| | - Nicola Brienza
- Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", 70124, Bari, Italy
| | | | - Giustino Varrassi
- Paolo Procacci Foundation, Via Tacito 7, 00193, Rome, Italy.
- World Institute of Pain, Winston-Salem, NC, USA.
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20
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Neethling E, Moreno Garijo J, Mangalam TK, Badiwala MV, Billia P, Wasowicz M, Van Rensburg A, Slinger P. Intraoperative and Early Postoperative Management of Heart Transplantation: Anesthetic Implications. J Cardiothorac Vasc Anesth 2020; 34:2189-2206. [DOI: 10.1053/j.jvca.2019.09.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 09/07/2019] [Accepted: 09/24/2019] [Indexed: 12/16/2022]
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21
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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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22
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Does methylene blue reduce adhesion during the healing process after tendon repair? Jt Dis Relat Surg 2020; 31:246-254. [PMID: 32584721 PMCID: PMC7489185 DOI: 10.5606/ehc.2020.74405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/15/2020] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES This study aims to biomechanically and histopathologically investigate the effects of methylene blue (MB) on preventing postoperative adhesion in chickens undergoing full- thickness flexor tendon incision. MATERIALS AND METHODS This study was performed between June 2017 and June 2018 on Hubbard JA 57 type chickens (age, 6 months; weight, 2.2±0.3 kg). Sixty-four tendons were studied in 32 chickens, including 16 in the control group and 16 in the experimental group. The second and third finger flexor digitorum profundus tendons of the left foot of each chicken were repaired primarily after a full-thickness incision approximately 1 cm proximal to the distal adhesion area. In the control (n=32) and experimental groups (n=32), 0.25 mL of normal saline and 0.25 mL of 1% MB solutions were applied locally to the surgical site, respectively. The operated limb was immobilized using a circular cast. 16 chickens were randomly selected in each group and examined at the fourth week, and the remaining 16 chickens were examined at the sixth week. Thirty-two of these tendons were evaluated using the Tang histopathological adhesion classification system, and the other 32 were evaluated with a biomechanical pull system. RESULTS Adhesion was found to be less in the experimental group compared to the control group at the end of the fourth and sixth weeks both histopathologically and biomechanically. Furthermore, adhesion was significantly less in the experimental group at the end of the sixth week compared to the fourth week both histopathologically and biomechanically. CONCLUSION Histopathological and biomechanical results show that MB, which has anti-inflammatory, antiseptic, antimicrobial and antioxidant effects, reduces adhesion during the healing process after tendon repair. We think that local MB application, particularly in surgeries performed after this type of injury, will be beneficial on early rehabilitation and functional results.
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23
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Otero Luna AV, Johnson R, Funaro M, Canarie MF, Pierce RW. Methylene Blue for Refractory Shock in Children: A Systematic Review and Survey Practice Analysis. Pediatr Crit Care Med 2020; 21:e378-e386. [PMID: 32453920 PMCID: PMC10563197 DOI: 10.1097/pcc.0000000000002295] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Shock refractory to fluid and catecholamine therapy has significant morbidity and mortality in children. The use of methylene blue to treat refractory shock in children is not well described. We aim to collect and summarize the literature and define physicians' practice patterns regarding the use of methylene blue to treat shock in children. DESIGN We conducted a systematic search of MEDLINE, Embase, PubMed, Web of Science, Cochrane for studies involving the use of methylene blue for catecholamine-refractory shock from database inception to 2019. Collected studies were analyzed qualitatively. To describe practice patterns of methylene blue use, we electronically distributed a survey to U.S.-based pediatric critical care physicians. We assessed physician knowledge and experience with methylene blue. Survey responses were quantitatively and qualitatively evaluated. SETTING Pediatric critical and cardiac care units. PATIENTS OR SUBJECTS Patients less than or equal to 25 years old with refractory shock treated with methylene blue. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One-thousand two-hundred ninety-three abstracts met search criteria, 139 articles underwent full-text review, and 24 studies were included. Studies investigated refractory shock induced by a variety of etiologies and found that methylene blue was generally safe and increased mean arterial blood pressure. There is overall lack of studies, low number of study patients, and low quality of studies identified. Our survey had a 22.5% response rate, representing 125 institutions. Similar proportions of physicians reported using (40%) or never even considering (43%) methylene blue for shock. The most common reasons for not using methylene blue were unfamiliarity with this drug, its proper dosing, and lack of evidentiary support. CONCLUSIONS Methylene blue appears safe and may benefit children with refractory shock. There is a stark divide in familiarity and practice patterns regarding its use among physicians. Studies to formally assess safety and efficacy of methylene blue in treating pediatric shock are warranted.
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Affiliation(s)
| | - Rachel Johnson
- Department of Pediatrics, Yale University, New Haven, CT
| | - Melissa Funaro
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, CT
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24
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Shah R, Wenger RK, Patel PA, Davis S, Ha B, Feinman JW, Patel S, Pulton D, Weiss SJ, Restrepo-Cardenas J, Aljure OD, Vasquez CR, Augoustides JG. Severe Vasoplegic Shock During Coronary Artery Bypass Surgery: Therapeutic challenges and Dilemmas in Hemodynamic Rescue. J Cardiothorac Vasc Anesth 2020; 34:1341-1347. [PMID: 32146101 DOI: 10.1053/j.jvca.2020.01.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 01/28/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Ronak Shah
- Department of Anesthesiology and Critical Care, Cardiovascular and Thoracic Section, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Robert K Wenger
- Department of Surgery, Division of Cardiac Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Prakash A Patel
- Department of Anesthesiology and Critical Care, Cardiovascular and Thoracic Section, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Scott Davis
- Department of Anesthesiology, Chester County Hospital, University of Pennsylvania, Philadelphia, PA
| | - Bao Ha
- Department of Anesthesiology and Critical Care, Cardiovascular and Thoracic Section, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jared W Feinman
- Department of Anesthesiology and Critical Care, Cardiovascular and Thoracic Section, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Saumil Patel
- Department of Anesthesiology and Critical Care, Cardiovascular and Thoracic Section, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Danielle Pulton
- Department of Anesthesiology and Critical Care, Cardiovascular and Thoracic Section, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stuart J Weiss
- Department of Anesthesiology and Critical Care, Cardiovascular and Thoracic Section, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Oscar D Aljure
- Department of Anesthesiology, Miller School of Medicine, University of Miami, Miami, FL
| | - Charles R Vasquez
- Department of Surgery, Division of Cardiac Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Department of Anesthesiology and Critical Care, Cardiovascular and Thoracic Section, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Oh ID, Shin E, Jeon JM, Woo H, Choi JH. Use of methylene blue in vasoplegic syndrome that developed during non-cardiac surgery - A case report. Anesth Pain Med (Seoul) 2019; 14:460-464. [PMID: 33329778 PMCID: PMC7713804 DOI: 10.17085/apm.2019.14.4.460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 10/31/2018] [Accepted: 02/01/2019] [Indexed: 11/30/2022] Open
Abstract
Background Vasoplegic syndrome is an increasingly recognized disease in perioperative medicine and is characterized by severe hypotension, normal or elevated cardiac output, and decreased systemic vascular resistance. It occurs commonly after cardiopulmonary bypass but may also occur after other types of surgery. Case Vasoplegic syndrome developed in our patient during posterior lumbar interbody fusion because of administering nicardipine after phenylephrine. However, the blood pressure did not increase as expected despite simultaneous use of norepinephrine and vasopressin to increase the reduced systemic vascular resistance. Conclusions We present a case of vasoplegic syndrome that developed during posterior lumbar interbody fusion and was treated successfully with methylene blue.
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Affiliation(s)
- In Duk Oh
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Eunsil Shin
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Jong-Mi Jeon
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Hyunho Woo
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Jeong-Hyun Choi
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Seoul, Korea
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Belletti A, Landoni G, Lomivorotov VV, Oriani A, Ajello S. Adrenergic Downregulation in Critical Care: Molecular Mechanisms and Therapeutic Evidence. J Cardiothorac Vasc Anesth 2019; 34:1023-1041. [PMID: 31839459 DOI: 10.1053/j.jvca.2019.10.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 09/09/2019] [Accepted: 10/10/2019] [Indexed: 02/08/2023]
Abstract
Catecholamines remain the mainstay of therapy for acute cardiovascular dysfunction. However, adrenergic receptors quickly undergo desensitization and downregulation after prolonged stimulation. Moreover, prolonged exposure to high circulating catecholamines levels is associated with several adverse effects on different organ systems. Unfortunately, in critically ill patients, adrenergic downregulation translates into progressive reduction of cardiovascular response to exogenous catecholamine administration, leading to refractory shock. Accordingly, there has been a growing interest in recent years toward use of noncatecholaminergic inotropes and vasopressors. Several studies investigating a wide variety of catecholamine-sparing strategies (eg, levosimendan, vasopressin, β-blockers, steroids, and use of mechanical circulatory support) have been published recently. Use of these agents was associated with improvement in hemodynamics and decreased catecholamine use but without a clear beneficial effect on major clinical outcomes. Accordingly, additional research is needed to define the optimal management of catecholamine-resistant shock.
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Affiliation(s)
- Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Vladimir V Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia; Novosibirsk State University, Novosibirsk, Russia
| | - Alessandro Oriani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Ajello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Vaikunth SS, Concepcion W, Daugherty T, Fowler M, Lutchman G, Maeda K, Rosenthal DN, Teuteberg J, Woo YJ, Lui GK. Short-term outcomes of en bloc combined heart and liver transplantation in the failing Fontan. Clin Transplant 2019; 33:e13540. [PMID: 30891780 DOI: 10.1111/ctr.13540] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 03/09/2019] [Accepted: 03/15/2019] [Indexed: 12/18/2022]
Abstract
Patients with failing Fontan physiology and liver cirrhosis are being considered for combined heart and liver transplantation. We performed a retrospective review of our experience with en bloc combined heart and liver transplantation in Fontan patients > 10 years old from 2006 to 18 per Institutional Review Board approval. Six females and 3 males (median age 20.7, range 14.2-41.3 years) underwent en bloc combined heart and liver transplantation. Indications for heart transplant included ventricular dysfunction, atrioventricular valve regurgitation, arrhythmia, and/or lymphatic abnormalities. Indication for liver transplant included portal hypertension and cirrhosis. Median Fontan/single ventricular end-diastolic pressure was 18/12 mm Hg, respectively. Median Model for End-Stage Liver Disease excluding International Normalized Ratio score was 10 (7-26), eight patients had a varices, ascites, splenomegaly, thrombocytopenia score of ≥ 2, and all patients had cirrhosis. Median cardiopulmonary bypass and donor ischemic times were 262 (178-307) and 287 (227-396) minutes, respectively. Median intensive care and hospital stay were 19 (5-96) and 29 (13-197) days, respectively. Survival was 100%, and rejection was 0% at 30 days and 1 year post-transplant. En bloc combined heart and liver transplantation is an acceptable treatment in the failing Fontan patient with liver cirrhosis.
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Affiliation(s)
- Sumeet S Vaikunth
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Waldo Concepcion
- Department of Transplant Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Tami Daugherty
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California
| | - Michael Fowler
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Glen Lutchman
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California
| | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - David N Rosenthal
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California
| | - Jeffrey Teuteberg
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - George K Lui
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California.,Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California
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Kast RE. Inhibiting the NLRP3 Inflammasome With Methylene Blue as Treatment Adjunct in Myelodysplasia. Front Oncol 2018; 8:280. [PMID: 30101125 PMCID: PMC6072867 DOI: 10.3389/fonc.2018.00280] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 07/04/2018] [Indexed: 11/17/2022] Open
Abstract
Myelodysplasia refers to a group of clonal hematopoietic neoplasms characterized by genetic heterogeneity, different clinical behaviors and prognoses. Some of this group of bone marrow failure conditions have known external causes, some are of unknown origin. Within marrow, intracellular, and extracellular elements of the innate immune system are activated and contribute to creation of multiple cytogenetic abnormalities and are central to the mode of hematopoietic cell failure. Basiorka et al. showed that NLRP3 inflammasome activity is essential to the innate immune system's destruction of marrow hematopoietic cells commonly in myelodysplasia. In April 2018 Hao et al. reported that methylene blue inhibits rat NLRP3 inflammasome function. Methylene blue has been in continuous use in humans for over a century. It is associated with an eminently benign side effect profile in human use. If as in rodents, methylene blue also inhibits NLRP3 inflammasome function in human myelodysplasia a trial of adjunctive methylene blue treatment in transfusion dependent, low risk myelodysplasia where marrow inflammation and apoptosis predominates, would be worth trying. HIGHLIGHTS- Cytogenetic abnormalities and innate immune activation are seen in myelodysplasia - The NLRP3 inflammasome is a core element generating marrow failure of myelodysplasia - In April 2018 methylene blue was reported to potently inhibit NLRP3 inflammasome function - Methylene blue has benign side effects and has been in human use for a century - Study of methylene blue treatment of myelodysplasia would be a low-risk intervention
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