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Ortoleva J, Dalia AA, Pisano DV, Shapeton A. Diagnosis and Management of Vasoplegia in Temporary Mechanical Circulatory Support: A Narrative Review. J Cardiothorac Vasc Anesth 2024; 38:1378-1389. [PMID: 38490900 DOI: 10.1053/j.jvca.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/10/2024] [Accepted: 02/18/2024] [Indexed: 03/17/2024]
Abstract
Refractory vasodilatory shock, or vasoplegia, is a pathophysiologic state observed in the intensive care unit and operating room in patients with a variety of primary diagnoses. Definitions of vasoplegia vary by source but are qualitatively defined clinically as a normal or high cardiac index and low systemic vascular resistance causing hypotension despite high-dose vasopressors in the setting of euvolemia. This definition can be difficult to apply to patients undergoing mechanical circulatory support (MCS). A large body of mostly retrospective literature exists on vasoplegia in the non-MCS population, but the increased use of temporary MCS justifies an examination of vasoplegia in this population. MCS, particularly extracorporeal membrane oxygenation, adds complexity to the diagnosis and management of vasoplegia due to challenges in determining cardiac output (or total blood flow), lack of clarity on appropriate dosing of noncatecholamine interventions, increased thrombosis risk, the difficulty in determining the endpoints of adequate volume resuscitation, and the unclear effects of rescue agents (methylene blue, hydroxocobalamin, and angiotensin II) on MCS device monitoring and function. Care teams must combine data from invasive and noninvasive sources to diagnose vasoplegia in this population. In this narrative review, the available literature is surveyed to provide guidance on the diagnosis and management of vasoplegia in the temporary MCS population, with a focus on noncatecholamine treatments and special considerations for patients supported by extracorporeal membrane oxygenation, transvalvular heart pumps, and other ventricular assist devices.
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Affiliation(s)
- Jamel Ortoleva
- Department of Anesthesiology, Boston Medical Center, Boston, MA.
| | - Adam A Dalia
- Division of Cardiac Anesthesiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Alexander Shapeton
- Veterans Affairs Boston Healthcare System, Department of Anesthesia, Critical Care and Pain Medicine, and Tufts University School of Medicine, Boston, MA
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Ballarin RS, Lazzarin T, Zornoff L, Azevedo PS, Pereira FWL, Tanni SE, Minicucci MF. Methylene blue in sepsis and septic shock: a systematic review and meta-analysis. Front Med (Lausanne) 2024; 11:1366062. [PMID: 38698779 PMCID: PMC11063345 DOI: 10.3389/fmed.2024.1366062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/15/2024] [Indexed: 05/05/2024] Open
Abstract
Background Methylene blue is an interesting approach in reducing fluid overload and vasoactive drug administration in vasodilatory shock. The inhibition of guanylate cyclase induced by methylene blue infusion reduces nitric oxide production and improves vasoconstriction. This systematic review and meta-analysis aimed to assess the effects of methylene blue administration compared to placebo on the hemodynamic status and clinical outcomes in patients with sepsis and septic shock. Methods The authors specifically included randomized controlled trials that compared the use of methylene blue with placebo in adult patients with sepsis and septic shock. The outcomes were length of intensive care unit stay, hemodynamic parameters [vasopressor use], and days on mechanical ventilation. We also evaluated the abnormal levels of methemoglobinemia. This systematic review and meta-analysis were recorded in PROSPERO with the ID CRD42023423470. Results During the initial search, a total of 1,014 records were identified, out of which 393 were duplicates. Fourteen citations were selected for detailed reading, and three were selected for inclusion. The studies enrolled 141 patients, with 70 of them in the methylene blue group and 71 of them in the control group. Methylene blue treatment was associated with a lower length of intensive care unit stay (MD -1.58; 95%CI -2.97, -0.20; I2 = 25%; p = 0.03), decreased days on mechanical ventilation (MD -0.72; 95%CI -1.26, -0.17; I2 = 0%; p = 0.010), and a shorter time to vasopressor discontinuation (MD -31.49; 95%CI -46.02, -16.96; I2 = 0%; p < 0.0001). No association was found with methemoglobinemia. Conclusion Administering methylene blue to patients with sepsis and septic shock leads to reduced time to vasopressor discontinuation, length of intensive care unit stay, and days on mechanical ventilation. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023423470, CRD42023423470.
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Arias-Ortiz J, Vincent JL. Administration of methylene blue in septic shock: pros and cons. Crit Care 2024; 28:46. [PMID: 38365828 PMCID: PMC10870439 DOI: 10.1186/s13054-024-04839-w] [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: 12/05/2023] [Accepted: 02/13/2024] [Indexed: 02/18/2024] Open
Abstract
Septic shock typically requires the administration of vasopressors. Adrenergic agents remain the first choice, namely norepinephrine. However, their use to counteract life-threatening hypotension comes with potential adverse effects, so that non-adrenergic vasopressors may also be considered. The use of agents that act through different mechanisms may also provide an advantage. Nitric oxide (NO) is the main driver of the vasodilation that leads to hypotension in septic shock, so several agents have been tested to counteract its effects. The use of non-selective NO synthase inhibitors has been of questionable benefit. Methylene blue, an inhibitor of soluble guanylate cyclase, an important enzyme involved in the NO signaling pathway in the vascular smooth muscle cell, has also been proposed. However, more than 25 years since the first clinical evaluation of MB administration in septic shock, the safety and benefits of its use are still not fully established, and it should not be used routinely in clinical practice until further evidence of its efficacy is available.
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Affiliation(s)
- Julian Arias-Ortiz
- Department of Intensive Care, Calderón Guardia Hospital, Universidad de Costa Rica, San José, Costa Rica
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, Brussels, Belgium.
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Huang X, Yan W, Chen Z, Qian Y. Effect of methylene blue on outcomes in patients with distributive shock: a meta-analysis of randomised controlled trials. BMJ Open 2024; 14:e080065. [PMID: 38216185 PMCID: PMC10806610 DOI: 10.1136/bmjopen-2023-080065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 12/20/2023] [Indexed: 01/14/2024] Open
Abstract
OBJECTIVE This meta-analysis aimed to demonstrate the effect of methylene blue (MB) in patients with distributive shock. DESIGN Meta-analysis. METHODS According to the Prospective International Register of Systematic Reviews (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched the relevant randomised controlled trials (RCTs) via PubMed, Embase and Cochrane Library from the date of database inception to 19 April 2023. The primary outcome was mortality during follow-up, and secondary outcomes included mean arterial pressure (mm Hg), mechanical ventilation time (hours), intensive care unit (ICU) length of stay (LOS) (days), hospital LOS (days) and heart rate (times/min). RESULTS This study included six RCTs with 265 participants. The study showed no significant difference in mortality between the MB and placebo groups (ORs: 0.59; 95% CI 0.32 to -1.06). However, MB reduced the duration of mechanical ventilation (mean difference (MD): -0.68; 95% CI -1.23 to -0.14), ICU LOS (MD: -1.54; 95% CI -2.61 to -0.48) and hospital LOS (MD: -1.97; 95% CI -3.92 to -0.11). CONCLUSIONS The use of MB may not reduce mortality in patients with distributive shock, but may shorten the duration of mechanical ventilation, ICU LOS and hospital LOS. More clinical studies are needed to confirm these findings in the future. TRIAL REGISTRATION NUMBER CRD42023415938.
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Affiliation(s)
- Xinhui Huang
- Medical College of Nanchang University, Nanchang, Jiangxi, China
- Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Wenqing Yan
- Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Zhi Chen
- Department of Critical Care Medicine, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yihong Qian
- Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
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Pisano DV, Wieruszewski PM, Ortoleva JP. Timing is Everything: Two Decades of Nitric Oxide Modulation in Vasoplegia. J Cardiothorac Vasc Anesth 2024; 38:339-340. [PMID: 38016819 DOI: 10.1053/j.jvca.2023.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 10/18/2023] [Accepted: 10/23/2023] [Indexed: 11/30/2023]
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Pruna A, Bonaccorso A, Belletti A, Turi S, Di Prima AL, D'amico F, Zangrillo A, Kotani Y, Landoni G. Methylene Blue Reduces Mortality in Critically Ill and Perioperative Patients: A Meta-Analysis of Randomized Trials. J Cardiothorac Vasc Anesth 2024; 38:268-274. [PMID: 37880041 DOI: 10.1053/j.jvca.2023.09.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 08/26/2023] [Accepted: 09/26/2023] [Indexed: 10/27/2023]
Abstract
Vasodilatory hypotension is common in critically ill and perioperative patients, and is associated with adverse outcomes. As a nitric oxide production inhibitor, methylene blue (MB) exerts its vasoconstrictor property and is an adjuvant for catecholamine-refractory vasodilatory shock. However, the effects of MB on clinically relevant outcomes remain unclear. Therefore, the authors performed a meta-analysis of randomized trials on MB in critically ill and perioperative patients. The authors searched through databases for randomized trials on MB in critically ill and perioperative patients, which yielded 11 studies consisting of 556 patients. The primary outcome was mortality at the longest follow-up. Secondary outcomes included hemodynamic parameters and organ dysfunction (PROSPERO: CRD42023409243). Nine out of the 11 included randomized trials reported mortality, which was significantly lower in the MB group (risk ratio, 0.60 [95% CI 0.43-0.84] p = 0.003), with findings confirmed in septic shock and cardiac surgery subgroups. The authors found reduced lengths of stay in the intensive care unit (mean difference [MD], -0.9 days [95% CI -1.06 to -0.77] p < 0.001) and in the hospital (MD, -2.2 days [95% CI, -2.68 to -1.70] p < 0.001) in the MB group. MB was associated with increased mean arterial pressure (MD, 8.4 mmHg [95% CI 5.01-11.75] p < 0.001) and systemic vascular resistance (MD, 94.5 dyn/s/cm5 [95% CI 17.73-171.15] p = 0.02), with no difference in cardiac output (standardized MD, 0.16 [95% CI, -0.25 to 0.57] p = 0.45). This meta-analysis showed that MB reverses vasodilation in critically ill and perioperative patients and might improve survival. Further adequately powered randomized trials are needed to confirm these findings.
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Affiliation(s)
- Alessandro Pruna
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandra Bonaccorso
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Turi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ambra Licia Di Prima
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Filippo D'amico
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
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Roeschl T, Hinrichs N, Hommel M, Pfahringer B, Balzer F, Falk V, O'Brien B, Ott SC, Potapov E, Schoenrath F, Meyer A. Systematic Assessment of Shock Severity in Postoperative Cardiac Surgery Patients. J Am Coll Cardiol 2023; 82:1691-1706. [PMID: 37852698 DOI: 10.1016/j.jacc.2023.08.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/05/2023] [Accepted: 08/15/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND The Society for Cardiovascular Angiography and Interventions (SCAI) shock classification has been shown to provide robust mortality risk stratification in a variety of cardiovascular patients. OBJECTIVES This study sought to evaluate the SCAI shock classification in postoperative cardiac surgery intensive care unit (CSICU) patients. METHODS This study retrospectively analyzed 26,792 postoperative CSICU admissions at a heart center between 2012 and 2022. Patients were classified into SCAI shock stages A to E using electronic health record data. Moreover, the impact of late deterioration (LD) as an additional risk modifier was investigated. RESULTS The proportions of patients in SCAI shock stages A to E were 24.4%, 18.8%, 8.4%, 35.5%, and 12.9%, and crude hospital mortality rates were 0.4%, 0.6%, 3.3%, 4.9%, and 30.2%, respectively. Similarly, the prevalence of postoperative complications and organ dysfunction increased across SCAI shock stages. After multivariable adjustment, each higher SCAI shock stage was associated with increased hospital mortality (adjusted OR: 1.26-16.59) compared with SCAI shock stage A, as was LD (adjusted OR: 8.2). The SCAI shock classification demonstrated a strong diagnostic performance for hospital mortality (area under the receiver operating characteristic: 0.84), which noticeably increased when LD was incorporated into the model (area under the receiver operating characteristic: 0.90). CONCLUSIONS The SCAI shock classification effectively risk-stratifies postoperative CSICU patients for mortality, postoperative complications, and organ dysfunction. Its application could, therefore, be extended to the field of cardiac surgery as a triage tool in postoperative care and as a selection criterion in research.
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Affiliation(s)
- Tobias Roeschl
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Charité-Universitätsmedizin Berlin, Institute of Medical Informatics, Berlin, Germany.
| | - Nils Hinrichs
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Charité-Universitätsmedizin Berlin, Institute of Medical Informatics, Berlin, Germany
| | - Matthias Hommel
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Deutsches Herzzentrum der Charité (DHZC), Department of Cardiac Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | - Boris Pfahringer
- Deutsches Herzzentrum der Charité (DHZC), Centre for Cardiovascular Telemedicine, Berlin, Germany
| | - Felix Balzer
- Charité-Universitätsmedizin Berlin, Institute of Medical Informatics, Berlin, Germany
| | - Volkmar Falk
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany; Translational Cardiovascular Technologies, Institute of Translational Medicine, Department of Health Sciences and Technology, Swiss Federal Institute of Technology, Zürich, Switzerland
| | - Benjamin O'Brien
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Deutsches Herzzentrum der Charité (DHZC), Department of Cardiac Anesthesiology and Intensive Care Medicine, Berlin, Germany; St Bartholomew's Hospital and Barts Heart Centre, Department of Perioperative Medicine, London, United Kingdom
| | - Sascha Christoph Ott
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Deutsches Herzzentrum der Charité (DHZC), Department of Cardiac Anesthesiology and Intensive Care Medicine, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Evgenij Potapov
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Felix Schoenrath
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Alexander Meyer
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Charité-Universitätsmedizin Berlin, Institute of Medical Informatics, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany
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Huang J, Gao X, Wang M, Yang Z, Xiang L, Li Y, Yi B, Gu J, Wen J, Lu K, Zhao H, Ma D, Chen L, Ning J. Prophylactic Administration with Methylene Blue Improves Hemodynamic Stabilization During Obstructive Jaundice-Related Diseases' Operation: a Blinded Randomized Controlled Trial. J Gastrointest Surg 2023; 27:1837-1845. [PMID: 37101089 PMCID: PMC10511601 DOI: 10.1007/s11605-022-05499-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 10/21/2022] [Indexed: 04/28/2023]
Abstract
OBJECTIVES Patients with obstruction jaundice are at a high risk of hypotension and need high volume of fluids and a high dose of catecholamine to maintain organ perfusion during operation procedure. All these likely contribute to high perioperative morbidity and mortality. The aim of the study is to evaluate the effects of methylene blue on the hemodynamics in patients undergoing surgeries associated with obstructive jaundice. DESIGN A prospective, randomized, and controlled clinical study. SETTING The enrolled patients randomly received 2 mg/kg of methylene blue in saline or saline (50 ml) before anesthesia induction. The primary outcome was the frequency and dose of noradrenaline administration to maintain mean arterial blood pressure over 65 mmHg or > 80% of baseline, and systemic vascular resistance (SVR) over 800 dyne/s/cm5 during operation. The secondary outcomes were liver and kidney functions, and ICU stay. PATIENTS Seventy patients were enrolled in the study and randomly assigned to receive either methylene blue or control (n = 35/group). RESULTS Fewer patients received noradrenaline in the methylene blue group when compared with the control group (13/35 vs 23/35, P = 0.017), and the noradrenaline dose administrated during operation was reduced in the methylene blue group when compared with the control group (0.32 ± 0.57 mg vs 1.787 ± 3.51 mg, P = 0.018). The blood level of creatinine, glutamic oxalacetic transaminase, and glutamic-pyruvic transaminase after the operation was reduced in the methylene blue group when compared with the control group. CONCLUSIONS Prophylactic administration of methylene blue before operation associated with obstructive jaundice improves hemodynamic stability and short-term prognosis. QUESTION Methylene blue use prevented refractory hypotension during cardiac surgery, sepsis, or anaphylactic shock. It is still unknown that methylene blue on the vascular hypo-tone associated with obstructive jaundice. FINDINGS Prophylactic administration with methylene blue improved peri-operative hemodynamic stability, and hepatic and kidney function on the patients with obstructive jaundice. MEANINGS Methylene blue is a promising and recommended drug for the patients undergoing the surgeries of relief obstructive jaundice during peri-operation management.
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Affiliation(s)
- Jian Huang
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Road, Chongqing, 400038 China
| | - Xian Gao
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Road, Chongqing, 400038 China
| | - Moran Wang
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Road, Chongqing, 400038 China
| | - Zhen Yang
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Road, Chongqing, 400038 China
| | - Lunli Xiang
- Department of Nephrology, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Road, Chongqing, 400038 China
| | - Yongshuai Li
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Road, Chongqing, 400038 China
| | - Bin Yi
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Road, Chongqing, 400038 China
| | - Jianteng Gu
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Road, Chongqing, 400038 China
| | - Jing Wen
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Road, Chongqing, 400038 China
| | - Kaizhi Lu
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Road, Chongqing, 400038 China
| | - Hongwen Zhao
- Department of Nephrology, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Road, Chongqing, 400038 China
| | - Daqing Ma
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW109NH UK
| | - Li Chen
- Breast Disease Center, Southwest Hospital, Third Military Medical University, Chongqing, 400038 China
| | - Jiaolin Ning
- Department of Anesthesiology, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Road, Chongqing, 400038 China
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Gökdemir BN, Çekmen N. Vasoplegic Syndrome and Anaesthesia: A Narrative Review. Turk J Anaesthesiol Reanim 2023; 51:280-289. [PMID: 37587654 PMCID: PMC10440482 DOI: 10.4274/tjar.2023.221093] [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: 10/06/2022] [Accepted: 02/23/2023] [Indexed: 08/18/2023] Open
Abstract
Vasoplegic syndrome (VS) is defined as low systemic vascular resistance, normal or high cardiac output, and resistant hypotension unresponsive to vasopressor agents and intravenous volume. VS is a frequently encountered complication in cardiovascular and transplantation surgery, burns, trauma, pancreatitis, and sepsis. The basis of the pathophysiology is associated with an imbalance of vasodilator and vasoconstrictive structure in vascular smooth muscle cells and is highly complex. The pathogenesis of VS has several mechanisms, including overproduction of iNO, stimulation of ATP-dependent K+ channels and NF-κB, and vasopressin receptor 1A (V1A-receptor) down-regulation. Available treatments involve volume and inotropes administration, vasopressin, methylene blue, hydroxocobalamin, Ca++, vitamin C, and thiamine, and should also restore vascular tone and improve vasoplegia. Other treatments could include angiotensin II, corticosteroids, NF-κB inhibitor, ATP-dependent K+ channel blocker, indigo carmine, and hyperbaric oxygen therapy. Despite modern advances in treatment, the mortality rate is still 30-50%. It is challenging for an anaesthesiologist to consider this syndrome's diagnosis and manage its treatment. Our review aims to review the diagnosis, predisposing factors, pathophysiology, treatment, and anaesthesia approach of VS during anaesthesia and to suggest a treatment algorithm.
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Affiliation(s)
- Begüm Nemika Gökdemir
- Department of Anaesthesiology and Reanimation, Başkent University Faculty of Medicine, Ankara, Turkey
| | - Nedim Çekmen
- Department of Anaesthesiology and Reanimation, Başkent University Faculty of Medicine, Ankara, Turkey
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Ibarra-Estrada M, Kattan E, Aguilera-González P, Sandoval-Plascencia L, Rico-Jauregui U, Gómez-Partida CA, Ortiz-Macías IX, López-Pulgarín JA, Chávez-Peña Q, Mijangos-Méndez JC, Aguirre-Avalos G, Hernández G. Early adjunctive methylene blue in patients with septic shock: a randomized controlled trial. Crit Care 2023; 27:110. [PMID: 36915146 PMCID: PMC10010212 DOI: 10.1186/s13054-023-04397-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/07/2023] [Indexed: 03/14/2023] Open
Abstract
PURPOSE Methylene blue (MB) has been tested as a rescue therapy for patients with refractory septic shock. However, there is a lack of evidence on MB as an adjuvant therapy, its' optimal timing, dosing and safety profile. We aimed to assess whether early adjunctive MB can reduce time to vasopressor discontinuation in patients with septic shock. METHODS In this single-center randomized controlled trial, we assigned patients with septic shock according to Sepsis-3 criteria to MB or placebo. Primary outcome was time to vasopressor discontinuation at 28 days. Secondary outcomes included vasopressor-free days at 28 days, days on mechanical ventilator, length of stay in ICU and hospital, and mortality at 28 days. RESULTS Among 91 randomized patients, forty-five were assigned to MB and 46 to placebo. The MB group had a shorter time to vasopressor discontinuation (69 h [IQR 59-83] vs 94 h [IQR 74-141]; p < 0.001), one more day of vasopressor-free days at day 28 (p = 0.008), a shorter ICU length of stay by 1.5 days (p = 0.039) and shorter hospital length of stay by 2.7 days (p = 0.027) compared to patients in the control group. Days on mechanical ventilator and mortality were similar. There were no serious adverse effects related to MB administration. CONCLUSION In patients with septic shock, MB initiated within 24 h reduced time to vasopressor discontinuation and increased vasopressor-free days at 28 days. It also reduced length of stay in ICU and hospital without adverse effects. Our study supports further research regarding MB in larger randomized clinical trials. Trial registration ClinicalTrials.gov registration number NCT04446871 , June 25, 2020, retrospectively registered.
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Affiliation(s)
- Miguel Ibarra-Estrada
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Universidad de Guadalajara, Coronel Calderón 777, El Retiro, Guadalajara, Jalisco, Mexico.
- Instituto Jalisciense de Cancerología, Guadalajara, Jalisco, Mexico.
- The Latin American Intensive Care Network (LIVEN), Guadalajara, Mexico.
| | - Eduardo Kattan
- The Latin American Intensive Care Network (LIVEN), Guadalajara, Mexico
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | | | - Uriel Rico-Jauregui
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Universidad de Guadalajara, Coronel Calderón 777, El Retiro, Guadalajara, Jalisco, Mexico
| | - Carlos A Gómez-Partida
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Universidad de Guadalajara, Coronel Calderón 777, El Retiro, Guadalajara, Jalisco, Mexico
| | - Iris X Ortiz-Macías
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Universidad de Guadalajara, Coronel Calderón 777, El Retiro, Guadalajara, Jalisco, Mexico
| | - José A López-Pulgarín
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Universidad de Guadalajara, Coronel Calderón 777, El Retiro, Guadalajara, Jalisco, Mexico
| | - Quetzalcóatl Chávez-Peña
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Universidad de Guadalajara, Coronel Calderón 777, El Retiro, Guadalajara, Jalisco, Mexico
| | - Julio C Mijangos-Méndez
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Universidad de Guadalajara, Coronel Calderón 777, El Retiro, Guadalajara, Jalisco, Mexico
| | - Guadalupe Aguirre-Avalos
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Universidad de Guadalajara, Coronel Calderón 777, El Retiro, Guadalajara, Jalisco, Mexico
| | - Glenn Hernández
- The Latin American Intensive Care Network (LIVEN), Guadalajara, Mexico
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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11
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Qin TX, Yao YT. Vasoplegic syndrome in patients undergoing heart transplantation. Front Surg 2023; 10:1114438. [PMID: 36860952 PMCID: PMC9968842 DOI: 10.3389/fsurg.2023.1114438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 01/11/2023] [Indexed: 02/16/2023] Open
Abstract
Objectives To summarize the risk factors, onset time, and treatment of vasoplegic syndrome in patients undergoing heart transplantation. Methods The PubMed, OVID, CNKI, VIP, and WANFANG databases were searched using the terms "vasoplegic syndrome," "vasoplegia," "vasodilatory shock," and "heart transplant*," to identify eligible studies. Data on patient characteristics, vasoplegic syndrome manifestation, perioperative management, and clinical outcomes were extracted and analyzed. Results Nine studies enrolling 12 patients (aged from 7 to 69 years) were included. Nine (75%) patients had nonischemic cardiomyopathy, and three (25%) patients had ischemic cardiomyopathy. The onset time of vasoplegic syndrome varied from intraoperatively to 2 weeks postoperatively. Nine (75%) patients developed various complications. All patients were insensitive to vasoactive agents. Conclusions Vasoplegic syndrome can occur at any time during the perioperative period of heart tranplantation, especially after the discontinuation of bypass. Methylene blue, angiotensin II, ascorbic acid, and hydroxocobalamin have been used to treat refractory vasoplegic syndrome.
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Affiliation(s)
- Tong-xin Qin
- Department of Anesthesiology, Shanxian Central Hospital, Heze, China
| | - Yun-tai Yao
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China,Correspondence: Qin T-x, Yao Y-t
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12
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Zhao L, Jian T, Shi L, Li Y, Wen Z, Guo L, Li Q, Jian X. Case report: Methemoglobinemia caused by nitrobenzene poisoning. Front Med (Lausanne) 2023; 10:1096644. [PMID: 36895721 PMCID: PMC9988939 DOI: 10.3389/fmed.2023.1096644] [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: 11/26/2022] [Accepted: 02/06/2023] [Indexed: 02/25/2023] Open
Abstract
Nitrobenzene poisoning is uncommon, with most cases occurring in the dye, paint, and other chemical industries. Nitrobenzene enters the body mainly through the skin, respiratory tract, and oral cavity. Nitrobenzene poisoning symptoms include hypermethemoglobinemia, hemolytic anemia, liver and kidney dysfunction, cardiogenic pulmonary edema, and toxic encephalopathy, which endanger people's lives. Therefore, we present a case of nitrobenzene poisoning caused by skin absorption, focusing on its clinical characteristics and treatment outcomes. A 58 years-old man presented to our department with confusion and cyanosis. He has a history of hypertension and cerebral infarction. The patient was diagnosed with moderate occupational acute benzene poisoning with nitro compounds. Symptomatic support, methylene blue, and other antioxidant treatments were commenced after diagnosis. After treatment, the patient's condition gradually improved, and he was discharged.
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Affiliation(s)
- Liwen Zhao
- Department of Occupational and Environmental Health, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Poisoning and Occupational Diseases, Emergency Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Tianzi Jian
- Department of Poisoning and Occupational Diseases, Emergency Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Longke Shi
- Department of Occupational and Environmental Health, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Poisoning and Occupational Diseases, Emergency Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Yaqian Li
- Department of Poisoning and Occupational Diseases, Emergency Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Zixin Wen
- Department of Poisoning and Occupational Diseases, Emergency Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, Jinan, Shandong China.,Nursing Theory and Practice Innovation Research Center, Shandong University, Jinan, Shandong, China.,Department of Nursing, Qilu Hospital of Shandong University, Jinan, Shandong China
| | - Lanlan Guo
- Department of Occupational and Environmental Health, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Poisoning and Occupational Diseases, Emergency Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Qilu Li
- The Hospital of Shandong University, Jinan, Shandong, China
| | - Xiangdong Jian
- Department of Occupational and Environmental Health, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Poisoning and Occupational Diseases, Emergency Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
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13
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Hwang NC, Sivathasan C. Review of Postoperative Care for Heart Transplant Recipients. J Cardiothorac Vasc Anesth 2023; 37:112-126. [PMID: 36323595 DOI: 10.1053/j.jvca.2022.09.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 09/10/2022] [Accepted: 09/14/2022] [Indexed: 11/11/2022]
Abstract
The early postoperative management strategies after heart transplantation include optimizing the function of the denervated heart, correcting the causes of hemodynamic instability, and initiating and maintaining immunosuppressive therapy, allograft rejection surveillance, and prophylaxis against infections caused by immunosuppression. The course of postoperative support is influenced by the quality of allograft myocardial protection prior to implantation and reperfusion, donor-recipient heart size matching, surgical technique of orthotopic heart transplantation, and patient factors (eg, preoperative condition, immunologic compatibility, postoperative vasomotor tone, severity and reversibility of pulmonary vascular hypertension, pulmonary function, mediastinal blood loss, and end-organ perfusion). This review provides an overview of the early postoperative care of recipients and includes a brief description of the surgical techniques for orthotopic heart transplantation.
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Affiliation(s)
- Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anesthesia, National Heart Centre, Singapore.
| | - Cumaraswamy Sivathasan
- Mechanical Cardiac Support and Heart Transplant Program, Department of Cardiothoracic Surgery, National Heart Centre, Singapore
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14
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Brennan KA, Bhutiani M, Kingeter MA, McEvoy MD. Updates in the Management of Perioperative Vasoplegic Syndrome. Adv Anesth 2022; 40:71-92. [PMID: 36333053 DOI: 10.1016/j.aan.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Vasoplegic syndrome occurs relatively frequently in cardiac surgery, liver transplant, major noncardiac surgery, in post-return of spontaneous circulation situations, and in pateints with sepsis. It is paramount for the anesthesiologist to understand both the pathophysiology of vasoplegia and the different treatment strategies available for rescuing a patient from life-threatening hypotension.
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Affiliation(s)
- Kaitlyn A Brennan
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, MAB 422, Nashville, TN 37212, USA
| | - Monica Bhutiani
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, VUH 4107, Nashville, TN 37212, USA
| | - Meredith A Kingeter
- Anesthesia Residency, Vanderbilt University Medical Center, 1215 21st Avenue South, Suite 5160 MCE NT, Nashville, TN 37212, USA
| | - Matthew D McEvoy
- VUMC Enhanced Recovery Programs, Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN 37232, USA.
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15
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Ballard HA, Jones E, Malavazzi Clemente MM, Damian D, Kovatsis PG. Educational Review: Error traps in anesthesia for pediatric liver transplantation. Paediatr Anaesth 2022; 32:1285-1291. [PMID: 36178188 PMCID: PMC9827908 DOI: 10.1111/pan.14565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/24/2022] [Accepted: 09/27/2022] [Indexed: 01/12/2023]
Abstract
Anesthetic and surgical techniques for the liver transplantation have progressed considerably over the past sixty years; however, this procedure is still fraught with substantial morbidity. To increase the safety culture associated with the liver transplantation, we detail nine error traps associated with anesthesia for pediatric liver transplantation. These potential pitfalls are divided into the operative phases: pre-operative preparation (Failure to have a dedicated anesthesia team for pediatric liver transplantation); pre-anhepatic (Failure to prepare for massive blood loss, Failure to monitor for coagulation abnormalities); anhepatic including reperfusion (Failure to prepare for clamping of the inferior vena cava, Failure to recognize metabolic changes, Failure to maintain homeostasis for reperfusion, Failure to prepare for Post-reperfusion syndrome); and post-anhepatic (Failure to optimize liver perfusion, Failure to maintain hemostatic balance). By offering practical advice on the preparation and treatment of these error traps, we aim to better prepare anesthesiologists to take care of pediatric patients undergoing the liver transplantation.
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Affiliation(s)
- Heather A. Ballard
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of ChicagoNorthwestern University Feinberg School of MedicineChicagoILUSA
| | - Elin Jones
- Department of AnaesthesiaBirmingham Children's HospitalBirminghamUK
| | | | - Daniela Damian
- Department of AnesthesiologyUPMC Children's Hospital of Pittsburgh and University of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Pete G. Kovatsis
- Department of Anesthesiology, Critical Care and Pain MedicineBoston Children's Hospital and Department of Anaesthesia, Harvard Medical SchoolBostonMassachusettsUSA
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16
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Naoum EE, Dalia AA, Roberts RJ, Devine LT, Ortoleva J. Methylene blue for vasodilatory shock in the intensive care unit: a retrospective, observational study. BMC Anesthesiol 2022; 22:199. [PMID: 35761204 PMCID: PMC9235079 DOI: 10.1186/s12871-022-01739-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/20/2022] [Indexed: 01/26/2023] Open
Abstract
Abstract
Background
Refractory vasodilatory shock is a state of uncontrolled vasodilation associated with underlying inflammation and endothelial dysregulation. Rescue therapy for vasoplegia refractory to catecholamines includes methylene blue (MB) which restores vascular tone. We hypothesized that (1) at least 40% of critically ill patients would respond positively to MB administration and (2) that those who responded to MB would have a survival benefit.
Methods
This study was a retrospective review that included all adult patients admitted to an intensive care unit treated with MB for the indication of refractory vasodilatory shock. Responders to MB were identified as those with a ≥ 10% increase in mean arterial pressure (MAP) within the first 1-2 hours after administration. We examined the association of mortality to the groups of responders versus non-responders to MB. A subgroup analysis in patients undergoing continuous renal replacement therapy (CRRT) was also performed.
Statistical calculations were performed in Microsoft Excel® (Redmond, WA, USA). Where appropriate, the comparison of averages and standard deviations of demographics, dosing, MAP, and reductions in vasopressor dosing were performed via Chi squared, Fisher's exact test, or two-tailed t-test with a p-value < 0.05 being considered as statistically significant. After using the F-test to assess for differences in variance, the proper two tailed t-test was used to compare SOFA scores among responders versus non-responders.
Results
A total of 223 patients were included in the responder analysis; 88 (39.5%) had a ≥ 10% increase in MAP post-MB administration that was not associated with a significant change in norepinephrine requirements between responders versus non-responders (p=0.41). There was a non-statistically significant trend (21.6% vs 14.8%, p=0.19) toward improved survival to hospital discharge in the MB responder group compared to the non-responder group. In 70 patients undergoing CRRT, there were 33 responders who were more likely to survive than those who were not (p = 0.0111).
Conclusions
In patients with refractory shock receiving MB, there is a non-statistically significant trend toward improved outcomes in responders based on a MAP increase >10%. Patients supported with CRRT who were identified as responders had decreased ICU mortality compared to non-responders.
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17
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Burgunder L, Heyrend C, Olson J, Stidham C, Lane RD, Workman JK, Larsen GY. Medication and Fluid Management of Pediatric Sepsis and Septic Shock. Paediatr Drugs 2022; 24:193-205. [PMID: 35307800 DOI: 10.1007/s40272-022-00497-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 01/02/2023]
Abstract
Sepsis is a life-threatening response to infection that contributes significantly to neonatal and pediatric morbidity and mortality worldwide. The key tenets of care include early recognition of potential sepsis, rapid intervention with appropriate fluids to restore adequate tissue perfusion, and empiric antibiotics to cover likely pathogens. Vasoactive/inotropic agents are recommended if tissue perfusion and hemodynamics are inadequate following initial fluid resuscitation. Several adjunctive therapies have been suggested with theoretical benefit, though definitive recommendations are not yet supported by research reports. This review focuses on the recommendations for medication and fluid management of pediatric sepsis and septic shock, highlighting issues related to antibiotic choices and antimicrobial stewardship, selection of intravenous fluids for resuscitation, and selection and use of vasoactive/inotropic medications. Controversy remains regarding resuscitation fluid volume and type, antibiotic choices depending upon infectious risks in the patient's community, and adjunctive therapies such as vitamin C, corticosteroids, intravenous immunoglobulin, and methylene blue. We include best practice recommendations based on international guidelines, a review of primary literature, and a discussion of ongoing clinical trials and the nuances of therapeutic choices.
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Affiliation(s)
- Lauren Burgunder
- Division of Pediatric Critical Care, Department of Pediatrics, Primary Children's Hospital, University of Utah, 100 North Mario Capecchi Drive, Salt Lake City, UT, 84113, USA
| | - Caroline Heyrend
- Division of Primary Children's Hospital Pharmacy, Salt Lake City, UT, USA
| | - Jared Olson
- Division of Primary Children's Hospital Pharmacy, Salt Lake City, UT, USA.,Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Chanelle Stidham
- Division of Primary Children's Hospital Pharmacy, Salt Lake City, UT, USA
| | - Roni D Lane
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Jennifer K Workman
- Division of Pediatric Critical Care, Department of Pediatrics, Primary Children's Hospital, University of Utah, 100 North Mario Capecchi Drive, Salt Lake City, UT, 84113, USA
| | - Gitte Y Larsen
- Division of Pediatric Critical Care, Department of Pediatrics, Primary Children's Hospital, University of Utah, 100 North Mario Capecchi Drive, Salt Lake City, UT, 84113, USA.
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18
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Pequignot B, Lescroart M, Orlowski S, Reynette N, Martini B, Albuisson E, Pina H, Tran N, Grandmougin D, Levy B. Methylene Blue Reduces Fluid Loading and Norepinephrine Requirements for Post-Resuscitation Syndrome in a Pig Model of Refractory Cardiac Arrest Resuscitated with Veno-Arterial ECMO. J Clin Med 2022; 11:2515. [PMID: 35566640 PMCID: PMC9100142 DOI: 10.3390/jcm11092515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 04/21/2022] [Accepted: 04/26/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Refractory cardiac arrest management relies on extracorporeal cardiopulmonary resuscitation (ECPR), requiring the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Circulatory flow recovery can be associated with an ischemia-reperfusion injury, leading to vasoplegia and vasopressor requirement. The aim of this work was to evaluate the impact on hemodynamics of a methylene blue bolus infusion in a porcine model of ischemic refractory cardiac arrest. METHODS Ischemic refractory cardiac arrest was induced in 20 pigs. After a low flow period of 30 min, VA-ECMO was initiated and the pigs were randomly assigned to the standard care group (norepinephrine + crystalloids) or methylene blue group (IV 2 mg·kg-1 bolus of methylene blue over 30 min + norepinephrine and crystalloids). Macrocirculatory parameters and lactate clearance were measured. Sublingual microcirculation was evaluated with sidestream dark field (SDF) imaging. The severity of the ischemic digestive lesions was assessed according to the histologic Chiu/Park scale. RESULTS Eighteen pigs were included. The total crystalloid load (5000 (6000-8000) mL vs. 17,000 (10,000-19,000) mL, p = 0.007, methylene blue vs. standard care group) and catecholamine requirements (0.31 (0.14-0.44) μg·kg-1·min-1 vs. 2.32 (1.17-5.55) μg·kg-1·min-1, methylene blue vs. standard care group, p = 0.004) were significantly reduced in the methylene blue group. There were no significant between-group differences in lactate clearance, sublingual capillary microvascular parameters assessed by SDF or histologic Chiu/Park scale. CONCLUSIONS In our refractory cardiac arrest porcine model treated with ECPR, methylene blue markedly reduced fluid loading and norepinephrine requirements in comparison to standard care during the first 6 h of VA-ECMO.
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Affiliation(s)
- Benjamin Pequignot
- Service de Medecine Intensive et Réanimation, Hôpital Brabois, CHRU Nancy, 54500 Vandoeuvre les Nancy, France; (B.P.); (M.L.)
- INSERM U 1116, Equipe 2, Groupe Choc, Faculté de Médecine, 54500 Vandoeuvre les Nancy, France; (S.O.); (D.G.)
- Faculté de Médecine, Université de Lorraine, 54000 Nancy, France; (E.A.); (N.T.)
| | - Mickael Lescroart
- Service de Medecine Intensive et Réanimation, Hôpital Brabois, CHRU Nancy, 54500 Vandoeuvre les Nancy, France; (B.P.); (M.L.)
- INSERM U 1116, Equipe 2, Groupe Choc, Faculté de Médecine, 54500 Vandoeuvre les Nancy, France; (S.O.); (D.G.)
- Faculté de Médecine, Université de Lorraine, 54000 Nancy, France; (E.A.); (N.T.)
| | - Sophie Orlowski
- INSERM U 1116, Equipe 2, Groupe Choc, Faculté de Médecine, 54500 Vandoeuvre les Nancy, France; (S.O.); (D.G.)
- Faculté de Médecine, Université de Lorraine, 54000 Nancy, France; (E.A.); (N.T.)
- Service de Biochimie, Pôle Laboratoires Hôpital Central, CHRU de Nancy, 54000 Nancy, France
| | - Nathan Reynette
- Ecole de Chirurgie, Faculté de Médecine, Université de Lorraine, 54000 Nancy, France; (N.R.); (B.M.)
| | - Bana Martini
- Ecole de Chirurgie, Faculté de Médecine, Université de Lorraine, 54000 Nancy, France; (N.R.); (B.M.)
| | - Eliane Albuisson
- Faculté de Médecine, Université de Lorraine, 54000 Nancy, France; (E.A.); (N.T.)
- Plateforme d’Aide à la Recherche Clinique (PARC), ESPRI-Biobase, Hôpital de Brabois, CHRU de Nancy, 54500 Vandoeuvre les Nancy, France
| | - Héloise Pina
- Département d’Anatomie Pathologique, Laboratoires de Biologie Médicale et de Biopatholgie, Hôpital Brabois, CHRU de Nancy, 54500 Vandoeuvre les Nancy, France;
| | - N’Guyen Tran
- Faculté de Médecine, Université de Lorraine, 54000 Nancy, France; (E.A.); (N.T.)
- Ecole de Chirurgie, Faculté de Médecine, Université de Lorraine, 54000 Nancy, France; (N.R.); (B.M.)
| | - Daniel Grandmougin
- INSERM U 1116, Equipe 2, Groupe Choc, Faculté de Médecine, 54500 Vandoeuvre les Nancy, France; (S.O.); (D.G.)
- Faculté de Médecine, Université de Lorraine, 54000 Nancy, France; (E.A.); (N.T.)
- Service de Chirurgie Cardiaque, Hôpital Brabois, CHRU Nancy, 54500 Vandoeuvre les Nancy, France
| | - Bruno Levy
- Service de Medecine Intensive et Réanimation, Hôpital Brabois, CHRU Nancy, 54500 Vandoeuvre les Nancy, France; (B.P.); (M.L.)
- INSERM U 1116, Equipe 2, Groupe Choc, Faculté de Médecine, 54500 Vandoeuvre les Nancy, France; (S.O.); (D.G.)
- Faculté de Médecine, Université de Lorraine, 54000 Nancy, France; (E.A.); (N.T.)
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19
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Ahmed F, Gulzar T, Kiran S, Ahmad I, Fatima A, Yasir S, Alhajaim WF, Khalil A, Ul-Islam M, Bakhsh EM, Kamal T. Nickel oxide and carboxymethyl cellulose composite beads as catalyst for the pollutant degradation. APPLIED NANOSCIENCE 2022. [DOI: 10.1007/s13204-022-02345-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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20
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Maurin C, Portran P, Schweizer R, Allaouchiche B, Junot S, Jacquet-Lagrèze M, Fellahi JL. Effects of methylene blue on microcirculatory alterations following cardiac surgery: A prospective cohort study. Eur J Anaesthesiol 2022; 39:333-341. [PMID: 34610607 DOI: 10.1097/eja.0000000000001611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Methylene blue is used as rescue therapy to treat catecholamine-refractory vasoplegic syndrome after cardiac surgery. However, its microcirculatory effects remain poorly documented. OBJECTIVE We aimed to study microcirculatory abnormalities in refractory vasoplegic syndrome following cardiac surgery with cardiopulmonary bypass and assess the effects of methylene blue. DESIGN A prospective open-label cohort study. SETTING 20-Bed ICU of a tertiary care hospital. PATIENTS 25 Adult patients receiving 1.5 mg kg-1 of methylene blue intravenously for refractory vasoplegic syndrome (defined as norepinephrine requirement more than 0.5 μg kg-1 min-1) to maintain mean arterial pressure (MAP) more than 65 mmHg and cardiac index (CI) more than 2.0 l min-1 m-2. MAIN OUTCOME MEASURES Complete haemodynamic set of measurements at baseline and 1 h after the administration of methylene blue. Sublingual microcirculation was investigated by sidestream dark field imaging to obtain microvascular flow index (MFI), total vessel density, perfused vessel density and heterogeneity index. Microvascular reactivity was assessed by peripheral near-infrared (IR) spectroscopy combined with a vascular occlusion test. We also performed a standardised measurement of capillary refill time. RESULTS Despite normalised CI (2.6 [2.0 to 3.8] l min-1 m-2) and MAP (66 [55 to 76] mmHg), patients with refractory vasoplegic syndrome showed severe microcirculatory alterations (MFI < 2.6). After methylene blue infusion, MFI significantly increased from 2.0 [0.1 to 2.5] to 2.2 [0.2 to 2.8] (P = 0.008), as did total vessel density from 13.5 [8.3 to 18.5] to 14.9 [10.1 to 14.7] mm mm-2 (P = 0.02) and perfused vessel density density from 7.4 [0.1 to 11.5] to 9.1 [0 to 20.1] mm mm-2 (P = 0.02), but with wide individual variation. Microvascular reactivity assessed by tissue oxygen resaturation speed also increased from 0.5 [0.1 to 1.8] to 0.7 [0.1 to 2.7]% s-1 (P = 0.002). Capillary refill time remained unchanged throughout the study. CONCLUSION In refractory vasoplegic syndrome following cardiac surgery, we found microcirculatory alterations despite normalised CI and MAP. The administration of methylene blue could improve microvascular perfusion and reactivity, and partially restore the loss of haemodynamic coherence. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04250389.
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Affiliation(s)
- Carole Maurin
- From the Service d'Anesthésie Réanimation, Hôpital Cardiovasculaire et Pneumologique Louis Pradel (CM, PP, RS, MJ-L, J-LF), Service d'Anesthésie-Réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon (BA), APCSe, Université de Lyon, VetAgro Sup - Campus Vétérinaire de Lyon (SJ) and Laboratoire CarMeN, Inserm U1060, Université Claude Bernard Lyon 1, Campus Lyon Santé Est, Lyon, France (MJ-L, J-LF)
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21
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Ives Tallman C, Zhang Y, Black N, Lynch K, Fayed M, Armenian P. Refractory vasodilatory shock secondary to metformin overdose supported with VA ECMO. Toxicol Rep 2022; 9:64-67. [PMID: 35004183 PMCID: PMC8718576 DOI: 10.1016/j.toxrep.2021.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 12/14/2021] [Accepted: 12/18/2021] [Indexed: 01/27/2023] Open
Abstract
Metformin overdose can lead to vasodilatory shock refractory to medical management. Extracorporeal circulatory support with venoarterial ECMO is an effective way to manage profound shock associated with metformin overdose. We report the highest recorded serum metformin level in the literature to date.
Metformin overdose may result in vasodilatory shock, lactic acidosis and death. Hemodialysis is an effective means of extracorporeal elimination, but may be insufficient in the shock setting. We present a case of a 39 yo male who presented with hypotension, coma, hypoglycemia, and lactate of 6.5 mmol/L after ingesting an unknown medication. Metformin overdose was suspected, and he was started on hemodialysis. He developed profound vasoplegia refractory to high doses of norepinephrine, vasopressin, epinephrine and phenylephrine. Venoarterial extracorporeal membrane oxygenation (VA ECMO) was initiated and he had full recovery. Serum analysis with high resolution liquid chromatography mass spectrometry revealed a metformin level of 678 μg/mL and trazodone level of 2.1 μg/mL. This case is one of only a handful of reported cases of metformin overdose requiring ECMO support, and we report the highest serum metformin levels in the literature to date. We recommend early aggressive hemodialysis and vasopressor support in all suspected cases of metformin toxicity as well as VA ECMO if refractory to these therapies. Objective We present a case of vasodilatory shock secondary to metformin overdose requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) support. This case is one of only a handful of reported cases of metformin overdose requiring ECMO support, and we report the highest serum metformin levels in the literature to date. Data sources University of San Francisco, Fresno. Study design Case report. Data extraction Clinical records and high resolution liquid chromatography mass spectroscopy analysis. Data synthesis None. Conclusions Venoarterial ECMO provided an effective means of hemodynamic support for a patient with severe metformin toxicity.
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Affiliation(s)
- Crystal Ives Tallman
- UCSF Fresno Department of Emergency Medicine, United States.,UCSF Fresno Department of Medicine, Pulmonary Critical Care Division, United States
| | - Yu Zhang
- UCSF Department of Laboratory Medicine, Division of Clinical Chemistry, San Francisco, CA, United States
| | - Nicholas Black
- UCSF Fresno Department of Emergency Medicine, United States
| | - Kara Lynch
- UCSF Department of Laboratory Medicine, Division of Clinical Chemistry, San Francisco, CA, United States
| | - Mohamed Fayed
- UCSF Fresno Department of Medicine, Pulmonary Critical Care Division, United States
| | - Patil Armenian
- UCSF Fresno Department of Emergency Medicine, United States
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22
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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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23
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Petermichl W, Gruber M, Schoeller I, Allouch K, Graf BM, Zausig YA. The additional use of methylene blue has a decatecholaminisation effect on cardiac vasoplegic syndrome after cardiac surgery. J Cardiothorac Surg 2021; 16:205. [PMID: 34321019 PMCID: PMC8320154 DOI: 10.1186/s13019-021-01579-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 07/09/2021] [Indexed: 11/10/2022] Open
Abstract
Background Postoperative vasoplegia with minimal responsiveness to vasopressors is common after cardiac surgery. Called cardiac vasoplegic syndrome (CVS), it is caused by multiple factors. Treating CVS involves a high dose of fluids and catecholamines, however high doses of catecholamines and fluids are associated with serious side effects. There is evidence that new therapeutic strategies can lead to a reduction in norepinephrine doses and mortality in CVS. Specifically, the use of non-adrenergic vasopressors such as methylene blue (MB) can be beneficial. Methods We retrospectively analyzed the electronic records of 8716 adult cardiac surgery patients from November 2008 to December 2016. Medication, hemodynamic and outcome parameter data were analyzed for CVS until discharge. We determined CVS according to the following parameters: a postoperative onset of ≤24 h, a reduced mean arterial pressure (MAP) of < 70 mmHg, a dose of norepinephrine ≥0.8 mg*h− 1 and a continuously increasing need for catecholamine, without ventricular dysfunction. Results We identified 513 patients with CVS. Perioperative risk factors were higher in patients treated with methylene blue (MB). Before MB administration patients had a significantly higher dose of norepinephrine, and MAP increased after MB administration. Norepinephrine could be reduced after MB administration and MAP remained stable at the same level even after the reduction of norepinephrine. Conclusions CVS patients have a severe systemic disease accompanied by significant operative stress and a high catecholamine requirement. The administration of MB in addition to standard treatment for CVS in the first 24 h was accompanied by an increase in MAP followed by a decrease in vasopressor requirement, indicating that early MB administration can be beneficial.
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Affiliation(s)
- Walter Petermichl
- Department of Anesthesiology, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
| | - Michael Gruber
- Department of Anesthesiology, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Ina Schoeller
- Department of Anesthesiology, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Kwahle Allouch
- Department of Anesthesiology, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Bernhard M Graf
- Department of Anesthesiology, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - York A Zausig
- Department of Anesthesiology, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.,Department of Anesthesiology, Aschaffenburg-Alzenau Hospital, Am Hasenkopf 1, 63739, Aschaffenburg, Germany
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24
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Belcher RM, Oldham C, Rapier AM, Gutteridge D. Hydroxocobalamin and extracorporeal membrane oxygenation (ECMO) for severe refractory shock in bupropion and citalopram overdose: a case report. TOXICOLOGY COMMUNICATIONS 2021. [DOI: 10.1080/24734306.2021.1949518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Rachel M. Belcher
- Department of Pharmacy, Intermountain Medical Center, Murray, UT, USA
| | - Crosby Oldham
- Department of Pharmacy, Intermountain Medical Center, Murray, UT, USA
| | - A. Marie Rapier
- Department of Pharmacy, Intermountain Medical Center, Murray, UT, USA
| | - Daniel Gutteridge
- Division of Pulmonology and Critical Care, Intermountain Medical Center, Murray, UT, USA
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25
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Lambert J, Hayanga JA, Turley S, McCarthy P, Salman M, Kabulski G, Henrickson R, Cook C, Hayanga HK. Successful treatment of intravenous drug abuser with refractory vasoplegic syndrome after mitral valve repair for infective endocarditis. SAGE Open Med Case Rep 2021; 9:2050313X211019788. [PMID: 34158944 PMCID: PMC8182181 DOI: 10.1177/2050313x211019788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 05/02/2021] [Indexed: 11/24/2022] Open
Abstract
Vasoplegic syndrome, a possible complication of cardiopulmonary bypass, is a critical
state of unregulated systemic vasodilation with decreased vascular resistance and a
pathological insensitivity to conventional inotropes and vasoconstrictors. This case
demonstrates the use of methylene blue and hydroxocobalamin as medications in the
treatment of refractory vasoplegic syndrome in the context of cardiac surgery due to their
differences in mechanism of action. A 24-year-old female with history of intravenous drug
abuse and hepatitis C infection underwent mitral valve repair for infective endocarditis.
Preoperative transesophageal echocardiography showed normal right ventricular function,
left ventricular ejection fraction of 65%–75%, and severe mitral regurgitation with
vegetation. In order to maintain a mean arterial pressure over 60 mmHg during
cardiopulmonary bypass, norepinephrine, epinephrine, and vasopressin infusions were
required. Given the patient’s minimal response to these medications, a 1.5 mg/kg bolus of
intravenous methylene blue was also given intraoperatively; vasoplegic syndrome remained
refractory in the post-cardiopulmonary bypass period. A 5 g dose of intravenous
hydroxocobalamin was administered in the intensive care unit postoperatively.
Postoperative liver function tests were abnormal, and post-cardiopulmonary bypass
transesophageal echocardiography revealed mildly decreased right ventricular function.
While in the intensive care unit, the patient was placed on venoarterial extracorporeal
membrane oxygenation and underwent therapeutic plasma exchange. Vasopressors were weaned
over the course of the next 24 h. The patient was able to be transferred out of the
intensive care unit on postoperative day 5. Traditional vasoconstrictors activate signal
transduction pathways that lead to myosin phosphorylation. Vasodilatory molecules such as
nitric oxide (NO) activate the enzyme soluble guanylyl cyclase (sGC), ultimately leading
to the dephosphorylation of myosin. Nitric Oxide Synthase (NOS) can potentially increase
NO levels 1000-fold when activated by inflammatory cytokines. Methylene blue is a direct
inhibitor of NOS. It also binds and inhibits sGC. Hydroxocobalamin is a direct inhibitor
of NO, likely inhibits NOS and may also act through additional mechanisms.
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Affiliation(s)
- Jacob Lambert
- School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Jw Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Steven Turley
- Division of Critical Care, West Virginia University, Morgantown, WV, USA
| | - Paul McCarthy
- Division of Critical Care, West Virginia University, Morgantown, WV, USA
| | - Muhammad Salman
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Galen Kabulski
- Division of Critical Care, West Virginia University, Morgantown, WV, USA
| | - Roy Henrickson
- Division of Cardiovascular and Thoracic Anesthesiology, West Virginia University, Morgantown, WV, USA
| | - Christopher Cook
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Heather K Hayanga
- Division of Cardiovascular and Thoracic Anesthesiology, West Virginia University, Morgantown, WV, USA
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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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27
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Methylene blue induces an analgesic effect by significantly decreasing neural firing rates and improves pain behaviors in rats. Biochem Biophys Res Commun 2021; 541:36-42. [PMID: 33465740 DOI: 10.1016/j.bbrc.2021.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 01/05/2021] [Indexed: 02/03/2023]
Abstract
Methylene blue (MB) is a blue cationic thiazine dye and currently used in different medical settings. Notably, there have been several attempts to introduce MB for attenuating pain in the last decade. Some clinical studies reported remarkable results, which, however, have been much debated. In addition, accumulating evidence have revealed that MB diminishes voltage-gated sodium channel currents. Accordingly, in the present study, we conducted in vivo experiments, including in vivo single nerve recording and behavioral test, to investigate whether MB dampens neural firing rates and ultimately contributes to pain relief. As a result, neural firing rates significantly decreased and finally converged to zero after MB administration. This event lasted longer than that of lidocaine and was dose-dependently modulated. Furthermore, there was a marked improvement in pain behaviors. The withdrawal threshold and latency of hind paws significantly rose post-MB administration. Therefore, these results demonstrate that MB lessens pain by significantly weakening neural excitability, which implies a strong possibility that this dye may be developed as a pain-relieving medication in the future. This is the first in vivo study to elucidate the effect of MB on nerves and pain relief.
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28
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Ortoleva J, Roberts RJ, Devine LT, French A, Kawabori M, Chen F, Shelton K, Dalia AA. Methylene Blue for Vasoplegia During Extracorporeal Membrane Oxygenation Support. J Cardiothorac Vasc Anesth 2020; 35:2694-2699. [PMID: 33455885 DOI: 10.1053/j.jvca.2020.12.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/23/2020] [Accepted: 12/25/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The treatment of refractory vasodilatory shock in patients undergoing extracorporeal membrane oxygenation (ECMO) is an area in which there is minimal literature. Based on previous literature, the authors hypothesized that at least 40% of ECMO patients with vasoplegia would respond positively to methylene blue (MB) administration and that those who responded to MB would have increased survival. DESIGN Retrospective observational study. SETTING Single institution, quaternary care hospital. PARTICIPANTS The study comprised 45 patients who received MB for vasoplegia during ECMO. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 45 patients who received MB, 25 patients (55.6%) experienced a ≥10% increase in mean arterial pressure (MAP) and a reduction in norepinephrine dosing in the one-to-two hour interval after MB administration. There was a trend for improvement in survival to discharge for those who responded to MB (32% v 10%; p = 0.15). In addition, patients who did not have at least a >5% increase in MAP (29 experienced a >5% increase and 16 experienced a ≤5% increase) after MB administration, experienced 100% mortality (p = 0.008). CONCLUSION This study suggested that approximately 50% of ECMO patients with vasoplegia can be expected to respond to MB with a >10% MAP improvement. The lack of a blood pressure response >5% after MB administration may portend poor survival. Larger prospective studies are needed to verify these preliminary results.
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Affiliation(s)
- Jamel Ortoleva
- Department of Critical Care, Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Russel J Roberts
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA
| | - Lauren T Devine
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA
| | - Amy French
- Department of Cardiology, Rhode Island Medical Center, Providence, RI
| | | | - Fredrick Chen
- Department of Cardiac Surgery, Tufts Medical Center, Boston, MA
| | - Kenneth Shelton
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Adam A Dalia
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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29
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Petrova ON, Lamarre I, Fasani F, Grillon C, Negrerie M. Soluble Guanylate Cyclase Inhibitors Discovered among Natural Compounds. JOURNAL OF NATURAL PRODUCTS 2020; 83:3642-3651. [PMID: 33290062 DOI: 10.1021/acs.jnatprod.0c00854] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Soluble guanylate cyclase (sGC) is the human receptor of nitric oxide (NO) in numerous kinds of cells and produces the second messenger 3',5'-cyclic guanosine monophosphate (cGMP) upon NO binding to its heme. sGC is involved in many cell signaling pathways both under healthy conditions and under pathological conditions, such as angiogenesis associated with tumor growth. Addressing the selective inhibition of the NO/cGMP pathway is a strategy worthwhile to be investigated for slowing down tumoral angiogenesis or for curing vasoplegia. However, sGC inhibitors are lacking investigation. We have explored a chemical library of various natural compounds and have discovered inhibitors of sGC. The selected compounds were evaluated for their inhibition of purified sGC in vitro and sGC in endothelial cells. Six natural compounds, from various organisms, have IC50 in the range 0.2-1.5 μM for inhibiting the NO-activated synthesis of cGMP by sGC, and selected compounds exhibit a quantified antiangiogenic activity using an endothelial cell line. These sGC inhibitors can be used directly as tools to investigate angiogenesis and cell signaling or as templates for drug design.
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Affiliation(s)
- Olga N Petrova
- Laboratoire d'Optique et Biosciences, INSERM U1182, Ecole Polytechnique, Palaiseau, France
| | - Isabelle Lamarre
- Laboratoire d'Optique et Biosciences, INSERM U1182, Ecole Polytechnique, Palaiseau, France
| | - Fabienne Fasani
- Centre de Biophysique Moléculaire, UPR4301 CNRS, Orléans, France
| | | | - Michel Negrerie
- Laboratoire d'Optique et Biosciences, INSERM U1182, Ecole Polytechnique, Palaiseau, France
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30
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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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31
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Jentzer JC, Hollenberg SM. Vasopressor and Inotrope Therapy in Cardiac Critical Care. J Intensive Care Med 2020; 36:843-856. [PMID: 32281470 DOI: 10.1177/0885066620917630] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patients admitted to the cardiac intensive care unit (CICU) are often in shock and require hemodynamic support. Identifying and addressing the pathophysiology mechanisms operating in an individual patient is crucial to achieving a successful outcome, while initiating circulatory support therapy to restore adequate tissue perfusion. Vasopressors and inotropes are the cornerstone of supportive medical therapy for shock, in addition to fluid resuscitation when indicated. Timely initiation of optimal vasopressor and inotrope therapy is essential for patients with shock, with the ultimate goals of restoring effective tissue perfusion in order to normalize cellular metabolism. Use of vasoactive agents for hemodynamic support of patients with shock should take both arterial pressure and tissue perfusion into account when choosing therapeutic interventions. For most patients with shock, including cardiogenic or septic shock, norepinephrine (NE) is an appropriate choice as a first-line vasopressor titrated to achieve an adequate arterial pressure due to a lower risk of adverse events than other catecholamine vasopressors. If tissue and organ perfusion remain inadequate, an inotrope such as dobutamine may be added to increase cardiac output to a sufficient level that meets tissue demand. Low doses of epinephrine or dopamine may be used for inotropic support, but high doses of these drugs carry an excessive risk of adverse events when used for vasopressor support and should be avoided. When NE alone is inadequate to achieve an adequate arterial pressure, addition of a noncatecholamine vasopressor such as vasopressin or angiotensin-II is reasonable, in addition to rescue therapies that may improve vasopressor responsiveness. In this review, we discuss the pharmacology and evidence-based use of vasopressor and inotrope drugs in critically ill patients, with a focus on the CICU population.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, 4352Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Steven M Hollenberg
- Department of Cardiology, 3673Hackensack University Medical Center, Hackensack, NJ, USA
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32
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Knotzer H, Poidinger B, Kleinsasser A. Pharmacologic Agents for the Treatment of Vasodilatory Shock. Curr Pharm Des 2020; 25:2133-2139. [PMID: 31272348 DOI: 10.2174/1381612825666190704101907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/20/2019] [Indexed: 01/05/2023]
Abstract
Vasodilatory shock is a life-threatening syndrome in critically ill patients and is characterized by severe hypotension and resultant tissue hypoperfusion. This shock state requires the use of vasopressor agents to restore adequate vascular tone. Norepinephrine is still recommended as first-line vasopressor in the management of critically ill patients suffering from severe vasodilation. In the recent time, catecholaminergic vasopressor drugs have been associated with possible side effects at higher dosages. This so-called catecholamine toxicity has focused on alternative noncatecholaminergic vasopressors or the use of moderate doses of multiple vasopressors with complementary mechanisms of action. Besides vasopressin and terlipressin, angiotensin II may be a promising drug for the management of vasodilatory shock. In addition, adjunctive drugs, such as hydrocortisone, methylene blue or ascorbic acid can be added to conventional vasopressor therapy. The objective of this review is to give an overview of the current available vasopressor agents used in vasodilatory shock. A thorough search of PubMed was conducted in order to identify the majority of studies related to the subject. Data on the outcome of several drugs and future perspective of possible management strategies for the therapy of vasodilatory shock are discussed.
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Affiliation(s)
- Hans Knotzer
- Institute of Anesthesiology and Critical Care Medicine II, Klinikum Wels, Wels, Austria
| | - Bernhard Poidinger
- Institute of Anesthesiology and Critical Care Medicine II, Klinikum Wels, Wels, Austria
| | - Axel Kleinsasser
- Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
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33
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Tchen S, Sullivan JB. Clinical utility of midodrine and methylene blue as catecholamine-sparing agents in intensive care unit patients with shock. J Crit Care 2020; 57:148-156. [PMID: 32145658 DOI: 10.1016/j.jcrc.2020.02.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 01/29/2020] [Accepted: 02/17/2020] [Indexed: 02/07/2023]
Abstract
Shock is common in the intensive care unit, affecting up to one third of patients. Treatment of shock is centered upon managing hypotension and ensuring adequate perfusion via administration of fluids and catecholamine vasopressors. Due to the risks associated with catecholamine vasopressors, interest has grown in using catecholamine-sparing agents such as midodrine and methylene blue. Midodrine is an orally administered alpha-1 adrenergic agonist while methylene blue is an intravenously administered blue dye used to restore vascular tone and increase blood pressure. Separate MEDLINE, Scopus, and Embase database searches were conducted to assess literature revolving around these agents. Examples of search terms included "midodrine", "methylene blue", "critically ill", "shock", and "catecholamine-sparing." Several studies have evaluated their use in patients with shock and found potential benefits in terms of causing significant elevations in blood pressure and hastening catecholamine vasopressor discontinuation with few adverse effects; however, robust evidence is lacking for these off-label indications. Because of the variety of dosing strategies used and the incongruences between patient populations, it is also challenging to define finite recommendations. This review aims to summarize current evidence for the use of midodrine and methylene blue as catecholamine-sparing agents in critically ill patients with resolving or refractory shock.
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Affiliation(s)
- Stephanie Tchen
- Froedtert Hospital, 9200 W Wisconsin Ave, Milwaukee, WI 53226, United States of America.
| | - Jesse B Sullivan
- Fairleigh Dickinson University School of Pharmacy & Health Sciences, Pharmacy Practice, 230 Park Ave, M-SP1-01, Florham Park, NJ 07932, United States of America.
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Kassel CA, Fremming BA, Brown BA, Markin NW. 2019 Clinical Update in Liver Transplantation. J Cardiothorac Vasc Anesth 2020; 35:1495-1502. [PMID: 32173208 DOI: 10.1053/j.jvca.2020.01.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 01/31/2020] [Indexed: 11/11/2022]
Abstract
Liver transplantation continues be the standard for treatment of end-stage liver disease, and even with recent advances in organ preservation, the anesthetic management continues to require understanding of multiple organ systems beyond the liver. Multiple factors contribute to hemodynamic changes after reperfusion of the liver graft that anesthesiologists should be aware of before unclamping. Concomitant renal dysfunction in end-stage liver disease is not uncommon, and preparation for continuous renal replacement therapy may need to be considered in certain cases. Cardiac evaluation of liver transplantation patients with an emphasis on arrhythmias, including atrial fibrillation, can help prevent both intraoperative and postoperative complications detrimental to the patient and graft. Finally, combined liver and thoracic organ transplantations may be indicated for certain disease processes that affect multiple organs. These cases require an understanding of the surgical technique and acknowledgment that some goals of the procedures may be in direct opposition to each other.
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Ortoleva J, Shapeton A, Vanneman M, Dalia AA. Vasoplegia During Cardiopulmonary Bypass: Current Literature and Rescue Therapy Options. J Cardiothorac Vasc Anesth 2019; 34:2766-2775. [PMID: 31917073 DOI: 10.1053/j.jvca.2019.12.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/04/2019] [Accepted: 12/09/2019] [Indexed: 11/11/2022]
Abstract
Vasoplegia syndrome in the cardiac surgical intensive care unit and postoperative period has been an area of interest to clinicians because of its prevalence and effects on morbidity and mortality. However, there is a paucity of evidence regarding the treatment of vasoplegia syndrome during cardiopulmonary bypass (on-CPB VS). This review aims to detail the incidence, outcomes, and possible treatment options for patients who develop vasoplegia during bypass. The pharmacologic rescue agents discussed are used in cases in which vasoplegia during CPB is refractory to standard catecholamine agents, such as norepinephrine, epinephrine, and phenylephrine. Methods to improve vasoplegia during CPB can be both pharmacologic and nonpharmacologic. In particular, optimization of CPB parameters plays an important nonpharmacologic role in vasoplegia during CPB. Pharmacologic agents that have been demonstrated as being effective in vasoplegia include vasopressin, terlipressin, methylene blue, hydroxocobalamin, angiotensin II (Giapreza), vitamin C, flurbiprofen (Ropion), and hydrocortisone. Although these agents have not been specifically evaluated for vasoplegia during CPB, they have shown signs of effectiveness for vasoplegia postoperatively to varying degrees. Understanding the evidence for, dosing, and side effects of these agents is crucial for cardiac anesthesiologists when treating vasoplegia during CPB bypass.
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Affiliation(s)
- Jamel Ortoleva
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Alexander Shapeton
- Department of Anesthesia, Critical Care and Pain Medicine, Veterans Affairs Boston Healthcare System, Harvard Medical School, Boston, MA
| | - Mathew Vanneman
- Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Adam A Dalia
- Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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Fujii S, Bainbridge D. Vasoplegia in Cardiac Surgery: Pave the Way for Prevention. J Cardiothorac Vasc Anesth 2019; 33:3281-3282. [PMID: 31447277 DOI: 10.1053/j.jvca.2019.07.137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 07/18/2019] [Accepted: 07/21/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Satoru Fujii
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, Ontario, Canada
| | - Daniel Bainbridge
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, Ontario, Canada
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Cox J, Noveras J, Harrell T, Nayak KR. When the pressure drops: A case of vasoplegia during a structural heart intervention. Catheter Cardiovasc Interv 2019; 94:280-284. [PMID: 31025531 DOI: 10.1002/ccd.28214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 02/07/2019] [Accepted: 03/16/2019] [Indexed: 01/21/2023]
Abstract
A 67-year-old male underwent general anesthesia for left atrial appendage occlusion. During the procedure, the patient developed catecholamine refractory hypotension requiring the administration of several vasopressin boluses to maintain adequate perfusion pressure. At the conclusion of the procedure, mild venous bleeding necessitated the administration of protamine. This led to a further decrease in the patient's blood pressure. Tamponade and continued volume loss were quickly ruled out leading to a diagnosis of vasoplegia syndrome (VS). The patient was appropriately treated with a vasopressin infusion with normalization of blood pressure and no significant morbidity or adverse outcome. With the use of general anesthesia during structural heart interventions on the rapid rise, we discuss the two common causes for vasoplegia along with evidence-based treatments and possible prevention strategies.
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Affiliation(s)
- Justin Cox
- Department of Cardiology, Naval Medical Center San Diego, San Diego, California
| | - Janette Noveras
- Department of Medicine, Naval Medical Center San Diego, San Diego, California
| | - Travis Harrell
- Department of Cardiology, Naval Medical Center San Diego, San Diego, California
| | - Keshav R Nayak
- Department of Cardiology, Naval Medical Center San Diego, San Diego, California.,San Diego Heart and Vascular Associates, San Diego, California.,Department of Cardiology, Scripps Mercy Hospital, San Diego, California
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Zhao P, Mei L. A clinical study of paraspinal nerve block on treatment of herpes zoster under ultrasonic guidance. Neurochirurgie 2019; 65:382-386. [PMID: 31348920 DOI: 10.1016/j.neuchi.2019.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 04/09/2019] [Accepted: 06/10/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To study the ultrasound guiding by methylenum coeruleum thoracic paravertebral block analgesia effect and promote healing of herpes zoster. METHODS A total of 87 patients with herpes zoster were randomly divided into an observation group and a control group, and the two groups received the same treatment including antiviral drug, nerve nutrition, in order to increase the body's resistance. The observation group were given thoracic paravertebral block with methylenum coeruleum guided by ultrasound, recorded visual analogue scale (VAS) of the two groups of patients for their hypersensitivity to pain 1d, 3d, 1 week, 2 weeks, 1 month after treatment, skin lesion healing time, incidence of postherpetic neuralgia (PHN), patients' satisfaction, etc. RESULTS: After administration of thoracic paravertebral block with methylenum coeruleum, VAS of the observation group expectedly decreased. At the same time, the VAS in the observation group was significantly lower than that in the control group, the skin healing time in the observation group was obviously shorter, and the incidence of PHN was lower than that in the control group. The satisfaction of observation group patients was higher than that in the control group (P<0.05). CONCLUSION To implement thoracic paravertebral block with methylenum coeruleum guided by ultrasound can help reduce the degree of hypersensitivity to pain, promoting the healing of herpes zoster could reduce the incidence of PHN, greatly improving patients' satisfaction.
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Affiliation(s)
- P Zhao
- Department of Anesthesiology, People's Hospital of Weifang, Weifang 261000, China
| | - L Mei
- Department of Anesthesiology, People's Hospital of Weifang, Weifang 261000, China.
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Evans A, McCurdy MT, Weiner M, Zaku B, Chow JH. Use of Angiotensin II for Post Cardiopulmonary Bypass Vasoplegic Syndrome. Ann Thorac Surg 2019; 108:e5-e7. [DOI: 10.1016/j.athoracsur.2018.11.047] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
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Abdelazim R, Salah D, Labib HA, El Midany AA. Methylene blue compared to norepinephrine in the management of vasoplegic syndrome in pediatric patients after cardiopulmonary bypass: a randomized controlled study. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2016.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Raafat Abdelazim
- Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain Shams University, Egypt
| | - Dina Salah
- Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain Shams University, Egypt
| | - Heba A. Labib
- Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain Shams University, Egypt
| | - Ashraf A. El Midany
- Department of Cardiothoracic Surgery, Faculty of Medicine, Ain Shams University, Egypt
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Ortoleva JP, Cobey FC. A Systematic Approach to the Treatment of Vasoplegia Based on Recent Advances in Pharmacotherapy. J Cardiothorac Vasc Anesth 2019; 33:1310-1314. [DOI: 10.1053/j.jvca.2018.11.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Indexed: 12/31/2022]
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Truby LK, DeRoo S, Spellman J, Jennings DL, Takeda K, Fine B, Restaino S, Farr M. Management of primary graft failure after heart transplantation: Preoperative risks, perioperative events, and postoperative decisions. Clin Transplant 2019; 33:e13557. [PMID: 30933386 DOI: 10.1111/ctr.13557] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 03/18/2019] [Accepted: 03/22/2019] [Indexed: 11/30/2022]
Abstract
Primary graft failure (PGF) after heart transplantation (HT) is a devastating and unexpected event characterized by failure of the graft to adequately support recipient circulation necessitating high doses of vasopressors and inotropes and/or temporary mechanical circulatory support. Although it represents an increasingly common event in the current era, there remains a high degree of variability in prevalence, reported risk factors, and approach to this clinical entity. The purpose of the current review is to highlight preoperative considerations including known incidence and risk factors, perioperative issues involving the identification and management of PGF, and postoperative decisions related to weaning of mechanical circulatory support and titration of immunosuppressive therapy. Lastly, we highlight future directions in PGF research, involving basic and translational research, that have the potential to uncover novel strategies of risk stratification and treatment. CASE: Our patient is a 53-year-old man with end-stage non-ischemic dilated cardiomyopathy complicated by ventricular tachycardia (VT), post-capillary pulmonary hypertension, and renal insufficiency. After progressing to NYHA Class IV symptoms, he underwent implantation of a durable left ventricular assist device (LVAD) as bridge to transplant (BTT). On device support, he developed recurrent VT resulting in multiple defibrillator discharges and hospital admission for intravenous anti-arrhythmic therapy. He is subsequently upgraded to a higher status on the waiting list. A suitable donor is identified, with an appropriate predicted heart mass and an anticipated ischemic time of <4 hours. He is taken to the operating room, where at the time of anesthesia induction he develops vasodilatory shock, requiring high-dose vasopressors, and cardiopulmonary bypass (CPB) support for dissection. After surgical anastomosis, cross clamp removal and reperfusion, graft function is extremely poor, there is significant bradycardia requiring pacing, and the patient is unable to be weaned successfully from CPB. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is initiated, and the patient is transferred to the intensive care unit. Retrospective flow crossmatch is negative. This patient is suffering from severe primary graft failure.
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Affiliation(s)
- Lauren K Truby
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Scott DeRoo
- Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Jessica Spellman
- Department of Anesthesia, Columbia University Irving Medical Center, New York, New York
| | - Douglas L Jennings
- Department of Pharmacology, New York Presbyterian Hospital, New York, New York
| | - Koji Takeda
- Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Barry Fine
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Susan Restaino
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Maryjane Farr
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
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Kratzert WB, Boyd EK, Saggar R, Channick R. Critical Care of Patients After Pulmonary Thromboendarterectomy. J Cardiothorac Vasc Anesth 2019; 33:3110-3126. [PMID: 30948200 DOI: 10.1053/j.jvca.2019.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/19/2019] [Accepted: 03/01/2019] [Indexed: 12/16/2022]
Abstract
Pulmonary thromboendarterectomy (PTE) remains the only curative surgery for patients with chronic thromboembolic pulmonary hypertension (CTEPH). Postoperative intensive care unit care challenges providers with unique disease physiology, operative sequelae, and the potential for detrimental complications. Central concerns in patients with CTEPH immediately after PTE relate to neurologic, pulmonary, hemodynamic, and hematologic aspects. Institutional experience in critical care for the CTEPH population, a multidisciplinary team approach, patient risk assessment, and integration of current concepts in critical care determine outcomes after PTE surgery. In this review, the authors will focus on specific aspects unique to this population, with integration of current available evidence and future directions. The goal of this review is to provide the cardiac anesthesiologist and intensivist with a comprehensive understanding of postoperative physiology, potential complications, and contemporary intensive care unit management immediately after pulmonary endarterectomy.
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Affiliation(s)
- Wolf B Kratzert
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Eva K Boyd
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Rajan Saggar
- Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Richard Channick
- Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Williams WH, Browne RC, Bui TP, Holmes AA, Thakar D. Case report on intravenous octreotide for the treatment of intraoperative vasoplegia following thymoma resection. SAGE Open Med Case Rep 2019; 7:2050313X19827744. [PMID: 30800305 PMCID: PMC6378416 DOI: 10.1177/2050313x19827744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 01/10/2019] [Indexed: 12/14/2022] Open
Abstract
Octreotide is a somatostatin analog known for its role in the treatment of acute variceal bleeding, enterocutaneous fistula and carcinoid syndrome. The reduction of portal pressure from splanchnic vasoconstriction has been attributed to the inhibition of nitric oxide synthesis, guanylate cyclase and release of glucagon. Octreotide has many therapeutic applications as a result of the ubiquitous nature of somatostatin receptors throughout the body. The effects of octreotide on vascular tone make it potentially useful in the treatment of intraoperative vasoplegia, hypotension with low systemic vascular resistance with preserved cardiac output that is refractory to adrenergic agonists. We present a case in which a patient undergoing thymoma resection developed vasoplegia that was effectively treated with octreotide. We believe that this case illustrates the need for further investigation on the potential efficacy of octreotide as an adjunct for the treatment of vasoplegia and other forms of shock.
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Affiliation(s)
| | | | - Thao P Bui
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - A Alex Holmes
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dilip Thakar
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Jentzer JC, Vallabhajosyula S, Khanna AK, Chawla LS, Busse LW, Kashani KB. Management of Refractory Vasodilatory Shock. Chest 2018; 154:416-426. [DOI: 10.1016/j.chest.2017.12.021] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 12/18/2017] [Accepted: 12/21/2017] [Indexed: 12/24/2022] Open
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Abstract
Angiotensin II (Ang II), part of the renin-angiotensin-aldosterone system (RAS), is a potent vasoconstrictor and has been recently approved for use by the US Food and Drug Administration in high-output shock. Though not a new drug, the recently published Angiotensin II for the Treatment of High Output Shock (ATHOS-3) trial, as well as a number of retrospective analyses have sparked renewed interest in the use of Ang II, which may have a role in treating refractory shock. We describe refractory shock, the unique mechanism of action of Ang II, RAS dysregulation in shock, and the evidence supporting the use of Ang II to restore blood pressure. Evidence suggests that Ang II may preferentially be of benefit in acute kidney injury and acute respiratory distress syndrome, where the RAS is known to be disrupted. Additionally, there may be a role for Ang II in cardiogenic shock, angiotensin converting enzyme inhibitor overdose, cardiac arrest, liver failure, and in settings of extracorporeal circulation.
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Affiliation(s)
- Rachel L Bussard
- Critical Care Pharmacy Specialist, Department of Pharmacy, Emory St Joseph's Hospital, Atlanta, GA, USA
| | - Laurence W Busse
- Department of Critical Care, Emory St Joseph's Hospital, Atlanta, GA, USA,
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA, USA,
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Desai SR, Hwang NC. Advances in Left Ventricular Assist Devices and Mechanical Circulatory Support. J Cardiothorac Vasc Anesth 2018. [DOI: 10.1053/j.jvca.2018.01.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Characterizing Predictors and Severity of Vasoplegia Syndrome After Heart Transplantation. Ann Thorac Surg 2018; 105:770-777. [DOI: 10.1016/j.athoracsur.2017.09.039] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 08/27/2017] [Accepted: 09/22/2017] [Indexed: 01/19/2023]
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