This case is the second report of DIIHA with iomeprol.

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 À1 of methylene blue intravenously for refractory vasoplegic syndrome (defined as norepinephrine requirement more than 0.5 mg kg À1 min À1 ) to maintain mean arterial pressure (MAP) more than 65 mmHg and cardiac index (CI) more than 2.0 l min À1 m À2 .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 À1 m À2 ) 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 ¼ 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 À2 (P ¼ 0.02) and perfused vessel density density from 7.4 [0.1 to 11.5] to 9.1 [0 to 20.1] mm mm À2 (P ¼ 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 À1 (P ¼ 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.

No abstract

Rational: HSCT is widely used as treatment of poor-risk pediatric hematological malignancies from 80’s. Many different TBI or busulfan based conditioning regimen have been developed. Although many studies have compared TBI vs busulfan, few studies were available for evaluating different TBI based regimen. Methods: In order to compare efficacy, safety and toxicity of these different TBI based regimen, we realized retrospective study regarding HSCT in pts under 18 years of age from French HSCT registry from 1985 to 2004. P value under 0.05 was considered as statistically significant. Results: A total of 702 pts were transplanted during this period using 26 different TBI based conditioning regimen but just 4 of them included more than 30 patients: TBI+Cyclophosphamide (R1, n=305), TBI+Cytarabine+Melphalan (R2, n=249), TBI+VP16 (R3, n=35) or TBI+Cyclophosphamide+VP16 (R4, n=30). We exposed here the results of 554 pts given either R1 or R2. Main characteristics and results are summarized in table. Engraftment rates were similar in R1 and R2. Ten years OS was significantly better for R1 vs R2 (57.8+/−4.1% vs 48.8+/−4%, P=0.0008). There were no significant differences for both conditioning regimen regarding the risk of relapse (R1: 35.8+/−3.9% vs R2: 27.6+/−3.9%), the risk of grade III and IV aGVHD (R1: 16.7+/−2.2% vs R2: 20.01+/−2.6%) and the risk of cGVHD (R1: 26.9+/−3.2% vs R2: 32.4+/−5.2%). TRM at 10 years was significantly worse for R2 vs R1 (33+/−3.3% vs 22.8+/−2.8%, P=0.004). The results obtained with TBI+VP16 were similar than those with TBI+Cy where the results from TBI+VP16+Cy were closed to those from TBI+Arac+Melphalan (data not shown). Discussion and Conclusion: Too many different TBI based conditioning regimen were used. In order to standardize procedures among transplant centers, we would like identify a gold standard. In our study, TBI + Cy appears safer than TBI+Cytarabine+Melphalan as conditioning regimen for pediatric hematological malignancies since OS and TRM were better although same relapse and GVHD rates were obtained. Main characteristics TBI + Cy (n=305) TBI+Arac+MEL (n=249) TBI: total body irradiation; Cy: cyclophosphamide; Arac: cytarabine; MEL: melphalan % of male 56 62 Median age at diagnosis (years) 11 (0–17.7) 5 (0.8–17.1) Median age at graft (years) 12.5 (0.4–18) 8.5 (1.9–17.8) Median time from diagnosis to graft (months) 8 (2–173.3) 24 (3–151) Diagnosis ALL low risk/high risk 139(46%)/17(6%) 191(77%)/30 (12%) AML low risk/high risk 46(15%)/43(14%) 3(1.2%)/7(2.8%) MDS 12 (4%) 4 (1.6%) CML chronic phase/other (%) 28(9%)/5(1.6%) 2(0.8%)/1(0.4%) Source of Stem Cells Bone marrow 222 (73%) 221 (89%) Peripheral blood 22 (7.3%) 5 (2%) Cord blood 60 (20%) 19 (7.6%) Sibling 145 (47%) 125 (50%) Unrelated 156 (51%) 102 (41%) Matched/Mismatched 69/31% 75/24% Median follow-up (months) 19.8 (0.7–229.5) 13 (0.2–210.9)