Management of vasodilatory shock after cardiac surgery: Identification of predisposing factors and use of a novel pressor agent

Argenziano, Michael; Chen, Jonathan M.; Choudhri, Asim F.; Cullinane, Suzanne; Garfein, Evan S.; Weinberg, Alan; Smith, Craig R.; Rose, Eric A.; Landry, Donald W.; Öz, Mehmet C.

doi:10.1016/s0022-5223(98)70049-2

Cited by 337 publications

(230 citation statements)

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“…Observing the other 55 studies we can find: 1) one study (1.67%) based on evidences through metanalysis of literature [13]; 2) seven review articles (11.67%) [4,14,23]. The other bibliographical citations in number of 44 (73.33%) are distributed as case reports (great majority) [24][25][26][27][28][29][30][31][32][33][34][35][36], letters [37][38][39][40][41][42][43][44], technical aspects of the MB use [45][46][47][48][49][50] and other studies involving risk [51,52], the VS incidence in the "off pump" CABG and the possibility of MB use in anaphylaxis and anaphylactic shock [53], also a proposal of the author of this text ( Figure 4) [54][55][56][57][58]. The presented numbers, surely, are not totally compatible with the total of publications, but it is possible to assume that this imprecision does not affect the general vision of the problem.…”

Section: Resultsmentioning

confidence: 99%

“…There was a change regarding the paradigm that inflammatory reaction associated with VS would be caused by blood exposure to the non-endothelial surface of the ECC, after it was verified that the inflammatory response is present in off-pump patients [54]. A change tendency is observed in the concept that, more than the contact with the CPB circuit, the contact of the blood with the wound EVORA, PRB ET AL -Methylene blue for vasoplegic syndrome treatment in heart surgery.…”

Section: Discussionmentioning

confidence: 99%

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Methylene blue for vasoplegic syndrome treatment in heart surgery: fifteen years of questions, answers, doubts and certainties

Évora¹,

Ribeiro

Vicente³

et al. 2009

Rev Bras Cir Cardiovasc

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Azul de metileno no tratamento da síndrome vasoplégica em cirurgia cardíaca. Quinze anos de perguntas, respostas, dúvidas e certezasMethylene blue for vasoplegic syndrome treatment in heart surgery. Fifteen years of questions, answers, doubts and certainties AbstractObjective: There is strong evidence that methylene blue (MB), an inhibitor of guanylate cyclase, is an excellent therapeutic option for vasoplegic syndrome (VS) treatment in heart surgery. The aim of this article is to review the MB's therapeutic function in the vasoplegic syndrome treatment.Methods: Fifteen years of literature review.Results: 1) Heparin and ACE inhibitors are risk factors; 2) In the recommended doses it is safe (the lethal dose is 40 mg/ kg); 3) The use of MB does not cause endothelial dysfunction; 4) The MB effect appears in cases of nitric oxide (NO) upregulation; 5) MB is not a vasoconstrictor, by blocking of the GMPc system it releases the AMPc system, facilitating the norepinephrine vasoconstrictor effect; 6) The most used dosage is 2 mg/kg as IV bolus followed by the same continuous infusion because plasmatic concentrations strongly decays in the first 40 minutes; 7) There is a possible "window of opportunity" for the MB's effectiveness.Conclusions: Although there are no definitive multicentric studies, the MB used to treat heart surgery VS, at the present time, is the best, safest and cheapest option, being a Brazilian contribution for the heart surgery.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Methylene blue for vasoplegic syndrome treatment in heart surgery: fifteen years of questions, answers, doubts and certainties

Évora¹,

Ribeiro

Vicente³

et al. 2009

Rev Bras Cir Cardiovasc

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“…3,4 In this case, we report the use of vasopressin in the treatment of acute distributive shock that occurred during the administration of aprotinin in a patient undergoing repeat cardiac surgery.…”

Section: Conclusion : La Vasopressine Associée à Des Alpha-agonistesmentioning

confidence: 99%

“…ASOPRESSIN has been recommended recently for the treatment of ventricular fibrillation, septic shock, 1,2 and post-cardiopulmonary bypass distributive shock. 3,4 In this case, we report the use of vasopressin in the treatment of acute distributive shock that occurred during the administration of aprotinin in a patient undergoing repeat cardiac surgery. …”

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confidence: 99%

Vasopressin for treatment of shock following aprotinin administration

Williams

Denault

Pellerin

et al. 2004

Can J Anesth/J Can Anesth

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P Pu ur rp po os se e: : To describe the utility of vasopressin in the treatment of acute distributive shock clinically compatible with the diagnosis of aprotinin anaphylaxis.C Cl li in ni ic ca al l f fe ea at tu ur re es s: : A 57-yr-old female patient underwent repeat cardiac surgery to treat prosthetic valve endocarditis. She had received aprotinin during her first surgery 60 days ago. Despite a negative test dose of iv aprotinin 20,000 KIU, when aprotinin loading was initiated during the repeat surgery, the patient developed bronchospasm and hypotension secondary to acute distributive shock. Bronchospasm responded to inhaled salbutamol and ipatropium. The hypotension was refractory to high doses of phenylephrine. Two doses of iv vasopressin 5 U reversed the vasodilation and reestablished normal blood pressure.C Co on nc cl lu us si io on n: : Vasopressin, in association with alpha-agonists, can reverse acute refractory distributive shock following aprotinin administration. ASOPRESSIN has been recommended recently for the treatment of ventricular fibrillation, septic shock, 1,2 and post-cardiopulmonary bypass distributive shock. 3,4 In this case, we report the use of vasopressin in the treatment of acute distributive shock that occurred during the administration of aprotinin in a patient undergoing repeat cardiac surgery. ObjectifC Ca as se e r re ep po or rt t A 57-yr-old, 56 kg woman with a history of rheumatic fever, type II diabetes mellitus, hypertension, and smoking underwent combined mechanical mitral (St. Jude 27 mm) and aortic (St. Jude 19 mm) valve replacements and left anterior descending coronary artery bypass with a left internal mammary artery graft. Her preoperative medications were metformin and hydrochlorothiazide. She had no known allergies. At the time of surgery, she received aprotinin (Bayer Vital, Leverkusen, Germany) as per the Hammersmith protocol. 5 Her postoperative course was uneventful.Two months later, the patient presented to the emergency room with chills and an altered level of consciousness. The patient was disoriented, stuporous, but arousable. She was tachycardic and had a temperature of 39°C without signs of meningismus or focal neurological findings. Laboratory tests revealed leukocytosis and acute azotemia with a serum creatinine of 221 µmol·L -1 . Cranial computerized tomography showed two small hypodensities compatible with embolic cerebral infarcts in the territories of each middle cerebral artery. Transesophageal echocardiography demonstrated a large vegetation on the mitral valve prosthesis, for which an emergency repeat cardiac surgery was scheduled. The patient was rehydrated, started on iv heparin, and treated with vancomycin, CARDIOTHORACIC ANESTHESIA, RESPIRATION AND AIRWAY 169 CAN J

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“…The mean arterial pressure (MAP) < 70 mm Hg, systemic vascular resistance index (SVRI) < 1400 dyn/s/cm 5 /m 2 , systemic vascular resistance (SVR) < 400 dyn/s/ cm 5 ; cardiac index (CI) > 2.5 l/min/m 2 , central venous pressure (CVP) > 10 mm Hg, and time coincidence: the presence of clinical symptoms 2-12 h after the end of cardiopulmonary bypass (CPB) [1][2][3][4].…”

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confidence: 99%

Vasoplegic versus septic shock in cardiac surgery. Possibilities of differentiating between them and implementing appropriate therapy

Kudliński¹,

Marczak²,

Cichoń³

2013

kitp

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Among patients undergoing on-pump cardiac surgery (cardiopulmonary bypass -CPB), there is a population of patients who, shortly after the end of the procedure (and CPB), exhibit symptoms of generalized hypotension related to very low systemic vascular resistance, the treatment of which requires very large doses of vasoconstrictors. This clinical condition is known as vasodilatation or vasoplegic shock (a distributive shock). Risk factors of postoperative vasoplegia such as initial patient condition, preoperative pharmacotherapy, cardiac procedure type, extracorporeal perfusion, the activation of intrinsic mechanisms leading to vasodilatation, and infectious factors (complicating the previously "sterile" vasoplegia course) should be taken into consideration when planning the treatment and aiming to improve the postoperative outcome. Whether vasoplegia is of infectious or sterile etiology remains the big issue which dictates postoperative therapy: empirical antibiotic de-escalation therapy vs. standard perioperative antibiotic prophylaxis. Key words: vasoplegia, septic shock, CPB, antibiotic prophylaxis. StreszczenieW kardiochirurgii z użyciem krążenia pozaustrojowego (cardiopulmonary bypass -CPB) obserwuje się populację pacjentów, u których w krótkim okresie po zakończeniu zabiegu (oraz CPB) występują objawy uogólnionej hipotensji związanej z bardzo niskim oporem obwodowym wymagającym zastosowania w terapii bardzo dużych dawek leków wazokonstrykcyjnych. Taki stan kliniczny określa się mianem wstrząsu wazodylatacyjnego lub wazoplegicznego (wstrząs dystrybucyjny). Istotnym problemem w leczeniu tego zespołu jest identyfikacja czynników ryzyka związanych z przedoperacyjnym stanem klinicznym pacjenta, prowadzoną terapią lekową, samym zabiegiem kardiochirurgicznym i jego rodzajem, prowadzeniem perfuzji w krążeniu pozaustrojowym, jak również aktywacją wewnątrzustrojowych mechanizmów powodujących wazodylatację oraz czynnikami infekcyjnymi wikłającymi "sterylny" przebieg wazoplegii. Odpowiedź na pytanie, czy jest to wstrząs wazodylatacyjny czy już wstrząs septyczny, implikuje wdrożenie adekwatnej terapii -empirycznej antybiotykoterapii deeskalacyjnej lub standardowej profilaktyki okołooperacyjnej. Słowa kluczowe: wazoplegia, wstrząs septyczny, krążenie pozaustrojowe, antybiotykoterapia.

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Management of vasodilatory shock after cardiac surgery: Identification of predisposing factors and use of a novel pressor agent

Cited by 337 publications

References 24 publications

Methylene blue for vasoplegic syndrome treatment in heart surgery: fifteen years of questions, answers, doubts and certainties

Methylene blue for vasoplegic syndrome treatment in heart surgery: fifteen years of questions, answers, doubts and certainties

Vasopressin for treatment of shock following aprotinin administration

Vasoplegic versus septic shock in cardiac surgery. Possibilities of differentiating between them and implementing appropriate therapy

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