Vasopressin therapy in cardiac surgery

Kunkes, Jordan; Baker, William L.; Hammond, Jonathan; Gluck, Jason

doi:10.1111/jocs.13968

Cited by 9 publications

(6 citation statements)

References 46 publications

(119 reference statements)

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“…Reasons for avoiding enteral feeding may relate to the severity of the patient's baseline clinical condition rather than to the use of AVP, especially as most AVP users felt AVP was a second-line medication. Porcine models have shown a decrease in blood flow in the gastric mucosa after cardiopulmonary bypass, exacerbated by the use of AVP ( 9 , 22 ), which could pose a theoretical risk of necrotizing enterocolitis. However, Alten et al reported no cases of necrotizing enterocolitis and adequate tolerance of enteral feeds in all patients with early initiation of AVP after cardiovascular bypass surgery ( 19 ).…”

Section: Discussionmentioning

confidence: 99%

International Survey on the Use of Arginine Vasopressin in the Postoperative Management of Single Ventricle Patients

et al. 2021

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Management of patients with single ventricle physiology after surgical palliation is challenging. Arginine vasopressin has gained popularity in recent years as a non-catecholamine vasoactive medication due to its unique properties. However, data regarding its use in the pediatric population is limited. Therefore, we designed a survey to explore whether and how clinicians use this medication in intensive care units for the postoperative management of single ventricle patients. This international survey aimed to assess usage, practices, and concepts related to arginine vasopressin in pediatric intensive care units worldwide. Directors of pediatric intensive care units who are members of the following international professional societies: European Society of Pediatric Neonatal Intensive Care, Association for European Pediatric and Congenital Cardiology, and Pediatric Cardiac Intensive Care Society were invited to participate in this survey. Of the 62 intensive care unit directors who responded, nearly half use arginine vasopressin in the postoperative management of neonatal single ventricle patients, and 90% also use the drug in subsequent surgical palliation. The primary indications are vasoplegia, hemodynamic instability, and refractory shock, although it is still considered a second-line medication. Conceptual benefits include improved hemodynamics and end-organ perfusion and decreased incidence of low cardiac output syndrome. Those practitioners who do not use arginine vasopressin cite lack of availability, fear of potential adverse effects, unclear indication for use, and lack of evidence suggesting improved outcomes. Both users and non-users described increased myocardial afterload and extreme vasoconstriction as potential disadvantages of the medication. Despite the lack of conclusive data demonstrating enhanced clinical outcomes, our study found arginine vasopressin is used widely in the care of infants and children with single ventricle physiology after the first stage and subsequent palliative surgeries. While many intensive care units use this medication, few had protocols, offering an area for further growth and development.

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Section: Discussionmentioning

confidence: 99%

International Survey on the Use of Arginine Vasopressin in the Postoperative Management of Single Ventricle Patients

et al. 2021

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“…Most of all, the increase in copeptin levels at baseline could reveal an advanced stage in the V1R desensitization process as described in severe HF, thus predicting the enormous need for AVP during the PCVS to overcome a rapidly increasing peripheral insensitivity. Recently, several studies have suggested that the use of 1-desamino-8- d -arginine-vasopressin (dDAVP) in this setting would reduce the need for high doses of NE and related adverse effects [ 29 ]. A recent meta-analysis showed that the precocious administration of low dose of dDAVP would reduce the rate of perioperative complications in patients undergoing elective and emergency cardiac surgery (OR 0.33, 95% CI 0.20–0.54) [ 30 ].…”

Section: Discussionmentioning

confidence: 99%

Neuroendocrine predictors of vasoplegia after cardiopulmonary bypass

Pasero

Berton

Motta

et al. 2020

J Endocrinol Invest

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Purpose Vasoplegia often complicates on-pump cardiac surgery. Systemic inflammatory response induced by extracorporeal circulation represents the major determinant, but adrenal insufficiency and postoperative vasopressin deficiency may have a role. Pathophysiological meaning of perioperative changes in endocrine markers of hydro-electrolyte balance has not still fully elucidated. Objectives of the present research study were to estimate the incidence of vasoplegia in a homogeneous cohort of not severe cardiopathic patients, to define the role of presurgical adrenal insufficiency, to evaluate copeptin and NT-proBNP trends in the perioperative. Methods We conducted a prospective cohort study in the cardiac intensive care unit of a tertiary referral center. We evaluated 350 consecutive patients scheduled for cardiac surgery; 55 subjects completed the study. Both standard and low-dose corticotropin stimulation tests were performed in the preoperative; copeptin and NT-proBNP were evaluated in the preoperative (T0), on day 1 (T1) and day 7 (T2) after surgery. Results Nine subjects (16.3%) developed vasoplegic syndrome with longer bypass and clamping time (p < 0.001). Reduced response to low-dose ACTH test was not associated to vasoplegia. Preoperative copeptin > 16.9 pmol/L accurately predicted the syndrome (AUC 0.86, 95% CI 0.73–0.94; OR 1.17, 95% CI 1.04–1.32). An evident correlation was observed at 7 days postoperative between NT-proBNP and copeptin (r 0.88, 95% CI 0.8–0.93; p < 0.001). Conclusion Preoperative impaired response to low-dose ACTH stimulation test is not a risk factor for post-cardiotomic vasoplegia; conversely, higher preoperative copeptin predicts the complication. On-pump cardiac surgery could be an interesting model of rapid heart failure progression.

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“…PCVS represents a serious complication after CPB, requiring a large amount of vasoactive agents, often burden by relevant side effects. The presurgical identification of subjects at high risk of developing PCVS would be useful in order to select these patients to a precocious usage of 1-deamino, 8-D arginine-vasopressin (dDAVP) in case of hypotension induced by CPB [28]. A recent meta-analysis of 8 randomized controlled trials showed that a low dose of dDAVP would reduce the rate of perioperative complications in patients undergoing elective and emergency cardiac surgery (OR 0.33, 95% CI 0.20-0.54) [29].…”

Section: Discussionmentioning

confidence: 99%

Copeptin assessment to predict vasoplegia after cardiopulmonary by-pass. An observational cohort study.

Pasero

Berton

Motta

et al. 2020

Preprint

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Background Post-cardiotomy vasoplegic syndrome is a vasodilatory shock characterized by a decrease of vascular tone with a normal or increased cardiac output. A relative deficit in vasopressin secretion in the postoperative was hypothesized. Copeptin is secreted in equimolar ratio with vasopressin but it is more stable and easier to measure. The aim of the present study was to investigate whether perioperative copeptin was associated with post-cardiotomy vasoplegic syndrome. Methods All patients scheduled for cardiac surgery were evaluated. Exclusion criteria were age < 18 years old, corticosteroids therapy, heart transplantation, extra-circulatory life support, sepsis, preoperative use of vasoactive drugs, off-pump surgery, chronic hepatic and renal failure, paraneoplastic syndrome, lack of informed consent. Post-cardiotomy vasoplegic syndrome was defined as a mean arterial pressure < 60 mmHg, a reduction of systemic vascular resistances < 1200 dyn*s/cm 5 *m 2 and/or the need of nor-epinephrine ³ 0.1 µg/kg/min. All patients underwent a preoperative evaluation of the corticotropin stimulation test; then, before surgery (T0), on day one after surgery (T1) and after 7 days (T2) copeptin and NT-proBNP concentration were measured. Results Among 55 enrolled patients, 9 (16.3%) developed post-cardiac surgery vasoplegia. Patients with vasoplegia had higher preoperative level of copeptin (19.2 pmol/L, IQR 17.89 – 21.29 vs 11.39 pmol/L, IQR 6.33 - 14.78; p < 0.001) and NT-proBNP (1435 pg/ml, IQR 721.75 – 1836.25 vs 365.5 pg/ml, IQR 141 - 977); p = 0.006) compared to the control group. At the multivariable analysis, preoperative copeptin resulted a significant predictor of vasoplegia (OR 1.56, 95% CI 1.002-1.33) and the ROC analysis showed an accurate copeptin cut off able to identify vasoplegic patients (> 16.9 pmol/L, AUC = 0.86, 95% CI 0.73-0.94). Otherwise, a lack of response to the low dose corticotropin test was not a predictor of PCVS; no patient presented a pathological response to the standard dose test. ConclusionsIncreased preoperative copeptin and NT-proBNP levels might be associated with an increased risk to develop post-cardiotomy vasoplegic syndrome. Our results suggest that patients with a decompensated neuroendocrine control of cardiovascular function are more prone to develop postoperative vasoplegia.

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Vasopressin therapy in cardiac surgery

Cited by 9 publications

References 46 publications

International Survey on the Use of Arginine Vasopressin in the Postoperative Management of Single Ventricle Patients

International Survey on the Use of Arginine Vasopressin in the Postoperative Management of Single Ventricle Patients

Neuroendocrine predictors of vasoplegia after cardiopulmonary bypass

Copeptin assessment to predict vasoplegia after cardiopulmonary by-pass. An observational cohort study.

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