Walter Petermichl1, Michael Gruber2, Ina Schoeller2, Kwahle Allouch2, Bernhard M Graf2, York A Zausig2,3. 1. Department of Anesthesiology, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany. walter.petermichl@ukr.de. 2. Department of Anesthesiology, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany. 3. Department of Anesthesiology, Aschaffenburg-Alzenau Hospital, Am Hasenkopf 1, 63739, Aschaffenburg, Germany.
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.
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.
Authors: Laura Pasin; Michele Umbrello; Teresa Greco; Massimo Zambon; Federico Pappalardo; Martina Crivellari; Giovanni Borghi; Andrea Morelli; Alberto Zangrillo; Giovanni Landoni Journal: Crit Care Resusc Date: 2013-03 Impact factor: 2.159
Authors: Marieke E van Vessem; Meindert Palmen; Lotte E Couperus; Bart Mertens; Remco R Berendsen; Laurens F Tops; Harriëtte F Verwey; Evert de Jonge; Robert J M Klautz; Martin J Schalij; Saskia L M A Beeres Journal: Eur J Cardiothorac Surg Date: 2017-03-01 Impact factor: 4.191
Authors: Ludhmila Abrahao Hajjar; Jean Louis Vincent; Filomena Regina Barbosa Gomes Galas; Andrew Rhodes; Giovanni Landoni; Eduardo Atsushi Osawa; Renato Rosa Melo; Marcia Rodrigues Sundin; Solimar Miranda Grande; Fabio A Gaiotto; Pablo Maria Pomerantzeff; Luis Oliveira Dallan; Rafael Alves Franco; Rosana Ely Nakamura; Luiz Augusto Lisboa; Juliano Pinheiro de Almeida; Aline Muller Gerent; Dayenne Hianae Souza; Maria Alice Gaiane; Julia Tizue Fukushima; Clarice Lee Park; Cristiane Zambolim; Graziela Santos Rocha Ferreira; Tânia Mara Strabelli; Felipe Lourenco Fernandes; Ligia Camara; Suely Zeferino; Valter Garcia Santos; Marilde Albuquerque Piccioni; Fabio Biscegli Jatene; Jose Otavio Costa Auler; Roberto Kalil Filho Journal: Anesthesiology Date: 2017-01 Impact factor: 7.892
Authors: Alessandro Belletti; Umberto Benedetto; Giuseppe Biondi-Zoccai; Carlo Leggieri; Paolo Silvani; Gianni D Angelini; Alberto Zangrillo; Giovanni Landoni Journal: J Crit Care Date: 2016-08-13 Impact factor: 3.425