The Vexing Problem
of Vasoplegia
SCOTT SILVESTRY MD
FLORIDA HOSPITAL TRANSPLANT INSTITUTE
No relevant disclosures
Vasoplegia
Unexpected refractory hypotension from a severe
SIRS response following cardiac surgery involving
cardiopulmonary bypass (CPB)
The incidence of VS in cardiac surgical patients is 8%
to 10 %, but may increase to upwards of 50% of
patients taking renin-angiotensin system (RAS)
antagonists.
No Standard Definition
Form of vasodilitory shock that occurs in the early
postoperative period (< 6 hours after weaning from CBP),
manifested by:
Hypotension [MAP < 70 without vasoactive agents]
Tachycardia
Normal or increased cardiac output [CI > 2.5 L / min / m2]
Low systemic vascular resistance [SVR < 800 dynes-s ·
cm−5 · m−2 ]
Vasoplegia Syndrome
Pts have poor prognosis,
Especially norepinephrine-resistant vasoplegia.
Catecholamine resistant vasoplegia lasting for
more than 36 to 48 hours has a mortality rate as
high as 25%.
Associated with longer hospital stays, prolonged
ICU stays, prolonged mechanical ventilation and
more sternal infections
Prophylactic Vasopressin in Patients Receiving the Angiotensin-Converting
Enzyme Inhibitor Ramipril Undergoing Coronary Artery Bypass Graft Surgery
A (n 16), patients discontinued ramipril 24 hours before surgery;
B (n 16), patients continued ramipril until the morning of surgery;
C (n 15), patients continued ramipril until the morning of surgery
and received vasopressin infusion (0.03 U/min) from the onset of
rewarming
Journal of Cardiothoracic and Vascular Anesthesia, Vol 24, No 2 (April), 2010: pp 230-238
Preoperative Methylene Blue Administration in
Patients at High Risk for Vasoplegic Syndrome During
Cardiac Surgery
One hundred patients scheduled for coronary
artery bypass graft surgery who were at high
risk for vasoplegia because they were
preoperatively using angiotensin-converting
enzyme inhibitors, calcium channel blockers,
and heparin were randomly assigned to either
receive preoperative methylene blue (group 1,
n = 50) or not receive it (group 2, controls, n =
50). Methylene blue (1% solution) was
administered intravenously at a dose of 2
mg/kg for more than 30 minutes, beginning in
the intensive care unit 1 hour before surgery.
Ozal et al ATS 79(5)16151619 2005.
Resuscitation goals
Target MAP between 70-80
Intravascular volume
expansion – careful
administration to avoid
excessive volume loading
Early vasopressor use
Vasopressin: Infusion rates up to
0.06 units/min (maximum) – first
line agent
Norepinephrine: Infusion rates
starting at 0.05 mcg/kg/min –
second line agent, as these
patients may be refractory to
refractory catecholamines.
Other suggested treatments
Methylene blue: 2 mg/kg IV
Correct underlying causes for a
metabolic acidosis
Statement 6: (grade C, level 2)
In patients with vasodilatory shock requiring
vasopressor support and with low filling pressures
methylene blue may reduce the duration of the
vasoplegic syndrome and the need for norepinephrine
infusion.
Methylene blue may also reduce mortality and
morbidity in these patients.
Statement 7: (grade C, level 2)
Prophylactic use of methylene blue may reduce
postoperative CPB hypotension and vasopressor
requirements. Methylene blue in this setting may also
be associated with shorter length of stay in the ICU.
Statement 8: (grade C, level 2)
Prophylactic use of vasopressin reduces postoperative
CPB hypotension and vasopressor requirements.
Vasopressin in this setting may also be associated with
shorter intubation time and length of stay in the ICU.
Role of EMCO/MCS ?
LVAD/BIVAD
ECMO
Case Reports
Treated 2 patients post OHT
1 LVAD
BiVAD
Normal Graft function/profound
hypotension
Profound Acidosis
36 hrs ECMO
Flows 6-8 liters
Resolution of acidosis/hypotension
Both survived with normal function
Summary
Vasoplegia remains hard to predict and
devastating in its impact.
Consider Discontinuing ACEi prior to
cardiac surgery.
Consider prophylactic Vasopression/MB in
high risk candidates.
Consider escalation of MCS ( ECMO/RVAD)
in appropriate scenarios (LVAD, Heart
transplant).
Thank you