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Hydroxocobalamin for the treatment of cardiac surgery-associated vasoplegia: a case series

  • Pranav R. Shah
  • Penny S. Reynolds
  • Nirvik Pal
  • Daniel Tang
  • Harry McCarthy
  • Bruce D. Spiess
Case Reports / Case Series

Abstract

Purpose

Vasoplegia is a clinical syndrome marked by severe arteriolar vasodilatation, hypotension, and low systemic vascular resistance refractory to multiple vasopressor treatment. We report our experience with hydroxocobalamin (B12) infusion as a potential rescue adjunct for refractory vasoplegia during cardiopulmonary bypass (CPB).

Methods

We performed a retrospective chart review of 33 patients undergoing cardiac surgery between 1 January 2013 and 31 December 2015, who were given intravenous B12 for refractory hypotension during, or immediately following, CPB. We assessed mean arterial pressure (MAP) responses using semi-parametric group-based models (trajectory analysis). Vasopressor use was evaluated by norepinephrine-equivalent rates calculated five minutes prior, and up to 60 min following, B12 administration.

Results

Patients were mostly male (82%), had a mean (SD) age of 53 (13) yr, and median (IQR) EuroSCORE mortality index of 9 [4-40]. Four patterns of MAP responses to B12 were identified. In Group 1 (“poor responders”) nine of 33 patients (27%) had the highest median [IQR] mortality risk (EuroSCORE 40 [4-52]), lowest mean pre-B12 MAP (50 mmHg), and minimal hemodynamic response in spite of continued vasopressor support. In contrast, Group 2 “responders” (8/33, 24%) showed a brisk MAP response (> 15 mmHg) to B12, sustained for > 60 min post-infusion, with 50% vasopressor reduction. Groups 3 and 4 had the lowest median mortality risk (EuroSCORE 8) and highest pre-B12 MAP (72 mmHg). Although Group 3 patients (“sustainers”; 9/33, 27%) showed a sustained MAP improvement, those in Group 4 (“rebounders”; 7/33, 21%) were characterized by hypertensive overshoot followed by a decrease in MAP.

Conclusion

These data indicate considerable heterogeneity in patient response to B12, potentially dependent on both patient preoperative condition and non-standardized time of administration. B12 may provide a useful alternative therapy for refractory hypotension and vasoplegia, but controlled clinical trials to assess efficacy are needed.

L’hydroxocobalamine pour le traitement de la vasoplégie associée à la chirurgie cardiaque : une série de cas

Résumé

Objectif

La vasoplégie est un syndrome clinique caractérisé par une vasodilatation artériolaire importante, une hypotension et une résistance vasculaire systémique basse réfractaire au traitement avec plusieurs vasopresseurs. Nous rapportons ici notre expérience concernant une perfusion d’hydroxocobalamine (B12) en tant qu’adjuvant de sauvetage potentiel pour traiter la vasoplégie pendant la circulation extracorporelle (CEC).

Méthode

Nous avons réalisé une analyse rétrospective des dossiers de 33 patients ayant subi une chirurgie cardiaque entre le 1er janvier 2013 et le 31 décembre 2015, et qui ont reçu de la vitamine B12 en intraveineuse pour traiter une hypotension réfractaire pendant ou immédiatement après la CEC. Nous avons évalué les réponses de la tension artérielle moyenne (TAM) à l’aide de modèles semi-paramétriques basés sur le groupe (analyse de trajectoire). L’utilisation de vasopresseurs a été évaluée en taux équivalents à la norépinéphrine et calculée de cinq minutes avant à 60 min après l’administration de B12.

Résultats

Les patients étaient principalement des hommes (82 %), d’un âge moyen (ÉT) de 53 (13) ans, et présentaient un indice de mortalité EuroSCORE médian (ÉIQ) de 9 [4-40]. Quatre types de réponses de la TAM à la B12 ont été identifiés. Dans le groupe 1 (« faible réponse »), neuf des 33 patients (27 %) ont affiché le risque de mortalité médian [ÉIQ] le plus élevé (EuroSCORE 40 [4-52]), la TAM moyenne la plus basse pré-B12 (50 mmHg) et une réponse hémodynamique minimale malgré un traitement continu de vasopresseurs. En revanche, chez les « répondants » du groupe 2 (8/33, 24 %), la réponse de la TAM à la B12 a été rapide (> 15 mmHg), soutenue pendant > 60 min après la perfusion, et l’administration de vasopresseurs a pu être réduite de 50 %. Les groupes 3 et 4 ont manifesté le risque de mortalité médian le plus faible (EuroSCORE 8) et la TAM pré-B12 la plus élevée (72 mmHg). Bien que chez les patients du groupe 3 (« réponse soutenue »; 9/33, 27 %) l’amélioration de la TAM se soit maintenue, les patients du groupe 4 (« réponse rebond »; 7/33, 21 %) étaient caractérisés par une réponse hypertensive suivi d’une diminution de la TAM.

Conclusion

Ces données indiquent une importante hétérogénéité de la réponse des patients à la vitamine B12, laquelle pourrait potentiellement dépendre tant de la condition préopératoire du patient que du moment non standardisé de l’administration de l’agent. La vitamine B12 pourrait constituer un traitement alternatif utile pour l’hypotension réfractaire et la vasoplégie, mais des essais cliniques contrôlés sont nécessaires pour évaluer son efficacité.

Notes

Acknowledgements

We thank P. Taylor and K. Francis (Pharmacy), M. Haines, M. Copland, and S. Bruffy for assistance with record extraction. We thanks the reviewers for thoughtful and constructive comments that greatly improved the manuscript.

Conflicts of interest

None declared.

Editorial responsibility

This submission was handled by Dr. Hilary P. Grocott, Editor-in-Chief, Canadian Journal of Anesthesia.

Author contributions

Pranav R. Shah contributed substantially to study conception and design, data collection and interpretation, and drafting the article and approved the final version of the manuscript. Penny S. Reynolds contributed substantially to data archiving, analysis and interpretation, wrote the manuscript, and approved the final version of the manuscript. Nirvik Pal, Daniel Tang, Harry McCarthy, and Bruce D. Spiess contributed to study design, data collection and interpretation, contributed to manuscript drafts, and approved the final version of the manuscript.

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Copyright information

© Canadian Anesthesiologists' Society 2017

Authors and Affiliations

  • Pranav R. Shah
    • 1
  • Penny S. Reynolds
    • 1
    • 2
  • Nirvik Pal
    • 1
  • Daniel Tang
    • 3
  • Harry McCarthy
    • 3
  • Bruce D. Spiess
    • 1
    • 2
  1. 1.Department of AnesthesiologyVirginia Commonwealth University-Medical College of VirginiaRichmondUSA
  2. 2.Department of Anesthesiology, College of MedicineUniversity of FloridaGainesvilleUSA
  3. 3.Department of SurgeryVirginia Commonwealth University-Medical College of VirginiaRichmondUSA

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