A retrospective analysis of terlipressin in bolus for the management of refractory vasoplegic hypotension after cardiac surgery

Abstract

Cardiac surgery performed with cardiopulmonary bypass (CPB) may be complicated by hypotension due to low systemic vascular resistance (SVR). Often in those cases, hypotension is resistant to pressor catecholamines. We report six cases of norepinephrine-resistant postcardiotomy hypotension, treated by terlipressin (TP), a potent vasopressor agent. Between May 2007 and May 2008, we treated six patients with TP administration (1 mg bolus) for post CPB refractory vasodilatory hypotension. Analyzed parameters were: mean arterial pressure (m-AP), SVR, cardiac output index (CI), mean pulmonary pressure (m-PP), and lactate, at baseline (before TP bolus) and 3 h after injection. Before TP bolus, the average m-AP was 53.32+/-8.86 mmHg, the CI was 3.45+/-0.24 l/min/m(2), the SVR was 650+/-62.03 dyne*s/cm(5) and the arterial lactate level was 4.6+/-0.95 mmol/l. Three hours after the TP bolus, the m-AP increased to 81.83+/-9.71 mmHg (P=0.002), the CI decreased to 2.88+/-0.14 l/min/m(2) (P=0.002), the SVR increased to 1154+/-116 dyne*s/cm(5) (P=0.002), and arterial lactates decreased to 3.13+/-0.78 mmol/l (P=0.015), without significant modification of m-PP and CVP. We treated postoperative refractory low SVR hypotension by TP administration in bolus. Exogenous administration of TP normalized SVR and increased the systemic arterial pressure with a minimum effect on pulmonary pressure. Subsequently, the effect on systemic blood pressure enhanced urine output. No major collateral effects were observed. The administration of TP in bolus may result as a useful alternative for treating refractory low SVR hypotension post CPB.

2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery

“…192 Vasopressors (epinephrine, norepinephrine, vasopressin, terlipressin, phenylephrine, metaraminol, methylene blue, hydroxocobalamin and combinations) are required to treat vasoplegic syndrome during CPB. 194,195 In an RCT enrolling patients under angiotensin-converting enzyme inhibitors, methylene blue was effective for the prevention/treatment of vasoplegic syndrome (compared to saline), resulting in lower lactate levels during and after CPB. 196 In a similar patient population, vasopressin was effective in preventing/treating vasoplegic syndrome compared to saline.…”

When the pressure drops: A case of vasoplegia during a structural heart intervention

“…Furthermore, Boccara et al found that patients undergoing carotid endarterectomy who had hypotension refractory to ephedrine had less hypotensive episodes when treated with terlipressin as opposed to norepinephrine. Few other studies have demonstrated the efficacy of AVP analogs in catecholamine refractory VS . However, use of RASi preoperatively in these studies was not reported.…”

Vasoplegic syndrome after cardiovascular surgery: A review of pathophysiology and outcome‐oriented therapeutic management

“…Therefore, MB is recommended only as a rescue therapy for treating post-cardiac surgery VPS. 29 High doses of hydroxocobalamin (5 gm iv bolus over 15 min, and maximum of 10 g) have been used successfully as a rescue therapy in a case report of refractory VPS during cardiac surgery on CPB, that was unresponsive to high doses of epinephrine, NE, vasopressin, and MB. 12 Therefore, hydroxocobalamin has been recommended only as a rescue therapy in VPS unresponsive to other vasopressors.…”