Extended duration infusion of high-dose hydroxocobalamin for vasoplegic syndrome following cardiac surgery

Seelhammer, Troy G.; Plack, Daniel L; Nei, Scott D; Wittwer, Erica D.; Nelson, James A.; Nabzdyk, Christoph S.

doi:10.1016/j.hrtlng.2020.11.003

Cited by 15 publications

(33 citation statements)

References 6 publications

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“…In the setting of sepsis, data are limited to a previous case report in which HCB was successfully used for the management of vasopressor refractory septic shock in two patients [18]. This case adds to that literature and suggests extending the dosing over four hours instead of a bolus [15,19].…”

Section: Discussionmentioning

confidence: 94%

“…Of note, we used the same dose as previously reported (5 g), but in our case, this was administered as an extended infusion over four hours. An extended duration infusion was utilized because a previous report described the duration of hemodynamic effect from a bolus lasting about 210 minutes [9], while the literature demonstrates positive hemodynamic effects extending to 600 minutes with the extended duration infusion [15,19]. Therefore, as previously mentioned, to sustain the desired effects beyond 210 minutes (observed for 19 hours in this case), the dose was extended over four hours.…”

Section: Discussionmentioning

confidence: 98%

“…This report supports previous literature and advocates for an extended duration infusion of high-dose HCB, which may offer an advantage by attenuating the prolonged NO dysfunction encountered in sepsis. This strategy was chosen because in a previous study of postcardiac surgery vasoplegia, the beneficial hemodynamic effects only lasted 210 minutes after a bolus [9], but lasted 600 minutes with an extended duration infusion [15,19]. In sepsis, NO elicits both beneficial and deleterious effects on various organ systems, which are not limited to a short timeframe such as during cardiopulmonary bypass cases [20].…”

Section: Discussionmentioning

confidence: 99%

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Extended Duration Infusion of Hydroxocobalamin for Vasoplegic Rescue in Septic Shock

Gerdes¹,

Seelhammer²,

Nei³

et al. 2021

Cureus

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Nitric oxide (NO) is a gaseous signaling molecule and a key endogenous mediator of vascular tone. Hydroxocobalamin (HCB) affects NO-mediated vasoplegia as (1) a direct inhibitor of nitric oxide synthase (NOS), thereby decreasing its production, and (2) by binding directly to NO and acting as a scavenger. HCB has been increasingly used in the treatment of refractory vasoplegia, particularly in cardiac surgery and liver transplant patients. Sepsis and septic shock are characterized by an increase in inducible NOS expression and activity with excessive NO production, resulting in endothelial dysfunction and profound systemic vasodilation. Therefore, a careful sustained reduction in NO burden represents a potential therapeutic target. Here, we present a case of refractory septic shock, which resolved after an extended duration infusion of high-dose HCB. We hope to foster further exploration regarding the safety, dosing, and efficacy of HCB when administered for vasopressor refractory septic shock.

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Section: Discussionmentioning

confidence: 94%

Section: Discussionmentioning

confidence: 98%

Section: Discussionmentioning

confidence: 99%

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Extended Duration Infusion of Hydroxocobalamin for Vasoplegic Rescue in Septic Shock

Gerdes¹,

Seelhammer²,

Nei³

et al. 2021

Cureus

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“…Given its off-label use in treating vasoplegia, the dosing of this drug in our center is based on its primary indication of cyanide poisoning - 5-10 g IV infusion over 15 minutes. A recently published case series from the USA investigated the effects of extended duration infusion of the same 5 g dose (median 6h, range 1-10h), finding a significant and gradual reduction of vasopressor requirements throughout the infusion, which appeared to be sustained after cessation [ 17 ]. Further studies may be helpful in determining optimal dosing for the indication of vasoplegic shock.…”

Section: Discussionmentioning

confidence: 99%

High-Dose Hydroxocobalamin for Refractory Vasoplegia Post Cardiac Surgery

Bak¹,

Smith²,

Murfin³

et al. 2022

Cureus

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Administration of high-dose hydroxocobalamin, or vitamin B12, is an emerging, targeted rescue therapy for the treatment of refractory vasoplegic shock. This is an uncommon but potentially life-threatening complication following cardiac surgery and carries a poor prognosis, particularly when patients fail to respond to first-line therapy with catecholamine vasopressors. This study describes our experience in treating refractory vasodilatory shock following cardiac surgery with high-dose hydroxocobalamin. Administration of hydroxocobalamin in seven patients was associated with an improvement in mean arterial blood pressure or reduction in vasopressor requirements, which were both immediate and sustained throughout our observational period. No deaths or adverse effects attributable to hydroxocobalamin administration occurred in our cohort. Our observations show that high-dose hydroxocobalamin is a safe and effective rescue therapy in refractory vasoplegic shock post cardiopulmonary bypass (CPB).

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“…Indeed, four distinct patterns were identified, including no response (“poor responders”, 27%), brisk and sustained increase (“responders”, 24%), progressive increase (“sustainers”, 27%) and brisk increase followed by rebound hypotension (“rebounders”, 21%) [ 127 ]. Since such heterogeneity might be due, partly, to the mode of administration (bolus), Seelhammer et al evaluated the effects of a continuous infusion of hydroxocobalamin (5 g over 6 h) post-operatively in 12 patients with severe VS, showing that such regimen permitted a prolonged (>10 h) and significant reduction in vasopressors in all patients [ 128 ].…”

Section: Managementmentioning

confidence: 99%

Vasoplegic Syndrome after Cardiopulmonary Bypass in Cardiovascular Surgery: Pathophysiology and Management in Critical Care

Ltaief

Ben-Hamouda

Rancati

et al. 2022

JCM

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Vasoplegic syndrome (VS) is a common complication following cardiovascular surgery with cardiopulmonary bypass (CPB), and its incidence varies from 5 to 44%. It is defined as a distributive form of shock due to a significant drop in vascular resistance after CPB. Risk factors of VS include heart failure with low ejection fraction, renal failure, pre-operative use of angiotensin-converting enzyme inhibitors, prolonged aortic cross-clamp and left ventricular assist device surgery. The pathophysiology of VS after CPB is multi-factorial. Surgical trauma, exposure to the elements of the CPB circuit and ischemia-reperfusion promote a systemic inflammatory response with the release of cytokines (IL-1β, IL-6, IL-8, and TNF-α) with vasodilating properties, both direct and indirect through the expression of inducible nitric oxide (NO) synthase. The resulting increase in NO production fosters a decrease in vascular resistance and a reduced responsiveness to vasopressor agents. Further mechanisms of vasodilation include the lowering of plasma vasopressin, the desensitization of adrenergic receptors, and the activation of ATP-dependent potassium (KATP) channels. Patients developing VS experience more complications and have increased mortality. Management includes primarily fluid resuscitation and conventional vasopressors (catecholamines and vasopressin), while alternative vasopressors (angiotensin 2, methylene blue, hydroxocobalamin) and anti-inflammatory strategies (corticosteroids) may be used as a rescue therapy in deteriorating patients, albeit with insufficient evidence to provide any strong recommendation. In this review, we present an update of the pathophysiological mechanisms of vasoplegic syndrome complicating CPB and discuss available therapeutic options.

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Extended duration infusion of high-dose hydroxocobalamin for vasoplegic syndrome following cardiac surgery

Cited by 15 publications

References 6 publications

Extended Duration Infusion of Hydroxocobalamin for Vasoplegic Rescue in Septic Shock

Extended Duration Infusion of Hydroxocobalamin for Vasoplegic Rescue in Septic Shock

High-Dose Hydroxocobalamin for Refractory Vasoplegia Post Cardiac Surgery

Vasoplegic Syndrome after Cardiopulmonary Bypass in Cardiovascular Surgery: Pathophysiology and Management in Critical Care

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