Table 1
Vasoplegic risk factors during cardiopulmonary bypass. BMI: body mass index; LVAD: left ventricular assist device; ACE: angiotensin converting enzyme
| Left ventricular ejection fraction > 40% |
| Male sex |
| Elderly |
| Higher BMI |
| Presence of LVAD |
| Duration of cardiopulmonary bypass |
| Immediate hypotension after cardiopulmonary bypass initiation |
| ACE inhibitor administration perioperatively |
| Infective endocarditis |
Figure 1
Pathophysiology of postcardiac vasoplegia syndrome. AVP: arginine-vasopressin; NE: norepinephrine; PHE: phenylephrine; V1: vasopressin receptor; α: alpha receptor; A2A ADP: adenosine receptor; NO: nitric oxide; SVR: systemic vascular resistance; CO: cardiac output; BP: blood pressure; LV: left ventricular; SIRS: systemic inflammatory response syndrome; A-M: actin-myosin; IP3: inositol triphosphate; KATP: adenosine triphosphate-sensitive potassium channel; ATP: adenosine triphosphate; cAMP: cyclic adenosine monophosphate; GTP: guanosine triphosphate; cCMP: cyclic guanosine monophosphate. Reprinted with permission from Elsevier.
Figure 2
Factors leading to the pathophysiology of vasoplegia.
Table 2
Therapeutic options for management of vasoplegia after cardiac surgery.1,10,42 NO: nitric oxide; V1: vasopressin; AT1: angiotensin 1
| TREATMENT OPTION | RECOMMENDED DOSAGE | MECHANISM OF ACTION |
|---|---|---|
| Catecholamines | ||
| Norepinephrine | 0.01-0.2 µg/kg/min | Strong α-1, α-2, and mild β-1 adrenergic agonist |
| Epinephrine | 0.01-0.5 mcg/kg/min | Strong α-1, α-2, and β-1 adrenergic agonist |
| Dopamine | 0-20 mcg/kg/min | α-1 adrenergic agonist at higher doses (dose-dependent agonism) |
| Phenylephrine | 0.5-5 µg/kg/min | α-1 and α-2 adrenergic agonist |
| Non-catecholamine agents | ||
| Vasopressin | 0.03 U/min | Acts on AVPR1a receptor to reduce vasodilatory effects of NO; V1 agonist |
| Methylene blue | 1.5-2.0 mg/kg/bolus over 15 to 30 minutes | Inhibits guanylyl cyclase and endothelial NO synthase |
| Angiotensin 2 | Start 20 ng/kg/min | AT1 agonist; stimulates release of vasopressin from posterior pituitary gland and release of aldosterone from adrenal gland |
| Hydroxocobalamin | 5 g infusion over 5 min | Inhibits guanylyl cyclase, endothelial NO synthase, and hydrogen sulfide |
| Ascorbic acid | 6 g IV bolus/day | Acts as a cofactor for catecholamine synthesis |
| Hydrocortisone | 50 mg bolus every 6 h or 100 mg every 8 h (10 mg/h) | Hydrocortisone in addition to vitamin C, and thiamine decrease required dose for vasopressors; improves catecholamine response |