[HSF] Any One Had This Complication?

Mon Apr 28 09:05:26 EDT 2008

Ah the ARB and ACE disaster. When I was initially attempting repairs I used
to not stop ACE (ARB's where not available then) and Ca channel blockers. I
used to end up with all these patients on dobut, dopa and adrenaline. These
hearts used to be bouncing on table but used to have low pressures. I
started floating swans and found that they indeed have less SVR's. Around
the same time the theory of ACEI induced vasoplegia came around and I
stopped all ACEI Ca blocjkers  for at lest 48 hours before surgery and there
was a dramatic reduction in the use of vasoconstricting inotropes.
Vasoplegia is now rare (In fact the last case I had was precisely in a
patient where the ACEI was mistakenly not stopped and when confronted with a
vasoplegic situation I rechecked the orders and found that the ACEI was not
withdrawn.) ACEI can be removed easily and I usually place the patient on
additional oral short acting nitrate during that period.
As far as resistant vasoplegia goes Methylene blue can be used (painful-
ccan cause renal Ischemia and problems with oximetry) and also other things
that can help are patient postioning (foot raising, stockings. People can
use a MAST antishock device if available) , Abdominal binders etc as
nonpharmacological means. Vasoplegia usually resolves with time. Keeping the
patient alive and well perfused being the challenge in the interim.
As an aside even small doses of dobutamine become extremely provasoplegic in
ACEI induced vasoplegia (I have repeatedly documented this) and needs to be
completely withdrawn. The best Inotrope in this situation (if required) is
usually Noradrenaline.
Prasanna
On Mon, Apr 28, 2008 at 7:52 AM, <smschwartz at mac.com> wrote:

> Valsartan (ARB).
> We try to use vasopress in doses below 0.1 mcg/kg/min. We also measure
> cerebral O2 sats with the Somanetics monitor. How do you handle a
> vasodilated patient, refractory to neosynephrine and vasopressin?
>
> SMSMD
>
> -----Original Message-----
>
> From:  Prasanna Simha M <prasannasimha at gmail.com>
> Subj:  Re: [HSF] Any One Had This Complication?
> Date:  Sun Apr 27, 2008 7:03 pm
> Size:  3K
> To:  OpenHeart-L at lists.hsforum.com
>
> Steve, Vasopressin can cause this.In fact it was the suspected culprit in
> one of the cases.
> What is Diovan ?
> Prasanna
>
> On Mon, Apr 28, 2008 at 4:41 AM, Steven Schwartz <smschwartz at mac.com>
> wrote:
>
> > Hal,
> > Very interesting timing. I did an aortic root replacement (27mm SJM with
> > valsalva graft), coronary reimplantation and RIMA-RCA for 80% proximal
> RCA
> > stenosis in a 65 yo man WITHOUT history of significant vascular disease
> (and
> > good distal pulses on exam). He had two bloody stools the evening after
> > surgery, but only a mild metabolic acidosis. The following morning,
> > hemodynamics were stable, but CK was about 5000, with very little MB
> > fraction. GI medicine has seen him, his abdomen in non-tender, and he
> seems
> > to be resolving what we think was a transient bowel ischemia. Pump flows
> > were >5 l/m, he had no acidosis during the pump run, but was
> significantly
> > vasodilated during and after bypass (requiring vasopressin infusion to
> keep
> > his BP > 50 mmHg). He was on 320mg of Diovan in addition to beta
> blockers
> > preop.
> > Any thoughts?
> > Steven Schwartz
> >
> >
> > On Apr 27, 2008, at 5:49 AM, Hgrmd at aol.com wrote:
> >
> >  Dear Members,
> > >  Last Friday was a tough day at the office.  First I did a  mitral,
> > > tricuspid, Cox-maze, CABG x1 on a 72 yo lady.  I then did an AVR,  MVR
> > > (heavily
> > > calcified posterior annulus), tricuspid, CABG x 4, Cox-maze on a 78
>  yo
> > > man.  His
> > > past history was notable for the fact that he had an  aorto-enteric
> > > fistula
> > > (previous AAA repair) requiring excision of the graft and  a right
> > > axillary-bifemoral bypass.  Intraop, I noticed that the LIMA had
> > >  unusually brisk flow.
> > > About 4 hours postop, he had a bright red  stool.  NG aspirate
> > > nonbloody.  By
> > > yesterday afternoon, he had begun  to develop abdominal tenderness.
>  He
> > > had a lap
> > > in the early evening.   There was a dead colon requiring resection.
>  The
> > > small
> > > bowel reportedly  looked ischemic, but viable.  He's much better this
> > > morning, though he's  now developed ATN.  His heart is working great.
> > >  It'll be a
> > > struggle,  but I'm cautiously optimistic he'll make it.  Anybody seen
> > > this
> > > scenario?
> > >
> > > Hal
> > >
> > >
> > >
> > > **************Need a new ride? Check out the largest site for U.S.
> used
> > > car
> > > listings at AOL Autos.
> > > (http://autos.aol.com/used?NCID=aolcmp00300000002851)
> > > _______________________________________________
> > > OpenHeart-L mailing list
> > >
> > > Send postings to:
> > > OpenHeart-L at lists.hsforum.com
> > >
> > > To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> > > http://mmp.cjp.com/mailman/listinfo/openheart-l
> > >
> > > All messages transmitted by the OpenHeart-L are subject to the
> policies
> > > and
> > > disclaimers posted at:
> > > http://www.hsforum.com/listdisclaim
> > > -----------------------------------------
> > >
> >
> > Steven M. Schwartz, MD
> > smschwartz at mac.com
> >
> >
> >
> >
> > _______________________________________________
> > OpenHeart-L mailing list
> >
> > Send postings to:
> > OpenHeart-L at lists.hsforum.com
> >
> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> > http://mmp.cjp.com/mailman/listinfo/openheart-l
> >
> > All messages transmitted by the OpenHeart-L are subject to the policies
> > anddisclaimers posted at:
> >
> > http://www.hsforum.com/listdisclaim
> > -----------------------------------------
> >
>
>
>
> --
> Prasanna Simha M
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
>  OpenHeart-L at lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the policies
> and
> disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------
>
> --- message truncated ---
>
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
>  OpenHeart-L at lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the policies
> and
> disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------
>

-- 
Prasanna Simha M