What is Vasoplegic Syndrome and Noncatecholamine Therapies?
Vasoplegic syndrome (VPS) is a serious but rare condition where the body’s blood vessels expand too much. This causes a significant drop in blood pressure, despite the heart functioning normally or even pumping more blood than usual. VPS most commonly appears during heart surgeries but can also occur during organ transplants, severe allergic reactions, and bacterial infections causing shock.
VPS can be fatal, with death rates of up to 25%, so it’s crucial to quickly identify and treat this condition. Primary treatment involves medication like catecholamines, but other possible treatments include substances like vasopressin, methylene blue, hydroxocobalamin, angiotensin II, and ascorbic acid, which have all shown benefits.
The development of VPS involves complex factors, including inflammation responses and disturbances of substances that control blood vessel size. Further complicating matters, there are a number of risk factors, varying from extended periods on a heart-lung bypass machine during surgery, to a patient’s medication history. Understanding these complexities may not be a part of standard medical training, emphasizing the need for more detailed learning when it comes to VPS.
What Causes Vasoplegic Syndrome and Noncatecholamine Therapies?
Cardiac surgery and the use of an external system mimicking the functions of the heart and lungs during surgery are common factors that can lead to vasoplegia, a condition characterized by extremely low blood pressure. These factors can increase the risk of Vasoplegic Syndrome (VPS) – especially if the bypass process (cardiopulmonary bypass) is prolonged.
Vasoplegia can easily occur during heart surgeries, particularly in older people. Other factors that could lead to this condition include prolonged clamping of the aorta (the major blood vessel supplying blood to the body), and the use of certain medications like angiotensin-converting enzyme inhibitors (ACEi, which is used to treat high blood pressure and heart failure) and diuretics (used to remove excess water and sodium from the body) before surgery.
Liver transplantation surgeries come with a high chance of developing VPS and are a significant risk factor during such operations. Other organ transplants, like kidney, heart, and lung transplants also pose an increased risk for VPS.
Additional risk factors for VPS include blood transfusions, the use of devices that support heart function (ventricular assist devices), the use of β-blockers and calcium channel blockers (both types of blood pressure medications), a medication for heart rhythm disorders known as amiodarone, and certain conditions like heart failure, and diabetes.
Below the clinical risk factors are outlined for vasoplegic syndrome in both heart and non-heart related surgeries.
Risk factors For Vasoplegic Syndrome
Cardiac Surgery Risk Factors: Male gender, High Body Mass Index (BMI), End-Stage Renal Disease (ESRD), Left Ventricular Assist Device (LVAD), Long cardiopulmonary bypass times, Infection of the heart’s inner lining (Infective endocarditis), Use of drugs that increase heart muscle flexibility and widen blood vessels (inodilators), Use of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs), Older age, Lower than normal ejection fraction (percentage of blood leaving your heart each time it contracts), Diabetes, History of heart attack, High score in the European System for Cardiac Operative Risk Evaluation (EURO score), and High number of blood transfusions.
Non-cardiac Surgery Risk Factors: Blood transfusions, Organ Transplant, Trauma, Burns, Serious infection spreading through the bloodstream (Sepsis), Inflammation of the pancreas (Pancreatitis), Use of the blood thinner medication Heparin, The diabetes medication known as Metformin, Use of the heart rhythm disorder medication identified as Amiodarone, Use of angiotensin-converting enzyme inhibitors (ACEi/ARBs) and calcium channel blockers, and the Use of diuretics.
Risk Factors and Frequency for Vasoplegic Syndrome and Noncatecholamine Therapies
Vasoplegic syndrome (VPS) is a condition mentioned in various medical studies, with reported cases varying from 5% to 25% in heart-related research. It’s also found in patients undergoing other procedures like liver transplantation. However, there’s no globally agreed-upon definition for VPS, which makes it hard to accurately count how many patients have it. Making matters more complex, VPS is also called by other names like distributive shock, vasoplegic shock, and post-cardiac surgery vasoplegia, all referring to similar conditions.
- VPS has been reported in heart-related studies and surgeries such as liver transplants.
- The lack of a globally accepted definition and the existence of similar conditions under different names make it difficult to accurately count VPS cases.
- If VPS is not treated, it is always fatal. Even with treatment, the death rate can be as high as 25%, especially when the condition doesn’t respond to standard treatments.
Signs and Symptoms of Vasoplegic Syndrome and Noncatecholamine Therapies
When estimating the risk of Vasoplegic Syndrome (VPS) in a patient, certain elements from their medical history are key factors to consider. These factors include the duration of heart-lung machine or aortic clamp use, the patient’s age, if they’ve been using angiotensin-converting enzyme inhibitors (commonly known as ACE inhibitors), and any occurrence of kidney failure.
VPS often results in signs of poor blood circulation. However, these signs are not always evident. Patients can have warm limbs, even with low blood pressure, because their blood vessels are opening up (vasodilation). The heart usually beats at a normal or faster rate as the body tries to make up for the low level of systemic vascular resistance. It’s also possible to notice signs that the tissues aren’t getting enough blood. The skin may develop a blotchy, marbled appearance or blood may not return as quickly as it should when a piece of skin is pressed and released (known as delayed capillary refill). Other signs include a decrease in urine formation (less than 0.5 ml per kg per minute) and changes in mental function such as reduced alertness and confusion.
- Duration of use of heart-lung machine or aortic clamp
- Patient’s age
- Use of ACE inhibitors
- Occurrence of kidney failure
- Low blood pressure
- Warm limbs
- Normal or faster heart rate
- Blotchy, marbled skin appearance or delayed capillary refill
- Decreased urine formation
- Reduced alertness or confusion
Testing for Vasoplegic Syndrome and Noncatecholamine Therapies
Vasoplegic syndrome, or VPS, is a condition where your blood vessels can’t tighten properly. This leads to low blood pressure because the blood cannot circulate efficiently, even though your heart is working normally or even harder than usual. There isn’t a universally accepted way to diagnose VPS, but doctors look at specific factors such as the average pressure in your arteries and how well your heart is pumping.
While people have known about the vasoplegic syndrome since the early 1950s, it has gained recent attention because it can cause dangerously low blood pressure during very specific operations like organ transplants or heart surgeries. It can also occur during severe allergic reactions (anaphylaxis) and in severe infections (septic shock).
The table below gives specific medical parameters that are characteristic of vasoplegic syndrome:
– Cardiac Index (CI): measures how well your heart is pumping. In VPS it is usually 2.2 liters per minute per square meter or more.
– Mean Arterial Pressure (MAP): the average pressure in a person’s arteries during one heartbeat. In VPS it is usually less than 60 mmHg.
– Systemic Vascular Resistance (SVR): measure of the resistance to blood flow. In VPS it is less than 800 dynes sec/cm5.
– Heart rate, right atrial pressure, left atrial pressure, pulmonary capillary wedge pressure, and mean pulmonary artery pressure: These are all different ways of measuring how your heart and blood vessels are functioning. In VPS all these values can be low.
– Vasopressor Dose: If 0.5 micrograms/kg/minute of norepinephrine equivalents (a type of medicine to raise blood pressure) isn’t working, then it could be a sign of VPS.
– Volume Expansion Response: If your body doesn’t respond to treatments intended to increase blood volume, it might be a sign of VPS.
Treatment Options for Vasoplegic Syndrome and Noncatecholamine Therapies
Vasoplegic syndrome is a medical issue where a person’s blood pressure remains low and their blood vessels are overly relaxed or dilated. Traditional therapies involving chemicals called catecholamines can sometimes be inadequate or potentially harmful. This means that doctors need to consider alternative treatments to overcome the challenges of this condition. Non-catecholamine treatments, such as vasopressin, methylene blue, hydroxocobalamin (a type of vitamin B12), angiotensin II, and ascorbic acid (vitamin C), provide different ways of managing the condition.
These alternative treatments, also known as non-catecholamine approaches, offer promising potential for managing vasoplegic syndrome. They work by restoring the normal tension of blood vessels and blocking key enzymes in dilation or relaxation of blood vessels. As the medical community continues to search for the best strategies to treat vasoplegia, this information helps provide insights for understanding and applying non-catecholamine therapies in real-world medical practice.
For instance, when standard drug therapy is ineffective at managing blood pressure or causes side effects, vasopressin may be used as an additional treatment. The way vasopressin works involves acting on a certain receptor to restore normal blood vessel tension. If traditional therapy isn’t working or isn’t safe, vasopressin offers a valid alternative approach.
Methylene blue is another potential treatment for this condition. While more research is needed to determine its precise effects on outcomes such as sickness and death rates, current evidence indicates that methylene blue can effectively enhance parameters indicative of good heart health and decrease the need for vasopressin, thereby preventing undesired effects.
A type of vitamin B12, known as hydroxocobalamin, may serve as a last resort for treating vasoplegia after cardiac surgery (heart surgery). It works by obstructing certain enzymes, ultimately reducing low blood pressure. However, it’s important to remember that its use is limited since it can cause changes in urine color and can slightly interfere with common lab measurements.
Angiotensin II is considered an option when high-dose vasopressors (drugs that constrict blood vessels) aren’t working. It can support the response to catecholamine-induced issues by redirecting blood from the intestines and promoting the clearance of lactic acid (a by-product of sugar metabolism).
Lastly, ascorbic acid, or vitamin C, has shown promise in treatment. This vitamin may help decrease the need for other vasopressors, hence reducing potential side effects. When vitamin C levels are reduced, as happens after a certain type of heart surgery, treatment with this vitamin could enhance the production of natural vasopressors (chemicals that increase blood pressure).
What else can Vasoplegic Syndrome and Noncatecholamine Therapies be?
Ventricular Septal Perforation (VPS) behaves differently than other heart conditions, like hypovolemic shock. Hypovolemic shock happens when you lose a lot of blood or body fluids, which can lower the amount of blood your heart pumps out. Your blood vessels can then narrow to try to keep your blood pressure normal. On the other hand, cardiogenic shock is when your heart can’t pump effectively following a heart attack or severe heart failure. This also results in less blood flow, but additionally, your blood vessels can tighten more to make up for the loss of effective pumping. Such differences mean that these two conditions involve unique body reactions and need to be treated differently.
What to expect with Vasoplegic Syndrome and Noncatecholamine Therapies
The future health of patients who develop a condition known as VPS largely depends on the root cause, and if there are any risk factors present. VPS can last for up to 72 hours, and it is associated with a higher risk of death, with rates reaching up to 25%. Orthotopic heart transplantation, which means replacing a diseased heart with a healthy one, is also associated with high early death rates, as much as 25%.
Patients who need vasopressors, a type of medication that constricts (narrows) blood vessels to increase blood pressure after heart surgery, is viewed as a significant health event. This emphasizes the need to identify risk factors early and plan for preventive and early treatment. Non-catecholamine therapies, like vasopressin and methylene blue, are a type of treatment that can reduce reliance on vasopressors and can help improve patient outcomes. Research supports that treating patients who rely heavily on vasopressors can improve their health outcomes, which emphasizes the need for more large studies on this subject.
Possible Complications When Diagnosed with Vasoplegic Syndrome and Noncatecholamine Therapies
People with this condition often need to be on a ventilator for an extended amount of time. Additionally, if they encounter a similar amount of blood loss, they typically need significantly more transfusions of packed red blood cells. They may also need more transfusions of fresh frozen plasma. There is a heightened risk of sudden kidney failure. Lastly, their stay in intensive care may be longer than typically expected.
- Long-term ventilator use
- Increased need for packed red blood cell transfusions after blood loss
- Greater demand for fresh frozen plasma transfusions
- Raised risk of sudden kidney failure
- Extended stay in the intensive care unit
Preventing Vasoplegic Syndrome and Noncatecholamine Therapies
Vasoplegic syndrome (VPS) is a condition where your body’s blood vessels become too relaxed. This can lead to low blood pressure, even when your heart is operating normally. This situation commonly occurs after certain operations, particularly heart surgeries, or during certain situations like infection, physical trauma, or following organ transplant surgeries involving the lungs, heart, or liver.
There are several factors that can make you more prone to VPS, such as heart disease, being older, living with diabetes, being male, obesity, or taking certain types of medication. These medications can include amiodarone, medications that help regulate hormones and blood pressure (angiotensin-converting enzyme inhibitors), and medicines that help relax and widen blood vessels (calcium-channel blockers).
If you have VPS, you might need to take in more fluids and be given medication that helps take your blood pressure back up to a healthy level (vasopressors). These vasopressor medications help by narrowing your blood vessels and increasing resistance to blood flow.
Remember, while VPS is typically a short-term condition, if it’s not attended to promptly and appropriately, it could lead to organ failure or even death.
