羟钴胺成功治疗非体外循环冠状动脉搭桥术后严重难治性血管麻痹性休克综合征：一例报告并文献复习

Severe Refractory Vasoplegic Shock Syndrome after OPCABG Successfully Treated with Hydroxycobalamin: A Case Report and Review of the Literature.

作者信息

Bacchi Beatrice, Cabrucci Francesco, Chiarello Bruno, Dokollari Aleksander, Bonacchi Massimo

机构信息

Cardiac Surgery F.U., Experimental and Clinical Medicine Department, University of Florence, 50134 Firenze, Italy.

Cardiac Surgery Department, St. Boniface Hospital, University of Manitoba, Winnipeg, MB R2H 2A6, Canada.

出版信息

J Clin Med. 2023 Dec 28;13(1):169. doi: 10.3390/jcm13010169.

DOI:10.3390/jcm13010169

PMID:38202178

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC10779867/

Abstract

BACKGROUND

Vasoplegic shock syndrome (VSS) after an off-pump coronary artery bypass graft (OPCABG) is an extremely rare condition. Inotropic support is usually the first-line therapy, though it can precipitate several complications or be ineffective. We report the first case of severe refractory VSS after OPCABG successfully treated with hydroxycobalamin.

METHODS

A 77-year-old gentleman underwent OPCABG for three vessels coronary artery disease. Preoperative LV ejection fraction was 28%, and the patient before surgery started sacubitril/valsartan titrated, then, at the highest dose. Surgery was uneventful and, by the end of the procedure, TEE showed improved biventricular contractility.

RESULTS

The patient was transferred to the ICU without inotropic support, but soon developed hypotension. TEE ruled out pericardial tamponade and confirmed fair contractility. Norepinephrine was titrated to a medium-high dose, vasopressin was started and a Swan-Ganz catheter was placed. SVR was 480 dyn·s·cm. Despite aggressive pharmacologic treatment (including methylprednisolone and methylene blue), no improvements were noticed. Ten grams of hydroxycobalamin were administered. One hour later, hemodynamic status re-assessment showed SVR > 800 dyn·s·cm. Afterward, vasopressors were gradually reduced.

CONCLUSIONS

Our case demonstrated the importance of adequate early treatment in VSS after OPCABG. This case report shows, for the first time, that hydroxycobalamin was effectively used to restore homeostasis.

摘要

背景

非体外循环冠状动脉搭桥术（OPCABG）后发生的血管麻痹性休克综合征（VSS）极为罕见。尽管正性肌力支持通常是一线治疗方法，但它可能引发多种并发症或无效。我们报告了首例经羟钴胺成功治疗的OPCABG术后严重难治性VSS病例。

方法

一名77岁男性因三支血管冠状动脉疾病接受OPCABG。术前左心室射血分数为28%，患者在手术前开始滴定沙库巴曲缬沙坦，随后达到最高剂量。手术过程顺利，手术结束时，经食管超声心动图（TEE）显示双心室收缩功能改善。

结果

患者在未使用正性肌力支持的情况下转入重症监护病房（ICU），但很快出现低血压。TEE排除心包填塞并确认收缩功能尚可。去甲肾上腺素滴定至中高剂量，开始使用血管加压素并放置了Swan-Ganz导管。全身血管阻力（SVR）为480 dyn·s·cm。尽管进行了积极的药物治疗（包括甲泼尼龙和亚甲蓝），但未见改善。给予10克羟钴胺。一小时后，血流动力学状态重新评估显示SVR>800 dyn·s·cm。此后，血管加压药逐渐减量。