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Vasoplegic Syndrome Otterbein University Digital Commons @ Otterbein Nursing Student Class Projects (Formerly MSN) Student Research & Creative Work Summer 2018 Vasoplegic Syndrome Monica Arce [email protected] Follow this and additional works at: https://digitalcommons.otterbein.edu/stu_msn Part of the Nursing Commons Recommended Citation Arce, Monica, "Vasoplegic Syndrome" (2018). Nursing Student Class Projects (Formerly MSN). 272. https://digitalcommons.otterbein.edu/stu_msn/272 This Project is brought to you for free and open access by the Student Research & Creative Work at Digital Commons @ Otterbein. It has been accepted for inclusion in Nursing Student Class Projects (Formerly MSN) by an authorized administrator of Digital Commons @ Otterbein. For more information, please contact [email protected]. Vasoplegic Syndrome Monica Arcé BSN-RN, CCRN Otterbein University, Westerville, Ohio Introduction Underlying Pathophysiology Significance of References Presentation of Process Treatments Abou-Arab, O., Martineau, L., Bar, S., Huette, • Contact with the CPB circuit immediately absorbs • The reinfused blood contains hemolyzed P., Amar, A. B., Caus, T., ... & Lorne, E. Pathophysiology • Vasopressors (high dose) What is Vasoplegic Risk Factors plasma proteins into the biomembranes and erythrocytes and macroaggregates such as (2018). Postoperative Vasoplegic directly activates the kinin, complement, and denatured proteins, fat globules and platelet and • Severe, persistent, refractory hypotension Syndrome Is Associated With Impaired clotting pathways leukocyte aggregates • Norepinephrine Syndrome? • Cardiopulmonary Bypass has a high morbidity and mortality Endothelial Vasomotor Response in Cardiac Surgery: A Prospective, • Vasoplegic syndrome is a loss of (Lambden, Creagh-Brown, Hunt, • The kinin pathway produces bradykinin and • These fragments clog small capillaries further • Vasopressin Observational Study. Journal of • Blood transfusion Summers, & Forni, 2018) vasomotor tone and a medical emergency kallikren which lead to neutrophil activation stimulating inflammation cardiothoracic and vascular anesthesia. (Shaefi, et al., 2018) • Phenylephrine Consultants, C. (2017, June 23). • Organ transplantation • Multifactorial and difficult to manage • Both the intrinsic and extrinsic clotting cascades • Additionally, reprofusion syndrome of the heart Transcatheter Aortic Valve Replacement • It causes severe hypotension and produce thrombin which results in fibrin deposits and lungs causes neutrophil adherence and • Methylene Blue (TAVR) Surgery | Cardiovascular • Sepsis • “Vasoplegic syndrome has been hypoperfusion to vital organs (Abou-Arab, further ROS release which causes direct protein, Consultants, Ltd. Retrieved from et al., 2018) attributed to a combination of endothelial • Thrombin goes on to activate platelets which lipid, and nucleic acid damage • β1 blockade http://cvcheart.com/transcatheter- • Shock States injury, arginine-vasopressin system adhere to other platelets, neutrophils, and dysfunction, release of other vasodilatory aortic-valve-replacement/ • Generally seen in post cardiac surgery • α agonist Lambden, S., Creagh-Brown, B. C., Hunt, J., exposed basement membranes • This increases capillary permeability causes inflammatory mediators, and a muscle 2 patients or during shock (Shaefi, et al., • Extended OR cases Summers, C., & Forni, L. G. (2018). interstitial edema and reduced intravascular hyperpolarization.” (Sharawy, 2014) 2018) • The complement pathway leads to formation of volume • Glucocorticoids Definitions and pathophysiology of (Liu, Yu, Yang, & Green, 2017) vasoplegic shock. Critical Care, 22(1). C5a which further activates neutrophils • Without appropriate systemic vascular • Requires very high dose pressors and • All leading to decreased volume and increasing NO • Blood Products doi:10.1186/s13054-018-2102-1 inotropic support resistance even a high cardiac output has Levy, B., Fritz, C., Tahon, E., Jacquot, A., • These neutrophils when activated release levels further dilating arterial smooth muscle no where to go Signs and Symptoms enzymes and reactive oxygen species (ROS) that • Isotonic Fluids Auchet, T., & Kimmoun, A. (2018). Vasoplegia treatments: the past, the • May be non-response to medications or adhere to membrane surfaces and to endothelial • An efflux of potassium through ATP sensitive • Leads to hypoperfusion of organ and present, and the future. Critical Care, fluids and require further escalation of • Significant arterial hypotension surfaces channels results in hyperpolarization of the cell (Levy, et al., 2018) organ systems which in turn leads to end 22(1), 52. care causing inactivation of voltage gated calcium organ failures (Abou-Arab, et al., 2018) Liu, H., Yu, L., Yang, L., & Green, M. S. (2017). • MAP <50 • “Multiple factors, including thrombin, C5a, and channels which causes further vasodilation and (Shaefi, et al., 2018) Vasoplegic syndrome: An update on Why does it matter? cytokines, activate endothelial cells that produce vascular disfunction • Understanding the pathophysiology of perioperative considerations. Journal of • Without clear identifiable cause vasoactive substances, including nitric oxide (NO) • As a CVICU nurse vasoplegia is frequently vasoplegia is of vital importance to clinical anesthesia, 40, 63-71. and prostacyclin, and express surface receptors.” seen in patients undergoing • NO then causes dephosphorylation of the myosin promptly treat the cause and maintain Picture 3. Methane Blue Omar, S., Zedan, A., & Nugent, K. (2015). • Refractory to traditional treatment (Omar, Zedan, & Nugent, 2015) cardiopulmonary bypass (CPB) or in long light chain by increasing production of cyclic GMP adequate oxygenation to tissues used to inhibit NO synthesis Cardiac vasoplegia syndrome: OR cases which prevents muscle contraction by limiting ("Singin' the blues: What can pathophysiology, risk • Normal or high cardiac output • Following the acute responses to CPB the actin and myosin interaction you do with methylene blue?") factors and treatment. The American • Vasoplegia is difficult to manage and inflammatory response is exacerbated by journal of the medical sciences, 349(1), • Low systemic vascular resistance requires excellent nursing and physician reinfusion of the blood lost during surgery (Omar, Zedan, & Nugent, 2015) 80-88. knowledge and attention Implication for Shaefi, S., Mittel, A., Klick, J., Evans, A., Ivascu, • Unresponsive to fluid therapy Conclusion N. S., Gutsche, J., & Augoustides, J. G. • Vasoplegia has a high mortality rate and is Nursing Care (2017). Vasoplegia following • Unresponsive to catecholamine treatment not well known • Understanding the risk factors along with • Understanding factors that lead to Cardiovascular Procedures– the signs and symptoms of vasoplegic vasoplegia can help prevent and Pathophysiology and Targeted (Liu, Yu, Yang, & Green, 2017) • It is common in most shock states in syndrome is of upmost importance to treat it Therapy. Journal of cardiothoracic and intensive care patients APNs vascular anesthesia • Multiple factors play a role in loss Sharawy, N. (2014). Vasoplegia in septic • CRNAs will experience vasoplegia and need • Nurses play a vital role in identifying of vasomotor tone all of which shock: Do we really fight the right enemy? Journal of Critical Care, 29(1), to be familiar with it both in post-op hypotension unresponsive to lead to low organ perfusion 83-87. doi:10.1016/j.jcrc.2013.08.021 patients and some shock state emergencies interventions • Refractive to normal hypotensive Singin' the blues: What can you do with methylene blue? (n.d.). Retrieved from • Severe hypotension is a medical treatments such as fluid and http://sinaiem.org/singin-the-blues- emergency and nurses at the bedside catecholamines what-can-you-do-with-methylene-blue/ should be prepared to take further • Goals of therapy include: restoring Sterling SA, Puskarich MA, Shapiro NI, interventions to maintain tissue Trzeciak S, Kline JA, Summers RL, Jones oxygenation such as fluids, oxygen, MAP, maintaining adequate cardiac output, and restoring AE. Characteristics and outcomes of ventilatory support, and vasoactive patients with vasoplegic versus tissue tissue perfusion (Sharawy, 2014) medications dysoxic septic shock. Shock. 2013;40(1):11. • Identification of possible high risk • Prevention, assessment, and early patients by CRNA’s in pre-op and post-op treatment are all of great should have close observation and importance to decrease morbidity constant blood pressure monitoring and mortality Picture 2. Visual representation of the • Nursing should be prepared for end of life pathophysiology involved in vasoplegic syndrome discussions and care, should interventions not succeed Picture 1. Cardiovascular system (Omar, Zedan, & Nugent, 2015) (Consultants, 2017).
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