Case Presentation: A 63 year-old Caucasian male with a history of severe symptomatic aortic insufficiency and coronary artery disease was seen in the intensive care unit status-post aortic valve replacement and single vessel coronary artery bypass graft (CABG). The patient tolerated the procedure well. Twenty-four hours after surgery, the patient developed hypotension requiring vasopressor support. The patient’s systolic blood pressure dropped into the 40-60s despite aggressive intravenous fluids, norepinephrine and dopamine drips. The patient maintained a weak pulse and was responsive. The patient was additionally started on epinephrine and vasopressin drips. The patient had a bedside echo that showed his postoperative changes, no evidence of tamponade, and a normal ejection fraction. His central venous pressure was in the 20s, cardiac output was 4.3L/min, and systemic vascular resistance ranged from 700-1700 dynes/cm2 on vasopressor support. The patient had been on appropriate perioperative antibiotics for CABG, had no fever and no other obvious source of infection. The patient was taken back to the operating room, but there was no bleeding found, the pericardium was normal and no other source of hypotension was discovered intraoperatively. Due to the patients recent cardiac surgery there was a concern for vasoplegic syndrome. Methylene blue was administered. The patient was maintained on vasopressors for 24 hours. The patient’s vasopressor requirement did decrease however he developed a severe metabolic acidosis and acute kidney injury. He was unable to tolerate continuous renal replacement therapy and the family decided to make the patient comfort care.
Discussion: Vasoplegic syndrome, a form of vasodilatory shock, is characterized by severe and persistent hypotension, tachycardia, decreased systemic vascular resistance with normal to high cardiac output, low filling pressure and poor response to fluid resuscitation. It is shown to have associations with anaphylaxis, severe sepsis and cardiopulmonary bypass surgery. Due to its ability to bind soluble guanylyl cyclase, methylene blue has been studied as an effective treatment modality in the post operative patient with vasoplegic syndrome.
This case demonstrates vasoplegic syndrome in the postoperative patient and the administration and role of methylene blue in the treatment of vasoplegic syndrome. Hospitalists frequently co-manage surgical patients and often lead code teams. It is important for us to recognize vasoplegic syndrome, as its recognition can lead to appropriate therapy.
To cite this abstract:
Vasoplegic Syndrome in a Postoperative Patient.
Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md..Abstract 677
Journal of Hospital Medicine, Volume 10, Suppl 2.
June 6th 2020.