Use of Intravenous Hydroxocobalamin for Vasoplegic Syndrome in Simultaneous Liver-Kidney Transplant: A Case Report

Vasoplegic syndrome can occur after reperfusion in liver transplantation. Generally, vasopressor infusions along with volume resuscitation are used to combat this process. There are case reports of the use of hydroxocobalamin to improve vasoplegia in liver transplant and cardiac surgery. In this case report, we describe a patient who received hydroxocobalamin for a simultaneous liver-kidney transplant. Use of this medication facilitated a prompt decrease of very high-dose vasopressor infusions and allowed completion of the kidney transplantation portion of this case. To our knowledge, use in combined liver-kidney transplant has not been described. In light of the dearth of medications to improve vasoplegia outside of vasopressor infusions, the use of hydroxocobalamin as a therapeutic intervention may gain importance.     

血管麻痹综合征

血管麻痹综合征（vasoplegic syndrome．VS）是公认的常发生于体外循环下心脏手术后的一种并发症，它以严重低血压伴血液动力学高排低阻为特征。类似脓毒血症暖休克变化。又称血管扩张性休克（vasodilatory shock），死亡率较高。本文就该综合征发病及治疗方面的新进展作一综述。     

Use of recombinant factor VIIa as a rescue treatment for intractable bleeding following repeat aortic arch repair

Hemorrhage, refractory to aggressive conventional therapy, at a rate of 16 L/hr following separation from cardiopulmonary bypass for aortic arch repair, was controlled with a dose of 90 μg/kg of recombinant factor VIIa, repeated once after 2 hours.     

Vasoplegic syndrome--the role of methylene blue.

Vasoplegic syndrome is a recognized complication following cardiac surgery using cardiopulmonary bypass and is associated with increased morbidity and mortality. In several patients profound post-operative vasodilatation does not respond to conventional vasoconstrictor therapy. Methylene blue has been advocated as an adjunct to conventional vasoconstrictors in such situations. There is limited data pertaining to the use of methylene blue and a number of reports have been anecdotal observations. This article reviews the incidence and problems associated with the vasoplegic syndrome, the mechanism of action of methylene blue, its effects and adverse reactions and the literature supporting its intra-operative and post-operative use. In cases where first-line therapy fails, the use of methylene blue seems to be a potent approach to refractory vasoplegia. The early use of methylene blue may halt the progression of low systemic vascular resistance even in patients responsive to norepinephrine and mitigate the need for prolonged vasoconstrictor use. However, dosing regimens and protocols need to be clearly defined before widespread routine use. Whether methylene blue should be the first line of therapy in patients with vasoplegia is a matter of debate, and there is inadequate evidence to support its use as a first line drug. More scientific evidence is needed to define the role of MB in the treatment of catecholamine refractory vasoplegia.     

High-Dose Vitamin D Supplementation Can Correct Hypovitaminosis D Prior to Total Knee Arthroplasty

BackgroundVitamin D deficiency in the perioperative surgical period is associated with inferior surgical outcomes. There are no established preoperative supplementation regimens in the orthopedic literature. The purpose of this study is to compare the efficacy between 2 different supplementation regimens of vitamin D prior to total knee arthroplasty.MethodsWe conducted a retrospective analysis of 174 patients identified as vitamin D deficient (25(OH)D < 30 ng/mL) who received one of 2 vitamin D supplementation protocols: (1) daily supplementation with D3 on a sliding scale from 1000 to 6000 IU or (2) a loading dose of 50,000 IU D3 weekly for 4 weeks then 2000 IU/d. Serum vitamin D levels were measured at 3 months and 1 month preoperatively.ResultsMean patient age was 65.5(±8.6) years, and 54.6% were female. Deficiency was corrected in 73.3% of patients in the loading dose group and 42.4% of patients in the daily, low-dose group [χ² (1, N = 174) = 16.53, P < .001]. Patients in the loading dose group also achieved a greater average correction in vitamin D levels.ConclusionThis is the first study to compare preoperative vitamin D supplementation protocols. A loading dose regimen of 50,000 IU weekly for 4 weeks followed by a maintenance dose of 2000 IU/d more effectively corrects vitamin D deficiency compared to a low-dose, daily regimen among total knee arthroplasty patients. We recommend this regimen for deficiency correction in patients who have been screened to be deficient in vitamin D preoperatively.