Vasoplegic shock during liver transplantation: Is the preoperative cGMP plasma level a potential predictor of hemodynamic instability?

Dmitri Bezinover, Patrick McQuillan, James Rossignol, Tadahiro Uemura, Zakiyah Kadry, Piotr Janicki

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Abstract

Background: Refractory hypotension is a frequent event during reperfusion of a liver graft. Measures that help maintain hemodynamic stability include correction of electrolytes and acid-base abnormalities as well as administration of fluid and/or catecholamines. Vasoplegic syndrome represents the most severe form of hemodynamic instability. Management of this condition is very difficult due primarily to the inadequate response to even very high doses of catecholamines. Case Report: A 60-year-old patient presented for liver transplantation due to end stage liver disease. After an initially uneventful hepatic phase, the patient developed excessive tachycardia and refractory hypotension during cross-clamping of the vena cava. The situation rapidly deteriorated despite administration of fluid and extremely high doses of norepinephrine and vasopressin. A transesophageal echocardiogram (TEE) performed at that time failed to demonstrate any cardiac dysfunction or signs of pulmonary emboli. Subsequent blood cultures and imaging studies did not confirm any signs of sepsis. Further investigation revealed an increased preoperative level of cyclic guanosine monophosphate (cGMP). cGMP is the second messenger for nitric oxide, and is responsible for relaxation of vascular smooth muscle with subsequent vasodilatation. This finding suggests a release of nitric oxide in the systemic circulation which could have been a potential cause for vasoplegic shock. Conclusions: Release of nitric oxide in the systemic circulation can be a potential cause of vasoplegic syndrome. Future investigation will demonstrate whether a patient's preoperative cGMP plasma level can be a potential predictor of intraoperative hemodynamic instability.

Original languageEnglish (US)
JournalMedical Science Monitor
Volume16
Issue number9
StatePublished - Oct 22 2010

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Vasoplegia
Cyclic GMP
Liver Transplantation
Shock
Nitric Oxide
Hemodynamics
Hypotension
Catecholamines
Venae Cavae
End Stage Liver Disease
Liver
Second Messenger Systems
Embolism
Vasopressins
Vascular Smooth Muscle
Constriction
Tachycardia
Vasodilation
Electrolytes
Reperfusion

All Science Journal Classification (ASJC) codes

  • Medicine(all)

Cite this

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title = "Vasoplegic shock during liver transplantation: Is the preoperative cGMP plasma level a potential predictor of hemodynamic instability?",
abstract = "Background: Refractory hypotension is a frequent event during reperfusion of a liver graft. Measures that help maintain hemodynamic stability include correction of electrolytes and acid-base abnormalities as well as administration of fluid and/or catecholamines. Vasoplegic syndrome represents the most severe form of hemodynamic instability. Management of this condition is very difficult due primarily to the inadequate response to even very high doses of catecholamines. Case Report: A 60-year-old patient presented for liver transplantation due to end stage liver disease. After an initially uneventful hepatic phase, the patient developed excessive tachycardia and refractory hypotension during cross-clamping of the vena cava. The situation rapidly deteriorated despite administration of fluid and extremely high doses of norepinephrine and vasopressin. A transesophageal echocardiogram (TEE) performed at that time failed to demonstrate any cardiac dysfunction or signs of pulmonary emboli. Subsequent blood cultures and imaging studies did not confirm any signs of sepsis. Further investigation revealed an increased preoperative level of cyclic guanosine monophosphate (cGMP). cGMP is the second messenger for nitric oxide, and is responsible for relaxation of vascular smooth muscle with subsequent vasodilatation. This finding suggests a release of nitric oxide in the systemic circulation which could have been a potential cause for vasoplegic shock. Conclusions: Release of nitric oxide in the systemic circulation can be a potential cause of vasoplegic syndrome. Future investigation will demonstrate whether a patient's preoperative cGMP plasma level can be a potential predictor of intraoperative hemodynamic instability.",
author = "Dmitri Bezinover and Patrick McQuillan and James Rossignol and Tadahiro Uemura and Zakiyah Kadry and Piotr Janicki",
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T1 - Vasoplegic shock during liver transplantation

T2 - Is the preoperative cGMP plasma level a potential predictor of hemodynamic instability?

AU - Bezinover, Dmitri

AU - McQuillan, Patrick

AU - Rossignol, James

AU - Uemura, Tadahiro

AU - Kadry, Zakiyah

AU - Janicki, Piotr

PY - 2010/10/22

Y1 - 2010/10/22

N2 - Background: Refractory hypotension is a frequent event during reperfusion of a liver graft. Measures that help maintain hemodynamic stability include correction of electrolytes and acid-base abnormalities as well as administration of fluid and/or catecholamines. Vasoplegic syndrome represents the most severe form of hemodynamic instability. Management of this condition is very difficult due primarily to the inadequate response to even very high doses of catecholamines. Case Report: A 60-year-old patient presented for liver transplantation due to end stage liver disease. After an initially uneventful hepatic phase, the patient developed excessive tachycardia and refractory hypotension during cross-clamping of the vena cava. The situation rapidly deteriorated despite administration of fluid and extremely high doses of norepinephrine and vasopressin. A transesophageal echocardiogram (TEE) performed at that time failed to demonstrate any cardiac dysfunction or signs of pulmonary emboli. Subsequent blood cultures and imaging studies did not confirm any signs of sepsis. Further investigation revealed an increased preoperative level of cyclic guanosine monophosphate (cGMP). cGMP is the second messenger for nitric oxide, and is responsible for relaxation of vascular smooth muscle with subsequent vasodilatation. This finding suggests a release of nitric oxide in the systemic circulation which could have been a potential cause for vasoplegic shock. Conclusions: Release of nitric oxide in the systemic circulation can be a potential cause of vasoplegic syndrome. Future investigation will demonstrate whether a patient's preoperative cGMP plasma level can be a potential predictor of intraoperative hemodynamic instability.

AB - Background: Refractory hypotension is a frequent event during reperfusion of a liver graft. Measures that help maintain hemodynamic stability include correction of electrolytes and acid-base abnormalities as well as administration of fluid and/or catecholamines. Vasoplegic syndrome represents the most severe form of hemodynamic instability. Management of this condition is very difficult due primarily to the inadequate response to even very high doses of catecholamines. Case Report: A 60-year-old patient presented for liver transplantation due to end stage liver disease. After an initially uneventful hepatic phase, the patient developed excessive tachycardia and refractory hypotension during cross-clamping of the vena cava. The situation rapidly deteriorated despite administration of fluid and extremely high doses of norepinephrine and vasopressin. A transesophageal echocardiogram (TEE) performed at that time failed to demonstrate any cardiac dysfunction or signs of pulmonary emboli. Subsequent blood cultures and imaging studies did not confirm any signs of sepsis. Further investigation revealed an increased preoperative level of cyclic guanosine monophosphate (cGMP). cGMP is the second messenger for nitric oxide, and is responsible for relaxation of vascular smooth muscle with subsequent vasodilatation. This finding suggests a release of nitric oxide in the systemic circulation which could have been a potential cause for vasoplegic shock. Conclusions: Release of nitric oxide in the systemic circulation can be a potential cause of vasoplegic syndrome. Future investigation will demonstrate whether a patient's preoperative cGMP plasma level can be a potential predictor of intraoperative hemodynamic instability.

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