From the Guidelines
Profound vasoplegia is caused by excessive vasodilation resulting from dysregulated inflammatory responses, often triggered by cardiopulmonary bypass, sepsis, anaphylaxis, or neurogenic shock, and should be treated with aggressive fluid resuscitation and vasopressor therapy, including first-line vasopressors such as norepinephrine and vasopressin, as recommended by the 2024 EACTS/EACTAIC/EBCP guidelines 1. The primary mechanisms of profound vasoplegia include overproduction of nitric oxide, activation of potassium channels, and vasopressin deficiency. Some key points to consider in the treatment of profound vasoplegia include:
- Aggressive fluid resuscitation to restore intravascular volume
- Vasopressor therapy with first-line vasopressors such as norepinephrine (starting at 0.01-0.1 mcg/kg/min, titrated to effect) and vasopressin (0.01-0.04 units/min) 1
- Adjunctive therapies such as methylene blue (1-2 mg/kg IV over 10-20 minutes), hydroxocobalamin (5g IV), angiotensin II (starting at 20 ng/kg/min), and hydrocortisone (200-300 mg/day in divided doses) may be considered for refractory cases 1
- Identifying and treating the underlying cause is crucial, whether it's controlling infection in sepsis, discontinuing triggering medications, or addressing other primary conditions
- Continuous hemodynamic monitoring is essential to guide therapy, with a goal of maintaining mean arterial pressure above 65 mmHg to ensure adequate organ perfusion 1 It is also important to note that the use of vasopressors to increase the MAP to values above 80 mmHg during CPB is not recommended, and targeting the MAP during CPB within the limits of individualized cerebral autoregulation data should be considered whenever possible 1.
From the FDA Drug Label
Blood volume depletion should always be corrected as fully as possible before any vasopressor is administered. The causes of profound vasoplegia are not directly stated in the provided drug labels, but blood volume depletion is mentioned as a condition that should be corrected before administering a vasopressor like norepinephrine.
- Occult blood volume depletion should always be suspected and corrected when present, as it can contribute to hypotension. Treatment approaches for profound vasoplegia may involve:
- Administration of norepinephrine to restore and maintain adequate blood pressure 2
- Correction of blood volume depletion before or concurrently with vasopressor administration 2
- Central venous pressure monitoring to detect and treat occult blood volume depletion 2
From the Research
Causes of Profound Vasoplegia
- Vasoplegia is a condition characterized by persistent low systemic vascular resistance despite a normal or high cardiac index, resulting in profound and uncontrolled vasodilation 3
- It may occur due to various conditions, including:
- Cardiac failure
- Sepsis
- Post-cardiac surgery
- Intrinsic processes that may drive vasoplegia include:
- Nitric oxide
- Prostanoids
- Endothelin-1
- Hydrogen sulphide
- Reactive oxygen species production 4
- Extrinsic drivers, including those mediated by glucocorticoid, catecholamine, and vasopressin responsiveness of the blood vessels, may also contribute to vasoplegia 4
Treatment Approaches for Profound Vasoplegia
- Early identification and prompt management of vasoplegia is crucial to prevent development of shock 3
- Various vasopressors are used in the management of vasoplegia, including:
- The use of Angiotensin II has been shown to be effective in treating refractory shock due to benazepril and amlodipine toxic ingestion 6
- Hydroxocobalamin has demonstrated efficacy in treating refractory vasoplegic syndrome after cardiopulmonary bypass, and may be used as a first-line option for inhibiting the nitric oxide system in vasoplegic syndrome that is refractory to other vasopressors 7