Key result
A single 5-g intravenous dose of hydroxocobalamin rapidly increased systemic vascular resistance and reduced vasopressor requirements in two patients with refractory vasoplegic syndrome after cardiopulmonary bypass, without the use of methylene blue.
Why the study?
Existing evidence on using hydroxocobalamin alone as a first-line option for inhibiting the nitric oxide system in refractory vasoplegic syndrome after cardiopulmonary bypass remains scant.
Does intravenous hydroxocobalamin without methylene blue improve refractory vasoplegic syndrome in patients after cardiopulmonary bypass?
Case Report (n=2)
No
Does intravenous hydroxocobalamin without methylene blue improve refractory vasoplegic syndrome in patients after cardiopulmonary bypass?
Intravenous hydroxocobalamin without methylene blue may be an effective option for treating vasoplegic syndrome refractory to other vasopressors after cardiopulmonary bypass.
May support hydroxocobalamin as an alternative in refractory post-CPB vasoplegia; hypothesis-generating and requires prospective validation.
BACKGROUND Cardiac vasoplegic syndrome is a form of vasodilatory shock characterized by profound vasodilation and low systemic vascular resistance, which results in significant hypotension despite high cardiac output and appropriate fluid resuscitation. In up to 45% of patients, cardiopulmonary bypass (CPB) can precipitate vasoplegic syndrome. Vasoplegic syndrome after CPB that is refractory to other vasopressors, such as catecholamine and vasopressin, has been successfully treated with inhibitors of the nitric oxide (NO) system, such as methylene blue and hydroxocobalamin. Methylene blue has been the treatment of choice because of its effectiveness for both prevention and rescue therapy. Hydroxocobalamin has demonstrated efficacy in combination with methylene blue, and also on its own when vasoplegic syndrome is refractory to methylene blue. CASE REPORT We present 2 cases that expand upon the existing evidence supporting the efficacy of hydroxocobalamin as a first-line option for inhibiting the NO system in vasoplegic syndrome that is refractory to other vasopressors. Specifically, we demonstrate the appropriate and successful use of hydroxocobalamin alone to treat refractory vasoplegic syndrome after CPB. CONCLUSIONS Refractory vasoplegic syndrome that occurs after CPB has been successfully treated with inhibitors of the NO system, such as methylene blue and hydroxocobalamin. The present cases expand upon the scant existing evidence of the efficacy of hydroxocobalamin as an appropriate option for refractory vasoplegic syndrome.
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Peyko et al. (2021) conducted a case report in Refractory vasoplegic syndrome (n=2). Intravenous Hydroxocobalamin was evaluated on Hemodynamic stability (increase in SVR and MAP, weaning of vasopressors). A single 5-g intravenous dose of hydroxocobalamin rapidly increased systemic vascular resistance and reduced vasopressor requirements in two patients with refractory vasoplegic syndrome after cardiopulmonary bypass, without the use of methylene blue.
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