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Correspondence

Management of Vasoplegia After Cardiopulmonary Bypass: Role of Prostaglandin Inhibition

Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104-4283

(Email: yiandoc{at}hotmail.com).

To the Editor:

I read with great interest the excellent recent clinical review by Dr Egi and colleagues [1] detailing vasopressor therapy for vasoplegic shock after adult cardiac surgery. Their systematic review discusses the evidence for the following drugs: phenylephrine, norepinephrine, dopamine, angiotensin II, methylene blue, and arginine vasopressin.

However, there is evidence for prostaglandin inhibition for restoration of vascular tone after adult cardiac surgery [2]. Effective prostaglandin inhibition was obtained by intravenous administration of a nonsteroidal anti-inflammatory agent, namely flurbiprofen (Ropion [Kaken Pharmaceutical Co, Ltd, Tokyo, Japan]).

The rationale for this therapy follows the observation that increases in serum prostaglandin levels during cardiopulmonary bypass are associated with the development of vasoplegia. A mechanism for this increase in prostaglandins, such as E₂, may be the decrease in first pass pulmonary metabolism due to cardiopulmonary bypass [3].

The evidence available seems to be based on a single, small randomized clinical trial (n = 36) [1]. As a result further trials are required: (1) to confirm this observation; (2) to delineate any potential harmful side effects of this therapy, given the known side effect profile of this drug class; and (3) to determine how this therapy can be integrated with the existing pharmacologic options as mentioned earlier.

Until these trials are available, prostaglandin inhibition may be a considered a rescue strategy in severe post-cardiotomy vasoplegia after first-line measures have proved inadequate. As such it may be a useful tool to assist in the challenging management of this syndrome.

	References

Top References

 

1. Egi M, Bellomo R, Langenberg C, et al. Selecting a vasopressor drug for vasoplegic shock after adult cardiac surgery: a systematic literature review Ann Thorac Surg 2007;83:715-723.[Abstract/Free Full Text]
2. Takewa Y, Seki T, Tatsumi E, Taenaka Y, Takano H. Prostaglandin synthesis inhibitor improves hypotension during normothermic cardiopulmonary bypass ASAIO J 2001;47:673-676.[Medline]
3. Takewa Y, Tatsumi E, Taeneka Y, et al. Hemodynamic effects of prostaglandins and catecholamines in graded reduction of pulmonary blood flow during venoarterial bypass in awake goats ASAIO J 1999;45:79-82.[Medline]

This article has been cited by other articles:

				M. Egi and R. Bellomo Reply Ann. Thorac. Surg., November 1, 2007; 84(5): 1796 - 1796. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): John G.T. Augoustides Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Augoustides, J. G.T. Search for Related Content PubMed PubMed Citation Articles by Augoustides, J. G.T. Related Collections Cardiac - pharmacology Related Article