Cascade of Complications Following Carotid Body Tumor Excision

Carotid body tumor excision can lead to various complications including vascular injury and pseudoaneurysm formation. Here we describe a case of carotid body tumor excision followed by series of complications including pseudoaneurysm formation, failure of primary surgical repair, carotid stump syndrome following parent artery occlusion, and persistent hypotension.

Should Vasopressors Be Started Early in Septic Shock?

Sepsis can influence blood volume, its distribution, vascular tone, and cardiac function. Persistent hypotension or the need for vasopressors after volume resuscitation is part of the definition of septic shock. Since increased positive fluid balance has been associated with increased morbidity and mortality in sepsis, timing of vasopressors in the treatment of septic shock seems crucial. However, conclusive evidence on timing and sequence of interventions with the goal to restore tissue perfusion is lacking. The aim of this narrative review is to depict the pathophysiology of hypotension in sepsis, evaluate how common interventions to treat hypotension interfere with physiology, and to give a resume of the results from clinical studies focusing on targets and timing of vasopressor in sepsis. The majority of studies comparing early versus late administration of vasopressors in septic shock are rather small, single-center, and retrospective. The range of “early” is between 1 and 12 hours. The available studies suggest a mean arterial pressure of 60 to 65 mm Hg as a threshold for increased risk of morbidity and mortality, whereas higher blood pressure targets do not seem to add further benefits. The data, albeit mostly from observational studies, speak for combining vasopressors with fluids rather “early” in the treatment of septic shock (within a 0–3-hour window). Nevertheless, the optimal resuscitation strategy should take into account the source of infection, the pathophysiology, the time and clinical course preceding the diagnosis of sepsis, and also comorbidities and sepsis-induced organ dysfunction.

When Your Pituitary Fails - A Rare Case of Pituitary Dysfunction Due to Nivolumab and Ipilimumab

Introduction: Immunomodulators like Nivolumab and Ipilimumab are important regimens in many malignancies. However, their use is linked with the rare side effect of pituitary dysfunction that if screened and treated can prevent misdiagnosis. Case Description: A 56-year-old male with a history of renal cell carcinoma status post bilateral partial nephrectomy with metastasis to the lung on Nivolumab/Ipilimumab presented with dizziness. He endorsed difficulty with balance, nausea, decreased appetite, feeling dehydrated and recent blood pressure readings in the 90s. Vitals on presentation were stable. An MRI, from 2 weeks ago, showed a slightly enlarged sella but no metastatic disease. The next day, he became hypotensive with minimal response to fluids and was started on Midodrine. However, considering his persistent hypotension, his cortisol level was checked and found to be profoundly low (<1). Literature review of his immunomodulator revealed the possibility of central adrenal insufficiency. In addition, he was noted to have a low TSH (0.02) with normal FT4 (1.08). Subsequently, his ACTH level was also found to be low (<1.5) which further elucidated a central cause for his adrenal insufficiency. Therefore, he was ultimately treated with PO hydrocortisone with plans to taper off in the next few weeks. Conclusion: This case demonstrates a rare yet significant side effect of Nivolumab/Ipilimumab therapy. Timely diagnosis and therapy can alleviate symptoms due to associated hormonal deficiencies. Moving forward it will be interesting to see if starting prophylactic steroids or routine screening will allow us to diagnose pituitary dysfunction due to Nivolumab/Ipilimumab earlier.

Abstract 16542: Hypotension and Pericardial Effusion Associated With High Frequency Jet Ventilation

Introduction: High frequency jet ventilation (HFJV) is used to increase catheter stability and improve outcomes during pulmonary vein isolation (PVI) [1,2,4]. In studies, hemodynamic intolerance of HFJV was rare. [1,3]. Hypothesis: HFJV during PVI is well tolerated and vasopressor-resistant hypotension requiring return to conventional ventilation is rare. Methods: Retrospective observational analysis of hemodynamic, blood gas, and echocardiographic data of PVIs performed with HFJV by 2 operators (PT, JW) at our institution between February 2019 and June 2020. Results: Among 193 PVIs, 8 cases (4%) of rapid onset hypotension associated with HFJV were found (Table). In 7 of 8 cases, persistent hypotension and abnormal gas exchange required conversion to conventional ventilation and a new, small pericardial effusion without tamponade was noted just after HFJV initiation. In these cases, initiation of HFJV was associated with a decrease in systolic function. Both the hemodynamic changes and effusion resolved completely within minutes of stopping HFJV. Four of 8 patients were rechallenged with HFJV, and had recurrent hypotension and effusion which resolved immediately after return to conventional ventilation. Conclusions: HFJV-associated rapid onset hypotension, often accompanied by transient pericardial effusion, is more common than previously reported, and resolves with cessation of HFJV. The mechanism of these changes may occur via CO2 levels and warrants further study.

Syntropic Lesions of the Cardiovascular System in Patients with Liver Cirrhosis: their Determination; Selected Pathogenetic Mechanisms; Characteristics and Specifics; Clinical Markers, Their Prognostic Value; Justification and Effectiveness of Modified Treatment (Second Notice)

Introduction. Comorbid syntropic lesions of the circulatory system in patients with liver cirrhosis (LC), although often fatal, are poorly studied. The aim of the study. To distinguish syntropic lesions of the cardiovascular system in patients with LC, to determine some of their pathogenetic mechanisms, nature, and characteristics, to determine clinical markers with prognostic value, to justify and evaluate the effectiveness of their modified treatment. Materials and methods. We processed medical records of 603 patients with LC and detected circulatory system lesions in 490 patients. Some of them had only one type of lesions (study groups): 103 patients were diagnosed with cirrhotic cardiomyopathy (CCMP), and 89 patients were diagnosed with arterial hypotension. Patients without the circulatory system lesions (113 patients) formed a comparison group. The purpose of the first step of the study was to determine syntropic comorbid lesions of the circulatory system. The purpose of the second step was to study some pathogenetic mechanisms of their formation. The purpose of the third step was to characterize these lesions, classify them, and determine their specific characteristics related to the severity of LC. The purpose of the fourth step was to determine their clinical markers. The purpose of the fifth step was to justify a modified course of treatment for patients with LC and syntropic cardiovascular lesions as well as to assess its effectiveness. Results. The presence of the combination of such complaints as nausea, jaundice of the skin and sclera in patients with LC and the absence of the “jellyfish head” symptom lets us think with 97.09 % sensitivity, 98.02 % specificity and 97.70 % accuracy about syntropic secondary CCMP. In the presence of the combination of such complaints as pain and heaviness in the right side of the abdomen, ascites, hepato-, splenomegaly and telangiectasia lets us think with 85.39 % sensitivity, 98.61 % specificity and 94.75 % accuracy about syntropic persistent hypotension. Improvement of the comprehensive treatment of patients with LC, syntropic secondary CCMP and persistent hypotension, taking into account the peculiarities of their pathogenesis and clinical course, can improve the quality of life of patients by 44.95 % and 40.39 %, respectively, and significantly increase the effectiveness of treatment. Conclusions. Clinical symptom complexes that indicate the presence of syntropic lesions of the circulatory system – a combination of complaints of nausea, jaundice and sclera in the absence of symptoms of “jellyfish head” indicates CCMP, and a combination of complaints of pain and heaviness in the right hypochondrium, ascites, hepato- and splenomegaly and telangiectasia indicate persistent hypotension. Improvement of the comprehensive treatment of patients with LC and CCMP by adding a β-blocker with α-blocking properties of carvedilol (1 tablet (3.125 mg) twice a day), cardio- and hepatoprotector thiotriazoline (in patients with LC and CCMP of the 1st degree of severity (100.0 mg) three times a day, patients with LC and CCMP II and III degrees of severity – intramuscularly 2.0 ml of 2.5 % solution (50.0 mg) three times a day for five days, then 1 tablet (100.0 mg) three times a day), and improvement of the comprehensive treatment of patients with LC and persistent hypotension of I and II degrees of severity by adding ivabradine (1 tablet (5.0 mg) in the morning after meals), patients for hypotension of III degree of severity – intravenous albumin solution (at the rate of 1.5 g/kg for at least 10 days), as well as α-lipoic acid (1 capsule (600.0 mg) in the morning after meals), in the presence of ascites and edema syndrome – spironolactone (in the dosage, which is provided by the severity of the complication, of us a blunt transition to a maintenance dose of 1 tablet (50.0 mg) in the morning after a meal) enhanced the quality of life by 44.95 % and 40.39 %, respectively, and significantly increased the effectiveness of treatment.