Terlipressin in catecholamine-resistant hyperdynamic shock patients after cardiac surgery

Introduction

Norepinephrine is favored in the treatment of hyperdynamic shock after cardiac surgery because of its reliable effectiveness to achieve an adequate medium arterial pressure. In some patients, however, norepinephrine may fail to restore blood pressure. Terlipressin can be used to reverse hypotension in patients with norepinephrine-resistant shock. We sought to determine the effects of terlipressin on hemodynamics, perfusion parameters and renal function in shock patients after cardiac surgery not responsive to high-dose norepinephrine (>0.5 μ/kg/min).

Methods

A prospective open-label study was carried out in 49 patients. The cause of shock was a documented infection in 34 patients, and a suspected one in 15 patients. After volume resuscitation, patients who needed norepinephrine in a higher dose than 0.5 μ/kg/min received 1 mg terlipressin in four doses with a 6-hour interval. The mean arterial pressure, heart rate, cardiac index, pulmonary artery occlusion pressure, mean pulmonary artery pressure, systemic vascular resistance index, pulmonary vascular resistance index, central venous pressure, lactate, and central venous saturation were measured before terlipressin, and 2 hours, 6 hours and 24 hours later.

Results

Terlipressin induced a significant increase in mean arterial pressure (P < 0.001), systemic vascular resistance (P < 0.001) and pulmonary vascular resistance (P < 0.001), and a significant decrease in heart rate (P < 0.001) and cardiac index (P < 0.001), without compromising central venous saturation (P = 0.65). Blood lactate concentrations significantly decreased over the study period (P < 0.001). Renal function, assessed by urine flow and creatinine clearance, was significantly improved (P < 0.001). A significant reduction in norepinephrine infusion rates was observed (P < 0.001).

Conclusion

In patients with hyperdynamic shock after cardiac surgery who need high doses of norepinephrine, terlipressin is effective to restore hemodynamic parameters and to reduce dose of vasoactive drugs, with no compromise in organic perfusion.