(1682) High-Dose Vitamin Administration for Vasoplegia in a Post-Cardiac Surgery Neonate: A Case Report

Introduction: Vasoplegia is a state of persistent low systemic vascular resistance with normal or high cardiac index resulting in intractable vasodilation and hypotension. The pathophysiology is a profound systemic inflammatory response and can occur in multiple clinical conditions. Several novel therapies, including vitamins, have shown promise in mitigating this inflammatory response in adult patients. We present a case of successful use of hydroxocobalamin, ascorbic acid, and thiamine in reversal of vasoplegia in a neonate post-congenital heart surgery on venoarterial extracorporeal membrane oxygenation (VA-ECMO).

Description: An 8-day old infant with d-Transposition of the Great Arteries with unrestricted atrial septal defect and intact ventricular septum underwent an arterial switch operation. Operative course was complicated by 2 runs of cardiopulmonary bypass (CPB) for revision of an intermural left coronary and cannulation to VA-ECMO for refractory mixed acidosis and hypotension. On post-operative day (POD) 1, she developed profound hypotension with mean arterial pressures (MAP) in the teen’s refractory to large volume administration, increase in ECMO flow, high-dose hydrocortisone (increased from initial stress dose to 25mg/m2 q6h IV), levothyroxine initiation and high-dose epinephrine, phenylephrine, and vasopressin infusions. POD 2 into 3, after consideration of interventions such as angiotensin II, a course of high-dose cyanocobalamin (500 mcg q24h IM x 3 days), ascorbic acid (30mg/kg q6h IV x5 days), and thiamine (4 mg/kg q12h IV x 5 days) was initiated for vasoplegia. Within 24 hours of initiating therapy, MAP’s increased into the mid-40’s and vasoactives were able to be weaned.

Discussion: Antioxidant therapies for management of vasoplegia have been studied in adult patients, however, no cases have combined high-dose hydroxocobalamin, ascorbic acid, and thiamine in a pediatric patient for this indication. In this case, an infant was able to be successfully weaned off vasoactive infusions for vasoplegia postcardiac surgery following the administration of this triple vitamin therapy. This highlights the importance of consideration for adjuvant therapies to potentially decrease morbidity and mortality associated with vasoplegia.