Does basiliximab induction trigger lifethreatening ARDS and shock in young patients after kidney transplantation?

BACKGROUND: Kidney disease Improving Global Outcomes (KDIGO) guidelines strongly recommend administering an anti-IL-2R mAb (i.e., basiliximab) for induction in all kidney transplant recipients. We describe a life-threatening episode of shock following basiliximab injection and review the literature. METHODS AND RESULTS: A 20-year-old male was given tacrolimus, methylprednisolone, mycophenolate, and basiliximab, 20 mg in the context of living-related kidney transplantation. On post-operative Day 1 (POD 1), he developed acute respiratory distress syndrome (ARDS), shock, multiple organ failure, and had a cardiac arrest. After effective resuscitation, he received rescue therapies (NO inhalation, extra-corporeal membrane oxygenation, and CVVHD) but lost the graft as the result of cortical necrosis. We conducted PubMed searches that yielded 7 similar cases; 6 required invasive ventilation. Three patients developed cardiac arrest, 3 required major inotropic support, and 2 developed MOF and myocardial depression. All but 1 patient recovered rapidly within a few days. There was no evidence for infectious, allergic, or over-hydration concerns. Although the direct causal role of basiliximab cannot be formally proven, the fact that ARDS at the time of induction therapy with other immunosuppressive agents is otherwise extremely rare suggests a direct role for basiliximab. CONCLUSIONS: Basiliximab could be associated with shock and ARDS.

Continuous mixed venous and central venous oxygen saturation in cardiac surgery with cardiopulmonary bypass.

BACKGROUND AND OBJECTIVE: Replacing mixed venous oxygen saturation (SvO2) monitoring by central venous oxygen saturation (ScvO2) monitoring in order to avoid the use of a pulmonary artery catheter and its related complications is still controversial in the setting of cardiac surgery. The influence of surgery, cardiopulmonary bypass and anaesthesia drugs on the relationship between SvO2 and ScvO2 has never been studied. METHODS: Fifteen patients scheduled for cardiac surgery with cardiopulmonary bypass were included in the study. SvO2 (from the pulmonary artery) and ScvO2 (from the superior vena cava) were continuously measured with fibre-optic catheters from induction of anaesthesia to 24 h postoperatively. RESULTS: A total of 9267 pairs of measurements were recorded. Mean bias between SvO2 and ScvO2 was 4.4% with limits of agreement of -13.6 and +22.5%, respectively. Trends of SvO2 and ScvO2 values followed very different patterns for some patients. Surgery, cardiopulmonary bypass and anaesthesia drugs did not influence the relationship between the two methods. CONCLUSION: Because of the large interindividual variability in the difference between SvO2 and ScvO2, the measure of ScvO2 should not replace the measure of SvO2 with a pulmonary artery catheter for the management of patients undergoing cardiac surgery with cardiopulmonary bypass.

No evidence of memory processing during propofol-remifentanil target-controlled infusion anesthesia with bispectral index monitoring in cardiac surgery.

OBJECTIVE: Auditory information presented during anesthesia can activate memory. Surgical stimulation may enhance memory formation. The authors' hypothesis is that implicit memory processing is not preserved during unconsciousness, even in the presence of a surgical stimulus. DESIGN: A double-blind randomized controlled trial. SETTING: A single-institution, university hospital. PARTICIPANTS: Thirty-eight adults undergoing cardiac surgery. INTERVENTIONS: Patients were randomized to continuously hear either disc A or B during surgery. On each disc, 20 different words were recorded. MEASUREMENTS AND MAIN RESULTS: Implicit and explicit memory were tested. The study design was that each group served as a control for the other. The responses from both groups on both lists allowed the authors to compare the likeliness of correctly identifying the words from a list whether it was heard while under anesthesia or not. During the interview, no patient had explicit recall as investigated by the free recall test, and no one reported dreaming. As for implicit memory processing, the difference between the mean rate of correct answers on the word-stem completion test for the disc the patients heard (3.42% for disc A and 13.15% for disc B) or did not hear (3.15% for disc A and 14.73% for disc B) was not statistically significant (p = 0.95 for A and p = 0.42 for B). CONCLUSIONS: Explicit and implicit memory were not detectable in patients anesthetized with an effect-site target-controlled infusion of propofol and remifentanil with bispectral index monitoring. These results suggest that there is no memory processing under anesthesia in the surgical setting.

Role of endothelins and nitric oxide in the pulmonary circulation of perinatal lambs during hyperoxia and hypoxia.

Endothelins (ET) have opposite vascular effects mediated through different receptors: ET(A) receptors mediating vasoconstriction and ET(B) receptors mediating vasoconstriction as well as vasodilation. The role of ET in acute hypoxic pulmonary vasoconstriction (HPV) was studied after dual ET receptor blockade with bosentan and nitric oxide (NO) synthase inhibition with nitro-L-arginine (L-NA). We started from the hypothesis that ET antagonism may inhibit HPV but, if not, would do so after NO synthase inhibition. HPV was evaluated in anesthetized lambs, with an intact pulmonary circulation, by the increase in the mean pulmonary artery pressure (Ppa) minus occluded Ppa (Ppao) gradient in response to hypoxia (inspiratory oxygen fraction of 0.1) at different levels of pulmonary flow (multipoint pressure/flow relationships). ET receptor antagonism decreased pulmonary and systemic vascular tone both in hyperoxia and hypoxia. ET antagonism had no effect on HPV. NO synthase inhibition increased pulmonary vascular tone more in hypoxia than in hyperoxia so that HPV was enhanced. After L-NA, bosentan still decreased pulmonary vascular tone in hypoxia but did not affect the magnitude of HPV. The present results suggest that ET and NO are involved in the regulation of basal pulmonary vascular tone. Furthermore, the vasodilator effect of bosentan persisted in the presence of NO synthase inhibition, suggesting a non NO-dependent vasodilator mechanism. The results from these experiments are in agreement with the idea that ET do not play a major role in HPV in the perinatal lamb, even when it is enhanced by NO synthase inhibition.

Endothelin receptor blockade in canine oleic acid-induced lung injury.

OBJECTIVE: To investigate the effects of endogenous endothelins on pulmonary haemodynamics and gas exchange in oleic acid lung injury. DESIGN: Prospective experimental study in dogs. SETTING: Animal research laboratory in a university teaching hospital. SUBJECTS. Seventeen anaesthetised and ventilated mongrel dogs. INTERVENTIONS: Nine pretreated dogs received an infusion of the endothelin A and B receptor antagonist bosentan (10 mg/kg) started before oleic acid. Eight treated dogs received bosentan started 90 min after oleic acid. Cardiac index (CI) was manipulated by inflating an inferior vena caval balloon or by opening a femoral arterio-venous bypass. MEASUREMENTS AND RESULTS: Pulmonary vascular resistance was defined by measuring the gradient between mean pulmonary artery pressure (MPAP) and occluded PAP (PAOP) at five levels of CI. Intrapulmonary shunt was measured using the inert gas SF(6). Pretreatment with bosentan prevented the oleic acid-induced shift of (MPAP-PAOP)/CI plots to higher pressures, but did not affect the increase in intrapulmonary shunt. Treatment of established oleic acid lung injury with bosentan had no effect. CONCLUSIONS: Pretreatment, but not treatment, with bosentan, in the dose used, blunted the oleic acid-induced increase in pulmonary vascular resistance, suggesting that endothelins contribute to the increase in pulmonary vascular tone in the early stages of oleic acid lung injury.