Fluid resuscitation and relation to respiratory support escalation in patients with and without pulmonary hypertension with sepsis.

STUDY OBJECTIVE: To compare guideline-based fluid resuscitation and need for respiratory support escalation in septic patients with pulmonary hypertension (PH) to those without PH. DESIGN: Single-center, retrospective cohort study. SETTING: Tertiary care academic medical center in Detroit, Michigan. PATIENTS: Adult patients with or without PH hospitalized and diagnosed with sepsis from November 1, 2013 through December 31, 2019. Patients with sepsis were assigned to one of two groups based on a previous PH diagnosis or no PH diagnosis. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was incidence of respiratory support escalation within 72 h from sepsis time zero. Respiratory support escalation included high-flow nasal cannula, bilevel positive airway pressure, or intubation. One-hundred and four patients were included with 52 patients in each study group. Patients with PH were more likely to require escalation of respiratory support compared to non-PH patients (32.7% vs. 11.5%; p = 0.009). Fewer patients with PH received 30 mL/kg of crystalloid within 6 h of time zero compared with non-PH patients (3.8% vs. 42.3%; p < 0.001). Vasopressor initiation was more common in patients with PH compared with the non-PH group (40.4% vs. 19.2%; p = 0.018). PH diagnosis was the only independent predictor of respiratory support escalation. CONCLUSIONS: During initial sepsis management when compared with patients without PH, patients with PH had increased instances of respiratory support escalation within 72 h of sepsis time zero despite lower fluid resuscitation volumes.

Anticoagulation of Percutaneous Ventricular Assist Device Using Argatroban-Based Purge Solution: A Case Series.

Impella devices are percutaneously inserted ventricular assist devices which require a continuous purge solution that contains heparin to prevent pump thrombosis and device failure. We describe 2 patients with heparin-induced thrombocytopenia (HIT) supported with an Impella device utilizing an argatroban-based purge solution. Case 1 involved an 83-year-old female with biventricular failure which resulted in right ventricle Impella support. The purge solution was changed to include argatroban due to concern of device clotting in the setting of HIT. Case 2 involved a 55-year-old male with worsening cardiogenic shock which resulted in left ventricle Impella support. Due to decreased purge flow rates and concerns for clotting, argatroban was added to the purge solution. Both patients' total argatroban regimens were monitored and adjusted by pharmacy, resulting in therapeutic anticoagulation without any major bleeding or thrombotic events. Subsequently, a protocol was designed and implemented. These case reports appear to demonstrate the safe and effective use of argatroban purge solutions for the necessary anticoagulation with an Impella device. Further studies are needed to confirm these results and determine the optimal dosing regimen.