Rev. Bras. Anestesiol. vol.67 número1

RevBrasAnestesiol.2017;67(1):89---91

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

CLINICAL

INFORMATION

Levosimendan

as

a

treatment

for

acute

renal

failure

associated

with

cardiogenic

shock

after

hip

fracture

Fabiola

Quinteros

Hinojosa

,

Margarita

Revelo

,

Alexander

Salazar

,

Genaro

Maggi

_,

_Renato

_Schiraldi

_,

_Nicolas

_Brogly

_,

_Fernando

_Gilsanz

a_{HospitalUniversitariodeLaPaz,ServiciodeAnestesiologia,Madrid,Spain}

b_{HospitalItalianodeBuenosAires,BuenosAires,Argentina}

Received10June2014;accepted7July2014 Availableonline28October2014

KEYWORDS

Levosimendan; Cardiogenicshock; Renalfailure; Hipfracture; Perioperativecare

Abstract Inotropicdrugsarepartofthetreatmentofheartfailure;however,inotropic treat-menthasbeenlargelydebatedduetotheincreasedincidenceofadverseeffectsandincreased mortality.Recentlylevosimendan,aninotropicpositiveagent,hasbeenprovedtobeeffective inacuteheartfailure,reducingthemortalityandimprovingcardiacandrenalperformance.We reportthecaseofa75-year-oldwomanwithhistoryofheartandrenalfailureandhipfracture. Levosimendanwasusedinpreoperativepreparationasanadjuvanttherapy,toimprovecardiac andrenalfunctionandtoallowsurgery.

©2014SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).

PALAVRAS-CHAVE

Levosimendana; Choquecardiogênico; Insuficiênciarenal; Fraturadequadril; Cuidados

perioperatórios

Levosimendanacomotratamentoparainsuficiênciarenalagudaassociadaachoque cardiogênicoapósfraturadequadril

Resumo Fármacos inotrópicos fazem parte do tratamento de insuficiência cardíaca; no entanto, o tratamentocominotrópicos tem sidoamplamente debatido devidoao aumento daincidênciadeefeitosadversosedamortalidade.Recentemente,levosimendana,umagente inotrópicopositivo,vemprovadosereficaznainsuficiênciacardíacaaguda,reduzindoa mor-talidadeemelhorandoodesempenhocardíacoerenal.Relatamosocasodeumapacientede 75anosdeidade,comhistóriadeinsuficiênciacardíacaerenalefraturadequadril. Levosi-mendanafoiusadanapreparac¸ãodopré-operatóriocomoterapiaadjuvanteparamelhorara func¸ãocardíacaerenalepermitiracirurgia.

©2014SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigo OpenAccess sobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).

∗_{Correspondingauthor.}

E-mail:[email protected](F.Q.Hinojosa).

http://dx.doi.org/10.1016/j.bjane.2014.07.009

90 F.Q.Hinojosaetal.

Introduction

Duringperioperativeperiodthedevelopmentofacuteheart failureincreasesmorbidityandmortality.1_{Cardiacfailureis}

animportantpublichealthproblem;itsincidenceamounts to 6---10% in the population over 65 years. Levosimendan (Simdax® _{---Orionpharma)isarecommendedtreatmentfor}

acuteheartfailure.2_{Itsmechanismofaction allowsforan}

increase in contractility3 _{and a reductionin both preload}

and afterload, improving stroke volume and cardiac out-put without adversely affecting diastolic function.4,5 _The

haemodynamicpositiveeffectsoflevosimendaninducealso a positive result on tissular perfusion, as reported when thedrughasbeen employedin treatingcardiogenic shock associatedwithrenalfailure.6_{Currently,therearefew}

stud-iesaboutthepreoperativeuseoflevosimendaninpatients undergoingnon-cardiacsurgicalprocedures.7

We report the case of a patient with a hip fracture; shedevelopedacuterenalfailuresecondarytocardiogenic shockbeforeundergoingsurgeryforfracturereduction. Lev-osimendanwasintroducedinthetreatmentwiththeaimof improvingcardiacandrenalfunctions;finally,itresultsinan effectivetoolforweaningthepatientfromhemofiltration beforesurgery.

Case

description

A75-year-oldwomanwithhistoryofhypertension,chronic atrialfibrillation,congestiveheartfailurewithbaselineLVEF of30%,anepisodeofpulmonaryembolismin2004,chronic renal failure(baseline creatinine 2.2mg/mL),obstructive sleepapnea-syndromeassociatedwithmorbidobesity,and dyslipidemia,wasadmittedtotheemergencydepartment becauseofaccidentalfallwithpertrochantericfractureof therightfemur.

During admission in ward, pending surgery, a tach-yarrhythmia,probablyassociatedwiththeacuteanaemia, provokedanacutecardiacfailurethatpresentedtogether acute renal failure. The patient was subsequently trans-ferredtotheIntensiveCareUnit(ICU).

Once intheICU, thepatientreceivedbasic monitoring (ECG, pulsioximetry) and advanced haemodynamic moni-toring,using centralvenous access(right internal jugular vein) and central arterial line (left femoral artery) and employing LiDCOTM _{plus system (LiDCO Ltd, Cambridge,}

UK). The parameters on admission in ICU were: invasive blood pressure 90/60; heart rate 120 beats per minute (ECGshowedatrial fibrillation); SpO293% (with 0.5FiO2);

cardiacindex: 2.4L/min/m2_{, systemicvascular resistance}

2500dyness/cm.5_{The patientshowedoliguricacuterenal}

failure(serumcreatinine:4.7mg/dL;urea:155mg/dL)and fluidoverload(positivebalanceof1787mLinthelast24h) refractorytotherapywithdiuretics.Forthesereasonsrenal replacement therapy was started with continuous veno-venous hemofiltration (CVVHF), coupled to non-invasive ventilation:Bi-levelPositiveAirwayPressure(BiPAP).

Persistent haemodynamic instability and hypotension were treated starting vasopressor therapy with nor-epinephrine at doses of 0.04mcg/kg/min. In lack of improvement,a trans-thoracicechocardiographywas per-formed,whichdiagnosedsystolicanddiastolicdysfunction

associated with pulmonary arterial hypertension, without signsofrecentthromboembolism.

In order to optimize the patient preoperatively and improve kidney function, it wasdecided tostart a treat-mentwithlevosimendanat0.05mcg/kg/min,avoidingthe induction bolus and gradually increasing the dose up to 0.1mcg/kg/min, accordingtothehaemodynamicresponse andthetoleranceofthepatient.

Progressive improvement in renal function, recovering spontaneous and satisfactory urine output and improved analytical values allowed suspending renal replacement therapypriortosurgery.

Thepatientunderwentsurgeryonday17ofadmission, underspinalanaesthesia.Theinterventionwasmarkedby significant bloodloss thatrequired intraoperative transfu-sionof3unitsofpackedredbloodcellsand2unitsoffresh frozen plasma,andpostoperativetransfusionof4units of packedredcells and2unitsoffresh frozenplasma, with-outrecording anydysfunctionin cardiacperformance.On day24,thepatientwasdischargedtothewardwithoutany renalreplacementtherapyorvasoactivetreatment.

Discussion

Due toits high morbidity and mortality in the periopera-tiveperiod,heartfailureinpatientsundergoingnon-cardiac surgeryshouldbeidentifiedandtreatedatanearlystageto ensureadequatepreoperativeoptimizationandtoachieve betterhaemodynamicconditionspriortosurgery.

Renalfailureishighlyprevalentinpatientswithchronic heart failure; it could have an incidence of up to 25%.8

Furthermore,thisfallinglomerularfiltrationcouldworsen morbidityandmortalityinacuteheartfailure.9

Therearefewstudies ontheeffectivenessof preoper-ativetherapyforpreventingandtreatingthedeterioration ofcardiacfunctioninpatientsundergoingmajorsurgery.7,10

Prophylactic use of conventional inotropic drugs is con-troversial: it maycausean increase in myocardial oxygen consumption,vasodilationandriskofarrhythmias.11

After its recent introduction in clinical practice, lev-osimendan, thanks to an original mechanism of action, has been proved tobeeffective in achievingan improve-ment in cardiac function and perfusion of tissues and to be associated with a significant reduction in mortal-ity incritically ill patients.12 _{The drughas been reported}

to present even anti-inflammatory, anti-oxidantand anti-apoptoticeffects.13 _{Levosimendanhasshowedabeneficial}

effectonrenalfunction inpatientswithestablishedrenal failure,probablybecauseofthe raiseinrenalblood flow, duetotheincreasedcardiacoutput,vasodilationand possi-bleanti-inflammatoryproperties.6,14

In the present case, levosimendan wasused as preop-erativetreatmentinordertooptimizecardiacperformance andtoimproverenalfunctionbeforesurgery.Thetreatment proved tobe effective;thepatientwassuccessfully with-drawn fromrenalreplacement,and shewassubmittedto theinterventionandsheshowedtopossessaneffective car-diacfunction,sincesheresistedtoacuteandhugechanges inintravascularvolume.

Levosimendanasatreatmentforacuterenalfailure 91

inarapid infusionof approximately10min,followedby a continuousinfusionof0.1mcg/kg/minfor24h.Inpatients withacutemyocardialfailure,theadministrationofa load-ing dose has been associated with hypotensive episodes, difficult to control with vasopressor drugs.15 _{In order to}

avoidthesehypotensiveepisodesthatmayworsen,instead ofimproving,patient’sprognosis,someauthorsrecommend amorecarefulprotocol, consistinginnoloadingdose and agradualincreasingininfusionrate.15 _{Inthepresentcase,}

theprogressive introductionof levosimendaninfusion was not associated to hypotensive episodes or an augmenta-tioninvasoconstrictorsrequirement.Thereducedsystemic resistance showed only the beneficial face of the medal, increasingrenalperfusionandimprovingmicrocirculation.

Conclusion

Levosimendanmayconstitute avalidchoice tobe consid-ered in the management of preoperative decompensated heartfailureassociatedwithrenalinsufficiency. Themain property of the drug (inotropic and vasodilation positive effects)allowedtorestorerenalfunctionandtopreparethe patientfortheintervention.Moreover,thenewequilibrium, betweenincreasedcardiacfunctionandbeneficial vasodila-tion,washelpful duringand afterinterventionbecauseit allowed the cardiovascular system of our patient to deal withtheconsequencesofhaemorrhageandfluidtherapy.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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