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Hasson DC, Gist KM, Seo J, Stenson EK, Kessel A, Haga T, LaFever S, Santiago MJ, Barhight M, Selewski D, Ricci Z, Ollberding NJ, Stanski NL. The Association Between Vasopressin and Adverse Kidney Outcomes in Children and Young Adults Requiring Vasopressors on Continuous Renal Replacement Therapy. Crit Care Explor 2024; 6:e1156. [PMID: 39318499 PMCID: PMC11419489 DOI: 10.1097/cce.0000000000001156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2024] Open
Abstract
OBJECTIVES Continuous renal replacement therapy (CRRT) and shock are both associated with high morbidity and mortality in the ICU. Adult data suggest renoprotective effects of vasopressin vs. catecholamines (norepinephrine and epinephrine). We aimed to determine whether vasopressin use during CRRT was associated with improved kidney outcomes in children and young adults. DESIGN Secondary analysis of Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK), a multicenter, retrospective cohort study. SETTING Neonatal, cardiac, PICUs at 34 centers internationally from January 1, 2015, to December 31, 2021. PATIENTS/SUBJECTS Patients younger than 25 years receiving CRRT for acute kidney injury and/or fluid overload and requiring vasopressors. Patients receiving vasopressin were compared with patients receiving only norepinephrine/epinephrine. The impact of timing of vasopressin relative to CRRT start was assessed by categorizing patients as: early (on or before day 0), intermediate (days 1-2), and late (days 3-7). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 1016 patients, 665 (65%) required vasopressors in the first week of CRRT. Of 665, 248 (37%) received vasopressin, 473 (71%) experienced Major Adverse Kidney Events at 90 days (MAKE-90) (death, renal replacement therapy dependence, and/or > 125% increase in serum creatinine from baseline 90 days from CRRT initiation), and 195 (29%) liberated from CRRT on the first attempt within 28 days. Receipt of vasopressin was associated with higher odds of MAKE-90 (adjusted odds ratio [aOR], 1.80; 95% CI, 1.20-2.71; p = 0.005) but not liberation success. In the vasopressin group, intermediate/late initiation was associated with higher odds of MAKE-90 (aOR, 2.67; 95% CI, 1.17-6.11; p = 0.02) compared with early initiation. CONCLUSIONS Nearly two-thirds of children and young adults receiving CRRT required vasopressors, including over one-third who received vasopressin. Receipt of vasopressin was associated with more MAKE-90, although earlier initiation in those who received it appears beneficial. Prospective studies are needed to understand the appropriate timing, dose, and subpopulation for use of vasopressin.
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Affiliation(s)
- Denise C. Hasson
- Division of Pediatric Critical Care Medicine, Hassenfeld Children’s Hospital at New York University Langone Health, New York, NY
| | - Katja M. Gist
- Division of Cardiac Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - JangDong Seo
- Division of Biostatistics and the University of Cincinnati, College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Erin K. Stenson
- Division of Pediatric Critical Care Medicine, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, CO
| | - Aaron Kessel
- Division of Critical Care Medicine, Northwell Health, Cohen Children’s Hospital Medical Center, New Hyde Park, NY
| | - Taiki Haga
- Department of Critical Care Medicine, Osaka City General Hospital, Osaka, Japan
| | - Sara LaFever
- Pediatric Intensive Care Unit and Pediatrics Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | - Maria Jose Santiago
- Pediatric Intensive Care Unit and Pediatrics Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | - Matthew Barhight
- Division of Critical Care Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - David Selewski
- Division of Pediatric Nephrology, Medical University of South Carolina, Charleston, SC
| | - Zaccaria Ricci
- Department of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Nicholas J. Ollberding
- Division of Biostatistics and the University of Cincinnati, College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Natalja L. Stanski
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - on behalf of the Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) Collaborative
- Division of Pediatric Critical Care Medicine, Hassenfeld Children’s Hospital at New York University Langone Health, New York, NY
- Division of Cardiac Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Division of Biostatistics and the University of Cincinnati, College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Division of Pediatric Critical Care Medicine, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, CO
- Division of Critical Care Medicine, Northwell Health, Cohen Children’s Hospital Medical Center, New Hyde Park, NY
- Department of Critical Care Medicine, Osaka City General Hospital, Osaka, Japan
- Pediatric Intensive Care Unit and Pediatrics Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
- Division of Critical Care Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
- Division of Pediatric Nephrology, Medical University of South Carolina, Charleston, SC
- Department of Pediatrics, Meyer Children’s Hospital IRCCS, Florence, Italy
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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Hwang KY, Phoon PHY, Hwang NC. Adverse Clinical Effects Associated With Non-catecholamine Pharmacologic Agents for Treatment of Vasoplegic Syndrome in Adult Cardiac Surgery. J Cardiothorac Vasc Anesth 2024; 38:802-819. [PMID: 38218651 DOI: 10.1053/j.jvca.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/23/2023] [Accepted: 12/11/2023] [Indexed: 01/15/2024]
Abstract
Vasoplegic syndrome is a relatively common complication that can happen during and after major adult cardiac surgery. It is associated with a higher rate of complications, including postoperative renal failure, longer duration of mechanical ventilation, and intensive care unit stay, as well as increased mortality. The underlying pathophysiology of vasoplegic syndrome is that of profound vascular hyporesponsiveness, and involves a complex interplay among inflammatory cytokines, cellular surface receptors, and nitric oxide (NO) production. The pharmacotherapy approaches for the treatment of vasoplegia include medications that increase vascular smooth muscle contraction via increasing cytosolic calcium in myocytes, reduce the vascular effects of NO and inflammation, and increase the biosynthesis of and vascular response to norepinephrine. Clinical trials have demonstrated the clinical efficacy of non-catecholamine pharmacologic agents in the treatment of vasoplegic syndrome. With an increase in their use today, it is important for clinicians to understand the adverse clinical outcomes and patient risk profiles associated with these agents, which will allow better-tailored medical therapy.
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Affiliation(s)
- Kai Yin Hwang
- Department of Anaesthesiology, National University Hospital, Singapore
| | - Priscilla Hui Yi Phoon
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore
| | - Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore.
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Sacha GL, Bauer SR. Optimizing Vasopressin Use and Initiation Timing in Septic Shock: A Narrative Review. Chest 2023; 164:1216-1227. [PMID: 37479058 PMCID: PMC10635838 DOI: 10.1016/j.chest.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 07/23/2023] Open
Abstract
TOPIC IMPORTANCE This review discusses the rationale for vasopressin use, summarizes the results of clinical trials evaluating vasopressin, and focuses on the timing of vasopressin initiation to provide clinicians guidance for optimal adjunctive vasopressin initiation in patients with septic shock. REVIEW FINDINGS Patients with septic shock require vasoactive agents to restore adequate tissue perfusion. After norepinephrine, vasopressin is the suggested second-line adjunctive agent in patients with persistent inadequate mean arterial pressure. Vasopressin use in practice is heterogeneous likely because of inconsistent clinical trial findings, the lack of specific recommendations for when it should be used, and the high drug acquisition cost. Despite these limitations, vasopressin has demonstrated price inelastic demand, and its use in the United States has continued to increase. However, questions remain regarding optimal vasopressin use in patients with septic shock, particularly regarding patient selection and the timing of vasopressin initiation. SUMMARY Experimental studies evaluating the initiation timing of vasopressin in patients with septic shock are limited, and recent observational studies have revealed an association between vasopressin initiation at lower norepinephrine-equivalent doses or lower lactate concentrations and lower mortality.
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Affiliation(s)
- Gretchen L Sacha
- Department of Pharmacy, Cleveland Clinic, Case Western Reserve University, Cleveland, OH.
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Case Western Reserve University, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
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Hamzaoui O, Goury A, Teboul JL. The Eight Unanswered and Answered Questions about the Use of Vasopressors in Septic Shock. J Clin Med 2023; 12:4589. [PMID: 37510705 PMCID: PMC10380663 DOI: 10.3390/jcm12144589] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/05/2023] [Accepted: 07/08/2023] [Indexed: 07/30/2023] Open
Abstract
Septic shock is mainly characterized-in addition to hypovolemia-by vasoplegia as a consequence of a release of inflammatory mediators. Systemic vasodilatation due to depressed vascular tone results in arterial hypotension, which induces or worsens organ hypoperfusion. Accordingly, vasopressor therapy is mandatory to correct hypotension and to reverse organ perfusion due to hypotension. Currently, two vasopressors are recommended to be used, norepinephrine and vasopressin. Norepinephrine, an α1-agonist agent, is the first-line vasopressor. Vasopressin is suggested to be added to norepinephrine in cases of inadequate mean arterial pressure instead of escalating the doses of norepinephrine. However, some questions about the bedside use of these vasopressors remain. Some of these questions have been well answered, some of them not clearly addressed, and some others not yet answered. Regarding norepinephrine, we firstly reviewed the arguments in favor of the choice of norepinephrine as a first-line vasopressor. Secondly, we detailed the arguments found in the recent literature in favor of an early introduction of norepinephrine. Thirdly, we reviewed the literature referring to the issue of titrating the doses of norepinephrine using an individualized resuscitation target, and finally, we addressed the issue of escalation of doses in case of refractory shock, a remaining unanswered question. For vasopressin, we reviewed the rationale for adding vasopressin to norepinephrine. Then, we discussed the optimal time for vasopressin administration. Subsequently, we addressed the issue of the optimal vasopressin dose, and finally we discussed the best strategy to wean these two vasopressors when combined.
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Affiliation(s)
- Olfa Hamzaoui
- Service de Médecine intensive réanimation polyvalente, Hôpital Robert Debré, CHU de Reims Université de Reims, 51092 Reims, France
- "Hémostase et Remodelage Vasculaire Post-Ischémie"-EA 3801, Unité HERVI, 51100 Reims, France
| | - Antoine Goury
- Service de Médecine intensive réanimation polyvalente, Hôpital Robert Debré, CHU de Reims Université de Reims, 51092 Reims, France
| | - Jean-Louis Teboul
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, AP-HP, Université Paris-Saclay, DMU CORREVE, FHU SEPSIS, 94270 Le Kremlin-Bicêtre, France
- INSERM-UMR_S999 LabEx-LERMIT, Hôpital Marie-Lannelongue, 92350 Le Plessis Robinson, France
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Verghis R, Blackwood B, McDowell C, Toner P, Hadfield D, Gordon AC, Clarke M, McAuley D. Heterogeneity of surrogate outcome measures used in critical care studies: A systematic review. Clin Trials 2023; 20:307-318. [PMID: 36946422 PMCID: PMC10617004 DOI: 10.1177/17407745231151842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND The choice of outcome measure is a critical decision in the design of any clinical trial, but many Phase III clinical trials in critical care fail to detect a difference between the interventions being compared. This may be because the surrogate outcomes used to show beneficial effects in early phase trials (which informed the design of the subsequent Phase III trials) are not valid guides to the differences between the interventions for the main outcomes of the Phase III trials. We undertook a systematic review (1) to generate a list of outcome measures used in critical care trials, (2) to determine the variability in the outcome reporting in the respiratory subgroup and (3) to create a smaller list of potential early phase endpoints in the respiratory subgroup. METHODS Data related to outcomes were extracted from studies published in the six top-ranked critical care journals between 2010 and 2020. Outcomes were classified into subcategories and categories. A subset of early phase endpoints relevant to the respiratory subgroup was selected for further investigation. The variability of the outcomes and the variability in reporting was investigated. RESULTS A total of 6905 references were retrieved and a total of 294 separate outcomes were identified from 58 studies. The outcomes were then classified into 11 categories and 66 subcategories. A subset of 22 outcomes relevant for the respiratory group were identified as potential early phase outcomes. The summary statistics, time points and definitions show the outcomes are analysed and reported in different ways. CONCLUSION The outcome measures were defined, analysed and reported in a variety of ways. This creates difficulties for synthesising data in systematic reviews and planning definitive trials. This review once again highlights an urgent need for standardisation and validation of surrogate outcomes reported in critical care trials. Future work should aim to validate and develop a core outcome set for surrogate outcomes in critical care trials.
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Affiliation(s)
- Rejina Verghis
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Bronagh Blackwood
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | | | - Philip Toner
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Daniel Hadfield
- Critical Care Unit, King’s College Hospital NHS Foundation Trust, London, UK
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Mike Clarke
- Centre of Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Daniel McAuley
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
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Hwang NC, Sivathasan C. Review of Postoperative Care for Heart Transplant Recipients. J Cardiothorac Vasc Anesth 2023; 37:112-126. [PMID: 36323595 DOI: 10.1053/j.jvca.2022.09.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 09/10/2022] [Accepted: 09/14/2022] [Indexed: 11/11/2022]
Abstract
The early postoperative management strategies after heart transplantation include optimizing the function of the denervated heart, correcting the causes of hemodynamic instability, and initiating and maintaining immunosuppressive therapy, allograft rejection surveillance, and prophylaxis against infections caused by immunosuppression. The course of postoperative support is influenced by the quality of allograft myocardial protection prior to implantation and reperfusion, donor-recipient heart size matching, surgical technique of orthotopic heart transplantation, and patient factors (eg, preoperative condition, immunologic compatibility, postoperative vasomotor tone, severity and reversibility of pulmonary vascular hypertension, pulmonary function, mediastinal blood loss, and end-organ perfusion). This review provides an overview of the early postoperative care of recipients and includes a brief description of the surgical techniques for orthotopic heart transplantation.
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Affiliation(s)
- Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anesthesia, National Heart Centre, Singapore.
| | - Cumaraswamy Sivathasan
- Mechanical Cardiac Support and Heart Transplant Program, Department of Cardiothoracic Surgery, National Heart Centre, Singapore
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Ltaief Z, Ben-Hamouda N, Rancati V, Gunga Z, Marcucci C, Kirsch M, Liaudet L. Vasoplegic Syndrome after Cardiopulmonary Bypass in Cardiovascular Surgery: Pathophysiology and Management in Critical Care. J Clin Med 2022; 11:6407. [PMID: 36362635 PMCID: PMC9658078 DOI: 10.3390/jcm11216407] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 09/13/2023] Open
Abstract
Vasoplegic syndrome (VS) is a common complication following cardiovascular surgery with cardiopulmonary bypass (CPB), and its incidence varies from 5 to 44%. It is defined as a distributive form of shock due to a significant drop in vascular resistance after CPB. Risk factors of VS include heart failure with low ejection fraction, renal failure, pre-operative use of angiotensin-converting enzyme inhibitors, prolonged aortic cross-clamp and left ventricular assist device surgery. The pathophysiology of VS after CPB is multi-factorial. Surgical trauma, exposure to the elements of the CPB circuit and ischemia-reperfusion promote a systemic inflammatory response with the release of cytokines (IL-1β, IL-6, IL-8, and TNF-α) with vasodilating properties, both direct and indirect through the expression of inducible nitric oxide (NO) synthase. The resulting increase in NO production fosters a decrease in vascular resistance and a reduced responsiveness to vasopressor agents. Further mechanisms of vasodilation include the lowering of plasma vasopressin, the desensitization of adrenergic receptors, and the activation of ATP-dependent potassium (KATP) channels. Patients developing VS experience more complications and have increased mortality. Management includes primarily fluid resuscitation and conventional vasopressors (catecholamines and vasopressin), while alternative vasopressors (angiotensin 2, methylene blue, hydroxocobalamin) and anti-inflammatory strategies (corticosteroids) may be used as a rescue therapy in deteriorating patients, albeit with insufficient evidence to provide any strong recommendation. In this review, we present an update of the pathophysiological mechanisms of vasoplegic syndrome complicating CPB and discuss available therapeutic options.
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Affiliation(s)
- Zied Ltaief
- Service of Adult Intensive Care, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Nawfel Ben-Hamouda
- Service of Adult Intensive Care, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Valentina Rancati
- Service of Anesthesiology, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Ziyad Gunga
- Service of Cardiac Surgery, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Carlo Marcucci
- Service of Anesthesiology, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Matthias Kirsch
- Service of Cardiac Surgery, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Lucas Liaudet
- Service of Adult Intensive Care, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
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Sahoo P, Kothari N, Goyal S, Sharma A, Bhatia PK. Comparison of Norepinephrine and Terlipressin vs Norepinephrine Alone for Management of Septic Shock: A Randomized Control Study. Indian J Crit Care Med 2022; 26:669-675. [PMID: 35836627 PMCID: PMC9237141 DOI: 10.5005/jp-journals-10071-24231] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Purpose To compare norepinephrine and terlipressin vs norepinephrine alone for management of septic shock. Materials and methods In this prospective, randomized control trial, 50 adult patients with septic shock were randomized into two groups. Group I received a combination of injection terlipressin 0.02 µg/kg/min (fixed dose) infusion and injection norepinephrine 0.01 µg/kg/min infusion and group II received injection norepinephrine 0.01 µg/kg/min infusion alone. Dose of noradrenaline in both the groups was titrated to achieve the target MAP of 65–70 mm Hg. The data collected were the dose of norepinephrine required to maintain an MAP of above 65 mm Hg, urine output, serum lactate, procalcitonin level, C-reactive protein, sequential organ failure assessment (SOFA) score, total duration of vasopressor support, and incidences of the adverse effects. Results The norepinephrine dose in group I vs group II at 12 hours was found to be 0.141 ± 0.067 vs 0.374 ± 0.096 µg/kg/min (p ≤0.005). The serum lactate was lower, and urine output was higher in group I than group II (p <0.05). Group I had a significantly greater reduction in SOFA score in 12 hours than group II. Group I patient also had a significant decrease in the duration of vasopressor administration than group II patients being discharged from the ICU. However, there was no difference in the mortality between the two groups during their ICU stay. Conclusion A low-dose continuous infusion of terlipressin and norepinephrine could help attain early resuscitation goals for managing patients with septic shock. How to cite this article Sahoo P, Kothari N, Goyal S, Sharma A, Bhatia PK. Comparison of Norepinephrine and Terlipressin vs Norepinephrine Alone for Management of Septic Shock: A Randomized Control Study. Indian J Crit Care Med 2022;26(6):669–675.
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Affiliation(s)
- Pallavi Sahoo
- Department of Anaesthesiology and Critical Care, AIIMS, Jodhpur, Rajasthan, India
| | - Nikhil Kothari
- Department of Anaesthesiology and Critical Care, AIIMS, Jodhpur, Rajasthan, India
| | - Shilpa Goyal
- Department of Anaesthesiology and Critical Care, AIIMS, Jodhpur, Rajasthan, India
| | - Ankur Sharma
- Department of Trauma and Emergency (Anaesthesia), AIIMS, Jodhpur, Rajasthan, India
- Ankur Sharma, Department of Trauma and Emergency (Anaesthesia), AIIMS, Jodhpur, Rajasthan, India, Phone: +91 9654045653, e-mail:
| | - Pradeep K Bhatia
- Department of Anaesthesiology and Critical Care, AIIMS, Jodhpur, Rajasthan, India
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Bauer SR, Sacha GL, Siuba MT, Lam SW, Reddy AJ, Duggal A, Vachharajani V. Association of Arterial pH With Hemodynamic Response to Vasopressin in Patients With Septic Shock: An Observational Cohort Study. Crit Care Explor 2022; 4:e0634. [PMID: 35156051 PMCID: PMC8826954 DOI: 10.1097/cce.0000000000000634] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Vasopressin is reported to retain vasoconstrictive activity in the setting of acidemia, but preclinical models are inconsistent and studies have not evaluated the clinical effectiveness of vasopressin based on arterial pH. This study sought to determine the association between arterial pH and blood pressure after vasopressin initiation in septic shock. DESIGN This retrospective, multicenter, observational cohort study evaluated the association of arterial pH at the time of vasopressin initiation with hemodynamic response to vasopressin and change in catecholamine dose after vasopressin initiation. Hemodynamic response was defined as a catecholamine dose decrease with mean arterial pressure greater than or equal to 65 mm Hg at 6 hours after vasopressin initiation. SETTING Patients from eight hospitals in a health system were evaluated. PATIENTS Patients with septic shock initiated on vasopressin as a catecholamine adjunct between January 2012 and November 2017 were screened for inclusion. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 1,350 patients were included. At the time of vasopressin initiation patients were severely ill with arterial pH 7.28 ± 0.13, Sequential Organ Failure Assessment 14.1 ± 3.5, lactate 5.6 ± 4.6 mmol/L, and norepinephrine-equivalent catecholamine dose 32.3 ± 25.4 µg/min. After adjusting for lactate and Sequential Organ Failure Assessment with multivariable logistic regression, lower arterial pH was independently associated with lower odds of hemodynamic response to vasopressin (for each 0.1 unit arterial pH was below 7.40, response odds ratio 0.79; 95% CI, 0.72-0.87). For each 0.1 unit the pH was below 7.40 at vasopressin initiation, the norepinephrine-equivalent catecholamine dose increased by 1.5 µg/min (95% CI, 0.5-2.5 µg/min) at 1 hour, and increased by 2.5 µg/min (95% CI, 1.4-3.5 µg/min) at 6 hours after vasopressin initiation. CONCLUSIONS Compared with higher arterial pH, patients with septic shock and low arterial pH had lower odds of vasopressin response and higher catecholamine doses after vasopressin initiation. Similar to other vasopressors, the clinical effectiveness of vasopressin appears to be impaired in the setting of acidemia.
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Affiliation(s)
- Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
| | | | - Matthew T Siuba
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Simon W Lam
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
| | - Anita J Reddy
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Abhijit Duggal
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Vidula Vachharajani
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
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Bauer SR, Sacha GL, Lam SW, Wang L, Reddy AJ, Duggal A, Vachharajani V. Hemodynamic Response to Vasopressin Dosage of 0.03 Units/Min vs. 0.04 Units/Min in Patients With Septic Shock. J Intensive Care Med 2022; 37:92-99. [PMID: 33251906 PMCID: PMC10243460 DOI: 10.1177/0885066620977181] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Arginine vasopressin (AVP) is suggested as an adjunct to norepinephrine in patients with septic shock. Guidelines recommend an AVP dosage up to 0.03 units/min, but 0.04 units/min is commonly used in practice based on initial studies. This study was designed to compare the incidence of hemodynamic response between initial fixed-dosage AVP 0.03 units/min and AVP 0.04 units/min. METHODS This retrospective, multi-hospital health system, cohort study included adult patients with septic shock receiving AVP as an adjunct to catecholamine vasopressors. Patients were excluded if they received an initial dosage other than 0.03 units/min or 0.04 units/min, or AVP was titrated within the first 6 hours of therapy. The primary outcome was hemodynamic response, defined as a mean arterial pressure ≥65 mm Hg and a decrease in catecholamine dosage at 6 hours after AVP initiation. Inverse probability of treatment weighting (IPTW) based on the propensity score for initial AVP dosage receipt was utilized to estimate adjusted exposure effects. RESULTS Of the 1536 patients included in the observed data, there was a nearly even split between initial AVP dosage of 0.03 units/min (n = 842 [54.8%]) and 0.04 units/min (n = 694 [45.2%]). Observed patients receiving AVP 0.03 units/min were more frequently treated at the main campus academic medical center (96.3% vs. 52.2%, p < 0.01) and in a medical intensive care unit (87.4% vs. 39.8%, p < 0.01). The IPTW analysis included 1379 patients with achievement of baseline covariate balance. There was no evidence for a difference between groups in the incidence of hemodynamic response (0.03 units/min 50.0% vs. 0.04 units/min 53.1%, adjusted relative risk 1.06 [95% CI 0.94, 1.20]). CONCLUSIONS Initial AVP dosing varied by hospital and unit type. Although commonly used, an initial AVP dosage of 0.04 units/min was not associated with a higher incidence of early hemodynamic response to AVP in patients with septic shock.
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Affiliation(s)
| | | | | | - Lu Wang
- Department of Pharmacy, Cleveland Clinic
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic
| | - Anita J. Reddy
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University
| | - Vidula Vachharajani
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic
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11
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García-Cortés M, Ortega-Alonso A, Andrade RJ. Safety of treating acute liver injury and failure. Expert Opin Drug Saf 2021; 21:191-203. [PMID: 34254839 DOI: 10.1080/14740338.2021.1955854] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Acute liver injury and progression to acute liver failure can be life-threatening conditions that require prompt careful clinical assessment and therapeutic management. AREAS COVERED The aim of this article is to review the safety and side effect profile of pharmacological therapies used in the treatment of acute liver injury with specific focus on hepatic toxicity. We performed an extensive literature search with the terms 'acute liver injury,' 'acute liver failure,' 'therapy,' 'safety,' 'adverse reactions' and 'drug induced liver injury.' A thorough discussion of the main drugs and devices used in patients with acute liver injury and acute liver failure, its safety profile and the management of complications associated to therapy of these conditions is presented. EXPERT OPINION Several pharmacological approaches are used in acute liver injury and acute liver failure in an empirical basis. Whilst steroids are frequently tried in serious drug-induced liver injury there is concern on a potential harmful effect of these agents because of the higher mortality in patients receiving the drug; hence, statistical approaches such as propensity score matching might help resolve this clinical dilemma. Likewise, properly designed clinical trials using old and new drugs for subjects with serious drug-induced liver injury are clearly needed.
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Affiliation(s)
- Miren García-Cortés
- Servicio De Aparato Digestivo, Instituto De Investigación Biomédica De Málaga-IBIMA. Hospital Universitario Virgen De La Victoria, Universidad De Málaga, Centro De Investigación Biomédica En Red De Enfermedades Hepáticas Y Digestivas CIBERehd, Málaga, Spain
| | - Aida Ortega-Alonso
- Servicio De Aparato Digestivo, Instituto De Investigación Biomédica De Málaga-IBIMA. Hospital Universitario Virgen De La Victoria, Universidad De Málaga, Centro De Investigación Biomédica En Red De Enfermedades Hepáticas Y Digestivas CIBERehd, Málaga, Spain
| | - Raúl J Andrade
- Servicio De Aparato Digestivo, Instituto De Investigación Biomédica De Málaga-IBIMA. Hospital Universitario Virgen De La Victoria, Universidad De Málaga, Centro De Investigación Biomédica En Red De Enfermedades Hepáticas Y Digestivas CIBERehd, Málaga, Spain
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12
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Guinot PG, Martin A, Berthoud V, Voizeux P, Bartamian L, Santangelo E, Bouhemad B, Nguyen M. Vasopressor-Sparing Strategies in Patients with Shock: A Scoping-Review and an Evidence-Based Strategy Proposition. J Clin Med 2021; 10:3164. [PMID: 34300330 PMCID: PMC8306396 DOI: 10.3390/jcm10143164] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 01/15/2023] Open
Abstract
Despite the abundant literature on vasopressor therapy, few studies have focused on vasopressor-sparing strategies in patients with shock. We performed a scoping-review of the published studies evaluating vasopressor-sparing strategies by analyzing the results from randomized controlled trials conducted in patients with shock, with a focus on vasopressor doses and/or duration reduction. We analyzed 143 studies, mainly performed in septic shock. Our analysis demonstrated that several pharmacological and non-pharmacological strategies are associated with a decrease in the duration of vasopressor therapy. These strategies are as follows: implementing a weaning strategy, vasopressin use, systemic glucocorticoid administration, beta-blockers, and normothermia. On the contrary, early goal directed therapies, including fluid therapy, oral vasopressors, vitamin C, and renal replacement therapy, are not associated with an increase in vasopressor-free days. Based on these results, we proposed an evidence-based vasopressor management strategy.
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Affiliation(s)
- Pierre-Grégoire Guinot
- Department of Anesthesiology and Intensive Care, CHU Dijon, 21000 Dijon, France; (A.M.); (V.B.); (P.V.); (L.B.); (E.S.); (B.B.); (M.N.)
- Lipness Team, INSERM Research Center LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, 21000 Dijon, France
| | - Audrey Martin
- Department of Anesthesiology and Intensive Care, CHU Dijon, 21000 Dijon, France; (A.M.); (V.B.); (P.V.); (L.B.); (E.S.); (B.B.); (M.N.)
| | - Vivien Berthoud
- Department of Anesthesiology and Intensive Care, CHU Dijon, 21000 Dijon, France; (A.M.); (V.B.); (P.V.); (L.B.); (E.S.); (B.B.); (M.N.)
| | - Pierre Voizeux
- Department of Anesthesiology and Intensive Care, CHU Dijon, 21000 Dijon, France; (A.M.); (V.B.); (P.V.); (L.B.); (E.S.); (B.B.); (M.N.)
| | - Loic Bartamian
- Department of Anesthesiology and Intensive Care, CHU Dijon, 21000 Dijon, France; (A.M.); (V.B.); (P.V.); (L.B.); (E.S.); (B.B.); (M.N.)
| | - Erminio Santangelo
- Department of Anesthesiology and Intensive Care, CHU Dijon, 21000 Dijon, France; (A.M.); (V.B.); (P.V.); (L.B.); (E.S.); (B.B.); (M.N.)
| | - Belaid Bouhemad
- Department of Anesthesiology and Intensive Care, CHU Dijon, 21000 Dijon, France; (A.M.); (V.B.); (P.V.); (L.B.); (E.S.); (B.B.); (M.N.)
- Lipness Team, INSERM Research Center LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, 21000 Dijon, France
| | - Maxime Nguyen
- Department of Anesthesiology and Intensive Care, CHU Dijon, 21000 Dijon, France; (A.M.); (V.B.); (P.V.); (L.B.); (E.S.); (B.B.); (M.N.)
- Lipness Team, INSERM Research Center LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, 21000 Dijon, France
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13
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Nakamura K, Nakano H, Naraba H, Mochizuki M, Takahashi Y, Sonoo T, Hashimoto H, Abe T, Hayakawa M, Yamakawa K. Vasopressin Loading for Refractory Septic Shock: A Preliminary Analysis of a Case Series. Front Med (Lausanne) 2021; 8:644195. [PMID: 34017842 PMCID: PMC8129171 DOI: 10.3389/fmed.2021.644195] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 04/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Vasopressin is one of the strong vasopressor agents associated with ischemic events. Responses to the administration of vasopressin differ among patients with septic shock. Although the administration of a high dose of vasopressin needs to be avoided, the effects of bolus loading have not yet been examined. Since the half-life of vasopressin is longer than that of catecholamines, we hypothesized that vasopressin loading may be effective for predicting responses to its continuous administration. Methods: We retrospectively analyzed consecutive cases of septic shock for which vasopressin was introduced with loading under noradrenaline at >0.2 μg/kg/min during the study period. Vasopressin was administered in a 1 U bolus followed by its continuous administration at 1 U/h. The proportion of patients with a negative catecholamine index (CAI) change 6 h after the introduction of vasopressin was set as the primary outcome. We defined non-responders for exploration as those with a mean arterial pressure change <18 mmHg 1 min after vasopressin loading, among whom none had a change in CAI <0. Results: Twenty-one consecutive cases were examined in the present study, and included 14 responders and 7 non-responders. The primary outcome accounted for 71.4% of responders and 0% of non-responders, with a significant difference (p = 0.0039). Median CAI changes 2, 4, and 6 h after the administration of vasopressin were 0, -5, and -10 in responders and +20, +10, and +10 in non-responders, respectively. CAI was not reduced in any non-responder. Outcomes including mortality were not significantly different between responders and non-responders. Digital ischemia (1/21) and mesenteric ischemia (1/21) were observed. Conclusions: Vasopressin loading may predict responses to its continuous administration in septic shock patients. Further investigations involving a safety analysis are needed.
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Affiliation(s)
- Kensuke Nakamura
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Ibaraki, Japan
| | - Hidehiko Nakano
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Ibaraki, Japan
| | - Hiromu Naraba
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Ibaraki, Japan.,TXP Medical Co., Ltd., Tokyo, Japan
| | - Masaki Mochizuki
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Ibaraki, Japan
| | - Yuji Takahashi
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Ibaraki, Japan
| | - Tomohiro Sonoo
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Ibaraki, Japan.,TXP Medical Co., Ltd., Tokyo, Japan
| | - Hideki Hashimoto
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Ibaraki, Japan
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan.,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo-shi, Japan
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical College Hospital, Takatsuki, Japan
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14
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Guarracino F, Habicher M, Treskatsch S, Sander M, Szekely A, Paternoster G, Salvi L, Lysenko L, Gaudard P, Giannakopoulos P, Kilger E, Rompola A, Häberle H, Knotzer J, Schirmer U, Fellahi JL, Hajjar LA, Kettner S, Groesdonk HV, Heringlake M. Vasopressor Therapy in Cardiac Surgery-An Experts' Consensus Statement. J Cardiothorac Vasc Anesth 2020; 35:1018-1029. [PMID: 33334651 DOI: 10.1053/j.jvca.2020.11.032] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 11/09/2020] [Accepted: 11/13/2020] [Indexed: 12/17/2022]
Abstract
Hemodynamic conditions with reduced systemic vascular resistance commonly are observed in patients undergoing cardiac surgery and may range from moderate reductions in vascular tone, as a side effect of general anesthetics, to a profound vasodilatory syndrome, often referred to as vasoplegic shock. Therapy with vasopressors is an important pillar in the treatment of these conditions. There is limited guidance on the appropriate choice of vasopressors to restore and optimize systemic vascular tone in patients undergoing cardiac surgery. A panel of experts in the field convened to develop statements and evidence-based recommendations on clinically relevant questions on the use of vasopressors in cardiac surgical patients, using a critical appraisal of the literature following the GRADE system and a modified Delphi process. The authors unanimously and strongly recommend the use of norepinephrine and/or vasopressin for restoration and maintenance of systemic perfusion pressure in cardiac surgical patients; despite that, the authors cannot recommend either of these drugs with respect to the risk of ischemic complications. The authors unanimously and strongly recommend against using dopamine for treating post-cardiac surgery vasoplegic shock and against using methylene blue for purposes other than a rescue therapy. The authors unanimously and weakly recommend that clinicians consider early addition of a second vasopressor (norepinephrine or vasopressin) if adequate vascular tone cannot be restored by a monotherapy with either norepinephrine or vasopressin and to consider using vasopressin as a first-line vasopressor or to add vasopressin to norepinephrine in cardiac surgical patients with pulmonary hypertension or right-sided heart dysfunction.
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Affiliation(s)
- Fabio Guarracino
- Department of Anesthesia and Intensive Care Medicine, University Hospital of Pisa, Pisa, Italy
| | - Marit Habicher
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Gieβen, Justus-Liebig University Gieβen, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Operative Intensive Care Medicine Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany
| | - Michael Sander
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Gieβen, Justus-Liebig University Gieβen, Germany
| | - Andrea Szekely
- Department of Anesthesia, Semmelweis University Budapest, Budapest, Hungary
| | - Gianluca Paternoster
- Division of Cardiac Resuscitation, Cardiovascular Anesthesia and Intensive Care, San Carlo Hospital, Potenza, Italy
| | - Luca Salvi
- IRCCS Centro Cardiologico Monzino, Milano, Italy
| | - Lidia Lysenko
- Department of Anesthesiology and Intensive Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Phillipe Gaudard
- Department of Anaesthesiology and Critical Care Medicine Arnaud de Villeneuve, CHU Montpellier, University of Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France
| | | | - Erich Kilger
- Department of Anesthesiology, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Amalia Rompola
- Department of Cardiac Surgery Intensive Care, Onassis Cardiac Center, Kallithea Athens, Greece
| | - Helene Häberle
- Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany
| | - Johann Knotzer
- Department of Anaesthesiology and Critical Care Medicine, County Hospital Wels, Wels, Austria
| | - Uwe Schirmer
- Institute for Anesthesiology, Heart, and Diabetes Center, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Jean-Luc Fellahi
- Department of Anesthesiology and Critical Care, Hôpital Cardiologique Louis Pradel, Lyon, France
| | - Ludhmila Abrahao Hajjar
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clínicas, Sao Paulo, Brazil
| | - Stephan Kettner
- Department of Anesthesiology and Intensive Care, Vienna Hospital Association, Vienna, Austria
| | | | - Matthias Heringlake
- Department of Anesthesiology and Intensive Care, Heart- and Diabetes Center Mecklenburg - Western Pomerania, Karlsburg, Germany.
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15
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Jones TW, Smith SE, Van Tuyl JS, Newsome AS. Sepsis With Preexisting Heart Failure: Management of Confounding Clinical Features. J Intensive Care Med 2020; 36:989-1012. [PMID: 32495686 DOI: 10.1177/0885066620928299] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Preexisting heart failure (HF) in patients with sepsis is associated with worse clinical outcomes. Core sepsis management includes aggressive volume resuscitation followed by vasopressors (and potentially inotropes) if fluid is inadequate to restore perfusion; however, large fluid boluses and vasoactive agents are concerning amid the cardiac dysfunction of HF. This review summarizes evidence regarding the influence of HF on sepsis clinical outcomes, pathophysiologic concerns, resuscitation targets, hemodynamic interventions, and adjunct management (ie, antiarrhythmics, positive pressure ventilatory support, and renal replacement therapy) in patients with sepsis and preexisting HF. Patients with sepsis and preexisting HF receive less fluid during resuscitation; however, evidence suggests traditional fluid resuscitation targets do not increase the risk of adverse events in HF patients with sepsis and likely improve outcomes. Norepinephrine remains the most well-supported vasopressor for patients with sepsis with preexisting HF, while dopamine may induce more cardiac adverse events. Dobutamine should be used cautiously given its generally detrimental effects but may have an application when combined with norepinephrine in patients with low cardiac output. Management of chronic HF medications warrants careful consideration for continuation or discontinuation upon development of sepsis, and β-blockers may be appropriate to continue in the absence of acute hemodynamic decompensation. Optimal management of atrial fibrillation may include β-blockers after acute hemodynamic stabilization as they have also shown independent benefits in sepsis. Positive pressure ventilatory support and renal replacement must be carefully monitored for effects on cardiac function when HF is present.
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Affiliation(s)
- Timothy W Jones
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Augusta, GA, USA
| | - Susan E Smith
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Athens, GA, USA
| | - Joseph S Van Tuyl
- Department of Pharmacy Practice, 14408St Louis College of Pharmacy, St Louis, MO, USA
| | - Andrea Sikora Newsome
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Augusta, GA, USA.,Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
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16
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Yao RQ, Xia DM, Wang LX, Wu GS, Zhu YB, Zhao HQ, Liu Q, Xia ZF, Ren C, Yao YM. Clinical Efficiency of Vasopressin or Its Analogs in Comparison With Catecholamines Alone on Patients With Septic Shock: A Systematic Review and Meta-Analysis. Front Pharmacol 2020; 11:563. [PMID: 32435192 PMCID: PMC7218087 DOI: 10.3389/fphar.2020.00563] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/14/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Vasopressin is an efficient remedy for septic shock patients as its great capacity in promoting hemodynamic stabilization. The aim of current systematic review and meta-analysis is to compare the clinical efficiency of vasopressin or its analogs with sole catecholamines on patients with septic shock. METHODS A systematic search of Cochrane Library, EMBASE, and PubMed online databases was performed up to 30 Oct 2019 to identify randomized controlled trials comparing use of vasopressin or its analogs (e.g., terlipressin, selepressin) with administration of catecholamines alone. RESULTS We included 23 RCTs with 4,225 patients in the current study. Compared with solely use of catecholamines, administration of vasopressin or its analogs was not associated with reduced 28-day or 30-day mortality among patients with septic shock [RR=0.94 (95% CI, 0.87-1.01), P=0.08, I2 = 0%]. The result of primary endpoint remained unchanged after conducting sensitivity analysis. Despite a significantly higher risk of digital ischemia in patients receiving vasopressin or its analogs [RR=2.65 (95% CI, 1.26-5.56), P < 0.01, I2 = 48%], there was no statistical significance in the pooled estimate for other secondary outcomes, including total adverse events, arrhythmia, acute myocardial infarction (AMI) and cardiac arrest, acute mesenteric ischemia, ICU/hospital length of stay, and mechanical ventilation (MV) duration. CONCLUSIONS The administration of vasopressin or its analogs was not associated with reduced 28-day or 30-day mortality among patients with septic shock, while an increased incidence of digital ischemia should be noted in patients receiving agonists for vasopressin receptors.
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Affiliation(s)
- Ren-qi Yao
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - De-meng Xia
- Department of Emergency, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Li-xue Wang
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China
| | - Guo-sheng Wu
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Yi-bing Zhu
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Beijing, China
| | - Hong-qiang Zhao
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China
| | - Qi Liu
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China
| | - Zhao-fan Xia
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Chao Ren
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China
| | - Yong-ming Yao
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China
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17
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Jentzer JC, Hollenberg SM. Vasopressor and Inotrope Therapy in Cardiac Critical Care. J Intensive Care Med 2020; 36:843-856. [PMID: 32281470 DOI: 10.1177/0885066620917630] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patients admitted to the cardiac intensive care unit (CICU) are often in shock and require hemodynamic support. Identifying and addressing the pathophysiology mechanisms operating in an individual patient is crucial to achieving a successful outcome, while initiating circulatory support therapy to restore adequate tissue perfusion. Vasopressors and inotropes are the cornerstone of supportive medical therapy for shock, in addition to fluid resuscitation when indicated. Timely initiation of optimal vasopressor and inotrope therapy is essential for patients with shock, with the ultimate goals of restoring effective tissue perfusion in order to normalize cellular metabolism. Use of vasoactive agents for hemodynamic support of patients with shock should take both arterial pressure and tissue perfusion into account when choosing therapeutic interventions. For most patients with shock, including cardiogenic or septic shock, norepinephrine (NE) is an appropriate choice as a first-line vasopressor titrated to achieve an adequate arterial pressure due to a lower risk of adverse events than other catecholamine vasopressors. If tissue and organ perfusion remain inadequate, an inotrope such as dobutamine may be added to increase cardiac output to a sufficient level that meets tissue demand. Low doses of epinephrine or dopamine may be used for inotropic support, but high doses of these drugs carry an excessive risk of adverse events when used for vasopressor support and should be avoided. When NE alone is inadequate to achieve an adequate arterial pressure, addition of a noncatecholamine vasopressor such as vasopressin or angiotensin-II is reasonable, in addition to rescue therapies that may improve vasopressor responsiveness. In this review, we discuss the pharmacology and evidence-based use of vasopressor and inotrope drugs in critically ill patients, with a focus on the CICU population.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, 4352Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Steven M Hollenberg
- Department of Cardiology, 3673Hackensack University Medical Center, Hackensack, NJ, USA
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18
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Schultz J, Andersen A, Lyhne MD, Arcanjo DDR, Kjaergaard B, Simonsen U, Nielsen-Kudsk JE. Terlipressin Increases Systemic and Lowers Pulmonary Arterial Pressure in Experimental Acute Pulmonary Embolism. Crit Care Med 2020; 48:e308-e315. [PMID: 32205621 DOI: 10.1097/ccm.0000000000004243] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES We investigated whether the vasopressin-analog, terlipressin induces systemic vasoconstriction and pulmonary vasodilation in a porcine model of acute pulmonary embolism. DESIGN Controlled, animal study. SETTING Tertiary medical center research laboratory. SUBJECTS Female pigs (n = 12, Cross of Land Race, Duroc, and Yorkshire ~ 60 kg). INTERVENTIONS Acute pulmonary embolism was induced by administration of three large autologous emboli. Animals then received four increasing doses of either terlipressin (n = 6) or vehicle (n = 6). MEASUREMENTS AND MAIN RESULTS Effects were evaluated in vivo at baseline, after pulmonary embolism and after each dose by invasive hemodynamic measures, transesophageal echocardiography, and blood analysis. Isolated pulmonary arteries were evaluated ex vivo in a myograph. Pulmonary embolism caused a four-fold increase in pulmonary vascular resistance (p < 0.0001) and a two-fold increase in mean pulmonary arterial pressure (p < 0.0001) compared with baseline. Terlipressin increased mean systemic blood pressure (28 ± 5 mm Hg; p < 0.0001) and systemic vascular resistance (1,320 ± 143 dynes; p < 0.0001) compared with vehicle. In the pulmonary circulation, terlipressin decreased mean pulmonary arterial pressure (-6.5 ± 1.8 mm Hg; p = 0.005) and tended to decrease pulmonary vascular resistance (-83 ± 33 dynes; p = 0.07). Terlipressin decreased cardiac output (-2.5 ± 0.5 L/min; p < 0.0001) and increased plasma lactate (2.7 ± 0.2 mmol/L; p < 0.0001), possibly indicating systemic hypoperfusion. A biomarker of cerebral ischemia, S100b, remained unchanged, suggesting preserved cerebral perfusion (0.17 ± 0.11 µg/L; p = 0.51). Ex vivo, terlipressin relaxed pulmonary and constricted mesenteric arteries. CONCLUSIONS Terlipressin caused systemic vasoconstriction and pulmonary vasodilation in a porcine in vivo model of acute pulmonary embolism and vasorelaxation in isolated pulmonary arteries. Despite positive vascular effects, cardiac output declined and plasma lactate increased probably due to a predominantly systemic vasoconstrictor effect of terlipressin. These findings should warrant careful translation to the clinical setting and does not suggest routine use in acute pulmonary embolism.
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Affiliation(s)
- Jacob Schultz
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Mads D Lyhne
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Daniel D R Arcanjo
- Department of Biophysics and Physiology, Federal University of Piauí, Teresina, Brazil
- Institute of Biomedicine, Aarhus University, Aarhus, Denmark
| | | | - Ulf Simonsen
- Institute of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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19
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Der-Nigoghossian C, Hammond DA, Ammar MA. Narrative Review of Controversies Involving Vasopressin Use in Septic Shock and Practical Considerations. Ann Pharmacother 2020; 54:706-714. [PMID: 31958982 DOI: 10.1177/1060028020901521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Objective: To summarize literature evaluating vasopressin use, focusing on clinical controversies regarding initiation, dosing, and discontinuation and interaction of vasopressin with other therapies in septic shock patients. Data Sources: A PubMed English-language literature search (January 2008 to December 2019) was performed using these terms: arginine vasopressin, septic, shock, and sepsis. Citations, including controlled trials, observational studies, review articles, guidelines, and consensus statements, were reviewed. Study Selection and Data Extraction: Relevant clinical data focusing on specific controversial questions regarding the utility of vasopressin in patients with septic shock were narratively summarized. Data Synthesis: Current literature does not strongly support the use of vasopressin as a first-line initial therapy for septic shock. Additionally, there are conflicting data for weight-based dosing of vasopressin in overweight patients. Evidence for vasopressin renal protection and interaction with corticosteroids is minimal. However, vasopressin has the ability to reduce catecholamine requirements in septic shock patients and may provide a mortality benefit in specific subgroups. Discontinuation of vasopressin last, not second to last, in resolving septic shock may reduce hypotension development. Relevance to Patient Care and Clinical Practice: This review addresses specific clinical controversies that drive vasopressin use in septic shock patients in real-world practice. Conclusion: Vasopressin should remain second-line adjunct to norepinephrine to augment mean arterial pressures. Dosing should be initiated at 0.03 U/min, and higher doses offer minimal benefit. There are conflicting data on the impact of weight on vasopressin response. Studies have failed to show renal benefit with vasopressin use or an interaction with corticosteroid therapy.
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Affiliation(s)
| | - Drayton A Hammond
- Rush University Medical Center, Chicago, IL, USA.,Rush Medical College, Chicago, IL, USA
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20
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Haiduc M, Radparvar S, Aitken SL, Altshuler J. Does Switching Norepinephrine to Phenylephrine in Septic Shock Complicated by Atrial Fibrillation With Rapid Ventricular Response Improve Time to Rate Control? J Intensive Care Med 2020; 36:191-196. [PMID: 31893966 DOI: 10.1177/0885066619896292] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) frequently develops during critical illness. In septic shock complicated by rapid AF, the use of phenylephrine may be advantageous secondary to its β-1 sparing properties. However, evidence supporting this strategy is lacking. OBJECTIVE The purpose of this study is to determine the clinical effect on rate control of transitioning norepinephrine to phenylephrine in septic shock patients who develop AF with a rapid ventricular response (RVR). METHODS A single-center retrospective study of septic shock patients admitted to the medical or surgical intensive care unit (ICU) who developed AF with RVR (heart rate >110 beats per minute [bpm]). Patients who were switched to phenylephrine were compared to those who remained on norepinephrine. The primary end point was sustained achievement of rate control. A time-varying Cox proportional hazards model was used to assess the primary end point. RESULTS A total of 67 patients were included in the study, of which 28 were switched to phenylephrine. Baseline characteristics were similar between groups. The unadjusted hazard ratio for achieving rate control was significant at 1.99 (95% confidence interval [CI]: 1.19-3.34; P < .01) for the phenylephrine group. The adjusted hazard ratio was 1.75 (95% CI: 0.86-3.53; P = .12). There were no statistically significant differences in mortality or ICU length of stay. CONCLUSION Our study suggests a potential clinical effect on achieving rate control when switching to phenylephrine cannot be excluded. It remains unclear if there is a benefit on mortality or length of stay outcomes in critically ill patients.
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Affiliation(s)
- Manuela Haiduc
- Department of Pharmacy, 5944The Mount Sinai Hospital, New York, NY, USA
| | - Sara Radparvar
- Department of Pharmacy, 5944The Mount Sinai Hospital, New York, NY, USA
| | - Samuel L Aitken
- Department of Pharmacy, Division of Pharmacy, 4002University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jerry Altshuler
- Department of Pharmacy, 3139Hackensack Meridian Health JFK Medical Center, Edison, NJ, USA
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21
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Huang P, Guo Y, Li B, Liu Q. Terlipressin Versus Norepinephrine for Septic Shock: A Systematic Review and Meta-Analysis. Front Pharmacol 2019; 10:1492. [PMID: 31920672 PMCID: PMC6936170 DOI: 10.3389/fphar.2019.01492] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 11/19/2019] [Indexed: 12/28/2022] Open
Abstract
Purpose: The meta-analysis aims to evaluate the efficacy and safety of terlipressin compared with norepinephrine for septic shock. Materials and Methods: The relevant studies from MEDLINE, Cochrane Library, Embase were searched by two independent investigators. A variety of keywords were used to search the studies. Stata software (version 11.0, Stata Corp LP, College Station, TX, USA) was used for statistical analysis. Results: A total of six studies were identified and incorporated into the meta-analysis. The results showed that there was no difference for 28-day mortality (RR = 0.99, 95% CI = [0.85,1.15], P = 0.849), AE (RR = 2.54, 95% CI = [0.58,11.08], P = 0.214), and MAP (SMD = -0.10, 95% CI = [-0.35,0.14], P = 0.405), OI, urinary output, Scr, total bilirubin, ALT, and AST between TP group and NE group. While TP could decrease HR at 24 and 48 h compared with NE. Conclusions: Current results suggest that terlipressin showed no added survival benefit for septic shock when compared with norepinephrine, while terlipressin could decrease heart rate in the late phase of septic shock compared with norepinephrine without further liver and kidney injury. Systematic Review Registration: PROSPERO (ID: CRD42019128743). Available online at: http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42019128743.
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Affiliation(s)
- Po Huang
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Yuhong Guo
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Bo Li
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Infection and Immunity Laboratory, Beijing Institute of Traditional Chinese Medicine, Beijing, China
| | - Qingquan Liu
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Infection and Immunity Laboratory, Beijing Institute of Traditional Chinese Medicine, Beijing, China.,Infection and Immunity Laboratory, Beijing Key Laboratory of Basic Research With Traditional Chinese Medicine on Infectious Diseases, Beijing, China
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22
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Yerke JR, Sacha GL, Scheraga RG, Culver DA, Abraham S, Torbic H, Lam SW, Ammar MA, Olman MA, Bauer SR. Vasopressin Plasma Concentrations Are Not Associated with Hemodynamic Response to Exogenous Vasopressin for Septic Shock. Pharmacotherapy 2019; 40:33-39. [PMID: 31705703 DOI: 10.1002/phar.2346] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Positive hemodynamic response to vasopressin after 6 hours of infusion was independently associated with lower mortality in a previous retrospective study of patients with septic shock. However, factors previously associated with higher plasma vasopressin concentration were not associated with response, and the relationship between plasma vasopressin concentration and hemodynamic response has not been evaluated. OBJECTIVES This cross-sectional study compared plasma vasopressin concentrations in hemodynamic responders and nonresponders to vasopressin in patients with septic shock to evaluate plasma vasopressin concentration as a therapeutic target for hemodynamic response to vasopressin. METHODS Adult patients with septic shock were included if they were treated with fixed-dose vasopressin as an adjunct to catecholamines for at least 3 hours. Patients were assigned to groups based on vasopressin response. RESULTS Ten hemodynamic responders to vasopressin and eight nonresponders were included. Blood samples for plasma vasopressin concentration were collected 3-6 hours after vasopressin initiation. Baseline characteristics were similar between groups. No difference was detected in plasma vasopressin concentrations between hemodynamic responders and nonresponders (median 88.6 pg/ml [interquartile range (IQR) 84.4-107.5 pg/ml] vs 89.9 pg/ml [IQR 67.5-157.4 pg/ml], p=0.79, respectively). We also did not detect a difference between groups after correcting for vasopressin dose; median vasopressin plasma concentration per 0.01 units/minute of vasopressin infusion for responders was 25.9 pg/ml (IQR 21.8-31.8 pg/ml) versus 29.5 pg/ml (IQR 23.0-57.5 pg/ml, p=0.48) for nonresponders. No difference in clinical outcomes was detected between groups. The findings were robust to multiple sensitivity analyses. CONCLUSIONS This study does not support the use of plasma vasopressin concentrations as a therapeutic target to predict hemodynamic response to exogenous vasopressin in septic shock.
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Affiliation(s)
- Jason R Yerke
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio
| | | | - Rachel G Scheraga
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Daniel A Culver
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Susamma Abraham
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Heather Torbic
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio
| | - Simon W Lam
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio
| | - Mahmoud A Ammar
- Department of Pharmacy, Yale New Haven Health System, New Haven, Connecticut
| | - Mitchell A Olman
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio
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23
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Smith SE, Rumbaugh KA. Utilization of vasopressin before and after protocol implementation in a surgical intensive care unit. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Susan E. Smith
- Department of Pharmaceutical Services Vanderbilt University Medical Center Nashville Tennessee
| | - Kelli A. Rumbaugh
- Department of Pharmaceutical Services Vanderbilt University Medical Center Nashville Tennessee
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24
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Nagendran M, Russell JA, Walley KR, Brett SJ, Perkins GD, Hajjar L, Mason AJ, Ashby D, Gordon AC. Vasopressin in septic shock: an individual patient data meta-analysis of randomised controlled trials. Intensive Care Med 2019; 45:844-855. [PMID: 31062052 DOI: 10.1007/s00134-019-05620-2] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 04/12/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE We performed an individual patient data meta-analysis to investigate the possible benefits and harms of vasopressin therapy in adults with septic shock both overall and in pre-defined subgroups. METHODS Our pre-specified study protocol is published on PROSPERO, CRD42017071698. We identified randomised clinical trials up to January 2019 investigating vasopressin therapy versus any other vasoactive comparator in adults with septic shock. Individual patient data from each trial were compiled. Conventional two-stage meta-analyses were performed as well as one-stage regression models with single treatment covariate interactions for subgroup analyses. RESULTS Four trials were included with a total of 1453 patients. For the primary outcomes, there was no effect of vasopressin on 28-day mortality [relative risk (RR) 0.98, 95% CI 0.86-1.12] or serious adverse events (RR 1.02, 95% CI 0.82-1.26). Vasopressin led to more digital ischaemia [absolute risk difference (ARD) 1.7%, 95% CI 0.3%-3.2%] but fewer arrhythmias (ARD - 2.8%, 95% CI - 0.2% to - 5.3%). Mesenteric ischaemia and acute coronary syndrome events were similar between groups. Vasopressin reduced the requirement for renal replacement therapy (RRT) (RR 0.86, 95% CI 0.74-0.99), but this finding was not robust to sensitivity analyses. There were no statistically significant interactions in the pre-defined subgroups (baseline kidney injury severity, baseline lactate, baseline norepinephrine requirement and time to study inclusion). CONCLUSIONS Vasopressin therapy in septic shock had no effect on 28-day mortality although the confidence intervals are wide. It appears safe but with a different side effect profile from norepinephrine. The finding on reduced RRT should be interpreted cautiously. Future trials should focus on long-term outcomes in select patient groups as well as incorporating cost effectiveness analyses regarding possible reduced RRT use.
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Affiliation(s)
- Myura Nagendran
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
| | - James A Russell
- Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Keith R Walley
- Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Stephen J Brett
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
- Centre for Perioperative and Critical Care Research, Imperial College Healthcare NHS Trust, London, UK
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University Hospitals Birmingham NHS Foundation Trust, University of Warwick, Coventry, UK
| | - Ludhmila Hajjar
- Instituto do Coracao, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Alexina J Mason
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Deborah Ashby
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Anthony C Gordon
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK.
- Centre for Perioperative and Critical Care Research, Imperial College Healthcare NHS Trust, London, UK.
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25
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Kislitsina ON, Rich JD, Wilcox JE, Pham DT, Churyla A, Vorovich EB, Ghafourian K, Yancy CW. Shock - Classification and Pathophysiological Principles of Therapeutics. Curr Cardiol Rev 2019; 15:102-113. [PMID: 30543176 PMCID: PMC6520577 DOI: 10.2174/1573403x15666181212125024] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 10/11/2018] [Accepted: 12/10/2018] [Indexed: 01/10/2023] Open
Abstract
The management of patients with shock is extremely challenging because of the myriad of possible clinical presentations in cardiogenic shock, septic shock and hypovolemic shock and the limitations of contemporary therapeutic options. The treatment of shock includes the administration of endogenous catecholamines (epinephrine, norepinephrine, and dopamine) as well as various vasopressor agents that have shown efficacy in the treatment of the various types of shock. In addition to the endogenous catecholamines, dobutamine, isoproterenol, phenylephrine, and milrinone have served as the mainstays of shock therapy for several decades. Recently, experimental studies have suggested that newer agents such as vasopressin, selepressin, calcium-sensitizing agents like levosimendan, cardiac-specific myosin activators like omecamtiv mecarbil (OM), istaroxime, and natriuretic peptides like nesiritide can enhance shock therapy, especially when shock presents a more complex clinical picture than normal. However, their ability to improve clinical outcomes remains to be proven. It is the purpose of this review to describe the mechanism of action, dosage requirements, advantages and disadvantages, and specific indications and contraindications for the use of each of these catecholamines and vasopressors, as well as to elucidate the most important clinical trials that serve as the basis of contemporary shock therapy.
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Affiliation(s)
- Olga N Kislitsina
- Department of Cardiac Surgery Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States.,Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Jonathan D Rich
- Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Jane E Wilcox
- Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Duc T Pham
- Department of Cardiac Surgery Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Andrei Churyla
- Department of Cardiac Surgery Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Esther B Vorovich
- Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Kambiz Ghafourian
- Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Clyde W Yancy
- Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
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26
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Zhu Y, Huang H, Xi X, Du B. Terlipressin for septic shock patients: a meta-analysis of randomized controlled study. J Intensive Care 2019; 7:16. [PMID: 30923620 PMCID: PMC6419496 DOI: 10.1186/s40560-019-0369-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 02/21/2019] [Indexed: 12/13/2022] Open
Abstract
Background Catecholamines are commonly used in septic shock but face limitations of their hypo-responsiveness and adverse events due to high dose. Terlipressin is a synthetic vasopressin analog with greater selectivity for the V1-receptor. A meta-analysis was conducted to evaluate the efficacy and safety of terlipressin in septic shock. Methods We searched for relevant studies in PubMed, Embase, and the Cochrane database from inception up to July 15, 2018. Randomized controlled trials (RCTs) were included if they reported data on any of the predefined outcomes in patients with septic shock and managed with terlipressin or any catecholamines. Results were expressed as risk ratio (RR) or mean difference (MD) with accompanying 95% confidence interval (CI). Heterogeneity, subgroup analysis, sensitivity analysis, and publication bias were explored. Results Ten studies with 928 patients were included. Despite the shorter duration of mechanical ventilation, use of terlipressin did not reduce the risk of mortality (RR = 0.94; 95% CI, 0.85 to 1.05; I2 = 0%; P = 0.28) when compared with control. This finding was confirmed by further subgroup and sensitivity analyses. In addition, lactate clearance, length of stay in ICU or hospital, total adverse events, digital ischemia, and arrhythmia were also similar between groups, while terlipressin was associated with shorter duration of mechanical ventilation and less norepinephrine requirements. Conclusions Current results suggest terlipressin did not show added survival benefit in septic shock therapy when compared with catecholamines. Electronic supplementary material The online version of this article (10.1186/s40560-019-0369-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yibing Zhu
- 1ICU, Fuxing Hospital, Capital Medical University, Peking, China
| | - Huibin Huang
- 2Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Peking, China.,3Department of Critical Care Medicine, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Xiuming Xi
- 1ICU, Fuxing Hospital, Capital Medical University, Peking, China
| | - Bin Du
- 2Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Peking, China
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27
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Sacha GL, Bauer SR, Lat I. Vasoactive Agent Use in Septic Shock: Beyond First-Line Recommendations. Pharmacotherapy 2019; 39:369-381. [PMID: 30644586 DOI: 10.1002/phar.2220] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Septic shock is a life-threatening disorder associated with high mortality rates requiring rapid identification and intervention. Vasoactive agents are often required to maintain goal hemodynamics and preserve tissue perfusion. However, guidance regarding the proper administration of adjunct agents for the management of septic shock is limited in patients who are refractory to norepinephrine. This review summarizes vasopressor agents and describes the nuanced application of these agents in patients with septic shock, specifically focusing on clinical scenarios with limited guidance including patients who are nonresponsive to first-line agents and individuals with mixed shock states, tachyarrhythmias, obesity, valvular abnormalities, or other comorbid conditions.
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Affiliation(s)
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio
| | - Ishaq Lat
- Department of Pharmacy, Shirley Ryan Ability Lab, Chicago, Illinois
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28
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Angiotensin II in septic shock. J Intensive Care Soc 2019; 20:77-79. [DOI: 10.1177/1751143718799921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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29
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Abstract
The Angiotensin II for the Treatment of Vasodilatory Shock (ATHOS-3) trial demonstrated the vasopressor effects and catecholamine-sparing properties of angiotensin II. As a result, the Food and Drug Administration has approved angiotensin II for the treatment of vasodilatory shock. This review details the goals of treatment of vasodilatory shock in addition to the history, current use, and recent research regarding the use of angiotensin II. An illustrative case of the use of angiotensin II is also incorporated for understanding the clinical utility of the drug.
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Affiliation(s)
- Brett J Wakefield
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8054, St Louis, MO 63110, USA
| | - Laurence W Busse
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Emory University School of Medicine, Emory St. Joseph's Hospital, 5665 Peachtree Dunwoody Road, Atlanta, GA 30342, USA
| | - Ashish K Khanna
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Center for Critical Care, Department of Outcomes Research, Cleveland Clinic, 9500 Euclid Avenue - G58, Cleveland, OH 44195, USA; Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
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31
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Regional differences in the treatment of refractory vasodilatory shock using Angiotensin II in High Output Shock (ATHOS-3) data. J Crit Care 2018; 50:188-194. [PMID: 30553989 DOI: 10.1016/j.jcrc.2018.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 12/06/2018] [Accepted: 12/06/2018] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Despite international guidelines, regional differences in treatment of vasodilatory shock remain. We characterized these differences using data from Angiotensin II in High Output Shock (ATHOS-3) trial. METHODS The 321 patients treated in the ATHOS-3 trial were included. Baseline and hour-48 data were analyzed for differences in demographics, clinical characteristics, and treatment patterns, and grouped into four geographical areas: United States, Canada, Europe, and Australasia. Differences were analyzed by Kruskal-Wallis tests for continuous, and chi-square tests for categorical data. Temporal analysis compared changes in the treatment of shock during the treatment period. RESULTS Differences in baseline characteristics across geographic areas were noted in BMI, albumin, CVP, MELD score, APACHE II score, and total SOFA score. Baseline norepinephrine and norepinephrine equivalent doses (NED) were higher (p < .0001 and p = .0494, respectively), and vasopressin use was lower (p < .0001) in Europe. Baseline steroids were utilized more in the US and Canada (p = .0011). CONCLUSIONS Management of vasodilatory shock differs globally with respect to utilization of steroids and vasopressors. This practice heterogeneity may influence shock trials interpretation and patient outcomes, though more definitive evidence would require larger prospective intervention data.
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32
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Chidambaram S, Goh EL, Rey VG, Khan MA. Vasopressin vs noradrenaline: Have we found the perfect recipe to improve outcome in septic shock? J Crit Care 2018; 49:99-104. [PMID: 30415181 DOI: 10.1016/j.jcrc.2018.10.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 10/04/2018] [Accepted: 10/29/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE The metabolic and circulatory disturbances in patients with septic shock results in a high mortality rate. There is a lack of high-level evidence on the optimal approach. We present a meta-analysis elucidating the outcomes of regimes with only noradrenaline versus a combination of noradrenaline and vasopressin in managing septic shock. METHODS A literature search of studies comparing the use of noradrenaline and vasopressin in septic shock was conducted, using MEDLINE and EMBASE databases. The primary outcome evaluated was mortality rate. Subgroup analysis of secondary measures was also conducted using Review Manager 5.3 software. RESULTS Four RCTs of 1039 patients were included. There is good evidence supporting a comparable mortality rate (RR: 0.92, 95% CI: 0.78, 1.08, p = .32, I2 = 0%), and moderate evidence supporting an equivalent length of ICU stay (MD: 0.14, 95% CI: -1.37, 1.65, p = .86, I2 = 46%) and occurrence of adverse events (RR: 1.19, 95% CI: 0.83, 1.70, p = .35, I2 = 13%) between the two cohorts. CONCLUSION The two regimes have equivalent outcomes, but vasopressin has a role in selected patients experiencing less severe septic shock beyond a 36-h period. Further work will make definitive clinical recommendations for optimal strategy of vasopressin or noradrenaline usage.
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Affiliation(s)
- Swathikan Chidambaram
- Faculty of Medicine, Imperial College London, South Kensington, London SW7 2AZ, United Kingdom
| | - En Lin Goh
- Faculty of Medicine, Imperial College London, South Kensington, London SW7 2AZ, United Kingdom
| | - Vanessa Garnelo Rey
- Department of Critical Care, Imperial College London, St Mary's Hospital, W2 1NY, London, United Kingdom
| | - Mansoor Ali Khan
- Department of Surgery and Trauma, Imperial College London, St Mary's Hospital, W2 1NY London, United Kingdom.
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33
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Jentzer JC, Vallabhajosyula S, Khanna AK, Chawla LS, Busse LW, Kashani KB. Management of Refractory Vasodilatory Shock. Chest 2018; 154:416-426. [DOI: 10.1016/j.chest.2017.12.021] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 12/18/2017] [Accepted: 12/21/2017] [Indexed: 12/24/2022] Open
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Abstract
Angiotensin II (Ang II), part of the renin-angiotensin-aldosterone system (RAS), is a potent vasoconstrictor and has been recently approved for use by the US Food and Drug Administration in high-output shock. Though not a new drug, the recently published Angiotensin II for the Treatment of High Output Shock (ATHOS-3) trial, as well as a number of retrospective analyses have sparked renewed interest in the use of Ang II, which may have a role in treating refractory shock. We describe refractory shock, the unique mechanism of action of Ang II, RAS dysregulation in shock, and the evidence supporting the use of Ang II to restore blood pressure. Evidence suggests that Ang II may preferentially be of benefit in acute kidney injury and acute respiratory distress syndrome, where the RAS is known to be disrupted. Additionally, there may be a role for Ang II in cardiogenic shock, angiotensin converting enzyme inhibitor overdose, cardiac arrest, liver failure, and in settings of extracorporeal circulation.
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Affiliation(s)
- Rachel L Bussard
- Critical Care Pharmacy Specialist, Department of Pharmacy, Emory St Joseph's Hospital, Atlanta, GA, USA
| | - Laurence W Busse
- Department of Critical Care, Emory St Joseph's Hospital, Atlanta, GA, USA,
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA, USA,
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35
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Bauer SR, Sacha GL, Lam SW. Safe Use of Vasopressin and Angiotensin II for Patients with Circulatory Shock. Pharmacotherapy 2018; 38:851-861. [DOI: 10.1002/phar.2147] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Seth R. Bauer
- Department of Pharmacy; Cleveland Clinic; Cleveland Ohio
| | | | - Simon W. Lam
- Department of Pharmacy; Cleveland Clinic; Cleveland Ohio
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36
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Terlipressin versus norepinephrine as infusion in patients with septic shock: a multicentre, randomised, double-blinded trial. Intensive Care Med 2018; 44:1816-1825. [PMID: 29971593 DOI: 10.1007/s00134-018-5267-9] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 06/05/2018] [Indexed: 02/05/2023]
Abstract
PURPOSE Recent clinical data suggest that terlipressin, a vasopressin analogue, may be more beneficial in septic shock patients than catecholamines. However, terlipressin's effect on mortality is unknown. We set out to ascertain the efficacy and safety of continuous terlipressin infusion compared with norepinephrine (NE) in patients with septic shock. METHODS In this multicentre, randomised, double-blinded trial, patients with septic shock recruited from 21 intensive care units in 11 provinces of China were randomised (1:1) to receive either terlipressin (20-160 µg/h with maximum infusion rate of 4 mg/day) or NE (4-30 µg/min) before open-label vasopressors. The primary endpoint was mortality 28 days after the start of infusion. Primary efficacy endpoint analysis and safety analysis were performed on the data from a modified intention-to-treat population. RESULTS Between 1 January 2013 and 28 February 2016, 617 patients were randomised (312 to the terlipressin group, 305 to the NE group). The modified intention-to-treat population comprised 526 (85.3%) patients (260 in the terlipressin group and 266 in the NE group). There was no significant difference in 28-day mortality rate between the terlipressin group (40%) and the NE group (38%) (odds ratio 0.93 [95% CI 0.55-1.56]; p = 0.80). Change in SOFA score on day 7 was similar between the two groups: - 7 (IQR - 11 to 3) in the terlipressin group and - 6 (IQR - 10 to 5) in the NE group. There was no difference between the groups in the number of days alive and free of vasopressors. Overall, serious adverse events were more common in the terlipressin group than in the NE group (30% vs 12%; p < 0.001). CONCLUSIONS In this multicentre, randomised, double-blinded trial, we observed no difference in mortality between terlipressin and NE infusion in patients with septic shock. Patients in the terlipressin group had a higher number of serious adverse events. TRIAL REGISTRATION This trial is registered at ClinicalTrials.gov: ID NCT01697410.
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Neuroendocrine Derangements in Early Septic Shock: Pharmacotherapy for Relative Adrenal and Vasopressin Insufficiency. Shock 2018; 48:284-293. [PMID: 28296657 DOI: 10.1097/shk.0000000000000864] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Septic shock is a leading cause of mortality in intensive care units throughout the world. While this disease state represents a highly complex pathophysiology involving numerous organ systems, the early approach to care includes adequate hemodynamic support traditionally achieved via infusions of vasoactive medications after adequate fluid resuscitation. Relative adrenal and vasopressin deficiencies are a common feature of septic shock that contribute to impaired hemodynamics. Hydrocortisone and vasopressin are endocrine system hormone analogues that target the acute neuroendocrine imbalance associated with septic shock. This clinically focused annotated review describes the pathophysiological mechanisms behind their use and explores the potential clinical roles of early administration and synergy when combined.
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Sacha GL, Lam SW, Duggal A, Torbic H, Bass SN, Welch SC, Butler RS, Bauer SR. Predictors of response to fixed-dose vasopressin in adult patients with septic shock. Ann Intensive Care 2018; 8:35. [PMID: 29511951 PMCID: PMC5840112 DOI: 10.1186/s13613-018-0379-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 02/26/2018] [Indexed: 01/23/2023] Open
Abstract
Background Vasopressin is often utilized for hemodynamic support in patients with septic shock. However, the most appropriate patient to initiate therapy in is unknown. This study was conducted to determine factors associated with hemodynamic response to fixed-dose vasopressin in patients with septic shock. Methods Single-center, retrospective cohort of patients receiving fixed-dose vasopressin for septic shock for at least 6 h with concomitant catecholamines in the medical, surgical, or neurosciences intensive care unit (ICU) at a tertiary care center. Patients were classified as responders or non-responders to fixed-dose vasopressin. Response was defined as a decrease in catecholamine dose requirements and achievement of mean arterial pressure ≥ 65 mmHg at 6 h after initiation of vasopressin. Results A total of 938 patients were included: 426 responders (45%), 512 non-responders (55%). Responders had lower rates of in-hospital (57 vs. 72%; P < 0.001) and ICU mortality (50 vs. 68%; P < 0.001), and increased ICU-free days at day 14 and hospital-free days at day 28 (2.3 ± 3.8 vs. 1.6 ± 3.3; P < 0.001 and 4.2 ± 7.2 vs. 2.8 ± 6.0; P < 0.001, respectively). On multivariable analysis, non-medical ICU location was associated with increased response odds (OR 1.70; P = 0.0049) and lactate at vasopressin initiation was associated with decreased response odds (OR 0.93; P = 0.0003). Factors not associated with response included APACHE III score, SOFA score, corticosteroid use, and catecholamine dose. Conclusion In this evaluation, 45% responded to the addition of vasopressin with improved outcomes compared to non-responders. The only factors found to be associated with vasopressin response were ICU location and lactate concentration.
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Affiliation(s)
- Gretchen L Sacha
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Avenue (Hb-105), Cleveland, OH, 44195, USA.
| | - Simon W Lam
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Avenue (Hb-105), Cleveland, OH, 44195, USA
| | - Abhijit Duggal
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Heather Torbic
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Avenue (Hb-105), Cleveland, OH, 44195, USA
| | - Stephanie N Bass
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Avenue (Hb-105), Cleveland, OH, 44195, USA
| | - Sarah C Welch
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Avenue (Hb-105), Cleveland, OH, 44195, USA
| | - Robert S Butler
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Avenue (Hb-105), Cleveland, OH, 44195, USA
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Sacha GL, Lam SW, Duggal A, Torbic H, Reddy AJ, Bauer SR. Hypotension Risk Based on Vasoactive Agent Discontinuation Order in Patients in the Recovery Phase of Septic Shock. Pharmacotherapy 2018; 38:319-326. [DOI: 10.1002/phar.2082] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
| | - Simon W. Lam
- Department of Pharmacy; Cleveland Clinic; Cleveland Ohio
| | | | - Heather Torbic
- Department of Pharmacy; Cleveland Clinic; Cleveland Ohio
| | | | - Seth R. Bauer
- Department of Pharmacy; Cleveland Clinic; Cleveland Ohio
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Buckley MS, MacLaren R. Concomitant vasopressin and hydrocortisone therapy on short-term hemodynamic effects and vasopressor requirements in refractory septic shock. J Crit Care 2017. [DOI: 10.1016/j.jcrc.2017.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Nascente APM, Freitas FGR, Bakker J, Bafi AT, Ladeira RT, Azevedo LCP, Lima A, Machado FR. Microcirculation improvement after short-term infusion of vasopressin in septic shock is dependent on noradrenaline. Clinics (Sao Paulo) 2017; 72:750-757. [PMID: 29319721 PMCID: PMC5738558 DOI: 10.6061/clinics/2017(12)06] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 10/11/2017] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES To assess the impact of vasopressin on the microcirculation and to develop a predictive model to estimate the probability of microcirculatory recruitment in patients with septic shock. METHODS This prospective interventional study included patients with septic shock receiving noradrenaline for less than 48 hours. We infused vasopressin at 0.04 U/min for one hour. Hemodynamic measurements, including sidestream dark-field imaging, were obtained immediately before vasopressin infusion, 1 hour after vasopressin infusion and 1 hour after vasopressin withdrawal. We defined patients with more than a 10% increase in total vascular density and perfused vascular density as responders. ClinicalTrials.gov: NCT02053675. RESULTS Eighteen patients were included, and nine (50%) showed improved microcirculation after infusion of vasopressin. The noradrenaline dose was significantly reduced after vasopressin (p=0.001) and was higher both at baseline and during vasopressin infusion in the responders than in the non-responders. The strongest predictor for a favorable microcirculatory response was the dose of noradrenaline at baseline (OR=4.5; 95% CI: 1.2-17.0; p=0.027). For patients using a noradrenaline dose higher than 0.38 mcg/kg/min, the probability that microcirculatory perfusion would be improved with vasopressin was 53% (sensitivity 78%, specificity 77%). CONCLUSIONS In patients with septic shock for no longer than 48 h, administration of vasopressin is likely to result in an improvement in microcirculation when the baseline noradrenaline dose is higher than 0.38 mcg/kg/min.
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Affiliation(s)
- Ana Paula Metran Nascente
- Departamento de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de Sao Paulo, Sao Paulo, SP, BR
| | | | - Jan Bakker
- Department of Intensive Care Adults, Erasmus MC - University Hospital Rotterdam, the Netherlands
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine. College of Physicians & Surgeons of Columbia, University of New York, USA
| | - Antônio Tonete Bafi
- Departamento de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de Sao Paulo, Sao Paulo, SP, BR
| | - Renata Teixeira Ladeira
- Departamento de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de Sao Paulo, Sao Paulo, SP, BR
| | | | - Alexandre Lima
- Department of Intensive Care Adults, Erasmus MC - University Hospital Rotterdam, the Netherlands
| | - Flavia Ribeiro Machado
- Departamento de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
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Allen B, Kram B, Kram S, Schultheis J, Wolf S, Gilstrap D, Shapiro M. Predictors of Vasopressin Responsiveness in Critically Ill Adults. Ann Pharmacother 2017; 52:126-132. [PMID: 28853293 DOI: 10.1177/1060028017729480] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Vasopressin is commonly used as an adjunct vasopressor in shock. However, response to vasopressin varies among critically ill patients. OBJECTIVE To identify patient-specific factors that are associated with vasopressin responsiveness in critically ill adults. METHODS This retrospective, multicenter study included adult patients who were admitted to an intensive care unit (ICU) and received vasopressin for shock. Patients were excluded if they received vasopressin for less than 30 minutes, if vasopressin was initiated prior to ICU arrival, or if an additional vasopressor was initiated within 30 minutes of starting vasopressin. Responsiveness was defined as an increase in mean arterial pressure of ≥10 mm Hg or the ability to taper a concurrent catecholamine vasopressor. Patient-specific factors evaluated in a multivariate analysis included age, gender, ethnicity, body mass index, type of shock, serum pH, Sequential Organ Failure Assessment (SOFA) score, and use of stress-dose steroids. These variables were also evaluated in a subgroup analysis of patients with septic shock. RESULTS Of 1619 patients screened, 400 patients were included, with 231 identified as vasopressin responsive and 169 as nonresponsive. Vasopressin used as an adjunct vasopressor, as opposed to first line, during shock was the only variable associated with vasopressin responsiveness (odds ratio [OR] = 1.71; 95% CI = 1.10 to 2.65). Among the subgroup of patients with septic shock, female patients had a higher odds of responding than male patients (OR = 2.10; 95% CI = 1.12 to 3.95). CONCLUSIONS Vasopressin initiated as an adjunct vasopressor, as opposed to first-line therapy, was associated with response.
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Affiliation(s)
| | | | - Shawn Kram
- 2 Duke University Hospital, Durham, NC, USA
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Genga KR, Russell JA. Update of Sepsis in the Intensive Care Unit. J Innate Immun 2017; 9:441-455. [PMID: 28697503 DOI: 10.1159/000477419] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 05/08/2017] [Indexed: 01/28/2023] Open
Abstract
Sepsis, the most common cause of admission to an intensive care unit (ICU), has had an increased incidence and prevalence over the last years with a simultaneous decrease in its short-term mortality. Sepsis survivors are more frequently discharged from hospital and often experience long-term outcomes such as late mortality, immune dysfunction, secondary infections, impaired quality of life, and unplanned readmissions. Early recognition and management of sepsis have challenged emergency care and critical care physicians and nurses. New sepsis definitions were produced and the Surviving Sepsis Campaign (SSC) 2016 was updated recently. Although hospital readmissions after sepsis are common, associated risk factors and how to manage patients who survive an episode of sepsis still need clarification. The immune dysfunction caused by sepsis/septic shock is complex, persistent, affects inflammatory and anti-inflammatory systems, and might be associated with long-term outcomes of sepsis. Several randomized controlled trials (RCT) that analyzed new (and old) interventions in sepsis/septic shock are discussed in this review in parallel with the SSC 2016 recommendations and other guidelines when relevant. RCTs addressing incidence, treatment, and prevention of important sepsis-associated organ dysfunction such as the acute respiratory distress syndrome, acute kidney injury, and brain dysfunction are highlighted. Finally, we briefly discuss the need for novel targets, predictive biomarkers, and new designs of RCTs in sepsis.
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Affiliation(s)
- Kelly Roveran Genga
- Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
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Vasopressin versus Norepinephrine in Patients with Vasoplegic Shock after Cardiac Surgery: The VANCS Randomized Controlled Trial. Anesthesiology 2017; 126:85-93. [PMID: 27841822 DOI: 10.1097/aln.0000000000001434] [Citation(s) in RCA: 185] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Vasoplegic syndrome is a common complication after cardiac surgery and impacts negatively on patient outcomes. The objective of this study was to evaluate whether vasopressin is superior to norepinephrine in reducing postoperative complications in patients with vasoplegic syndrome. METHODS This prospective, randomized, double-blind trial was conducted at the Heart Institute, University of Sao Paulo, Sao Paulo, Brazil, between January 2012 and March 2014. Patients with vasoplegic shock (defined as mean arterial pressure less than 65 mmHg resistant to fluid challenge and cardiac index greater than 2.2 l · min · m) after cardiac surgery were randomized to receive vasopressin (0.01 to 0.06 U/min) or norepinephrine (10 to 60 μg/min) to maintain arterial pressure. The primary endpoint was a composite of mortality or severe complications (stroke, requirement for mechanical ventilation for longer than 48 h, deep sternal wound infection, reoperation, or acute renal failure) within 30 days. RESULTS A total of 330 patients were randomized, and 300 were infused with one of the study drugs (vasopressin, 149; norepinephrine, 151). The primary outcome occurred in 32% of the vasopressin patients and in 49% of the norepinephrine patients (unadjusted hazard ratio, 0.55; 95% CI, 0.38 to 0.80; P = 0.0014). Regarding adverse events, the authors found a lower occurrence of atrial fibrillation in the vasopressin group (63.8% vs. 82.1%; P = 0.0004) and no difference between groups in the rates of digital ischemia, mesenteric ischemia, hyponatremia, and myocardial infarction. CONCLUSIONS The authors' results suggest that vasopressin can be used as a first-line vasopressor agent in postcardiac surgery vasoplegic shock and improves clinical outcomes.
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Hrymak C, Strumpher J, Jacobsohn E. Acute Right Ventricle Failure in the Intensive Care Unit: Assessment and Management. Can J Cardiol 2017; 33:61-71. [DOI: 10.1016/j.cjca.2016.10.030] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 10/29/2016] [Accepted: 10/30/2016] [Indexed: 12/29/2022] Open
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Choong K. Vasopressin in Pediatric Critical Care. J Pediatr Intensive Care 2016; 5:182-188. [PMID: 31110903 PMCID: PMC6512420 DOI: 10.1055/s-0036-1583282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 10/15/2015] [Indexed: 10/21/2022] Open
Abstract
Vasopressin is a unique hormone with complex receptor physiology and numerous physiologic functions beyond its well-known vascular actions and osmoregulation. While vasopressin has in the past been primarily used in the management of diabetes insipidus and acute gastrointestinal bleeding, an increased understanding of the physiology of refractory shock, and the role of vasopressin in maintaining cardiovascular homeostasis prompted a renewed interest in the therapeutic roles for this hormone in the critical care setting. Identifying vasopressin-deficient individuals for the purposes of assessing responsiveness to exogenous hormone and prognosticating outcome has expanded research into the evaluation of vasopressin and its precursor, copeptin as useful biomarkers. This review summarizes the current evidence for vasopressin in critically ill children, with a specific focus on its use in the management of shock. We outline important considerations and current guidelines, when considering the use of vasopressin or its analogues in the pediatric critical care setting.
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Affiliation(s)
- Karen Choong
- Department of Pediatrics, Critical Care, Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Hessler M, Kampmeier T, Rehberg S. Effect of non-adrenergic vasopressors on macro- and microvascular coupling in distributive shock. Best Pract Res Clin Anaesthesiol 2016; 30:465-477. [DOI: 10.1016/j.bpa.2016.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 10/31/2016] [Indexed: 02/07/2023]
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Kwon S, Crowley G, Haider SH, Zhang L, Nolan A. Nephroprotective strategies in septic shock: the VANISH trial. J Thorac Dis 2016; 8:E1508-E1510. [PMID: 28066645 DOI: 10.21037/jtd.2016.11.44] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Sophia Kwon
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University, School of Medicine, New York, USA;; Department of Medicine, Hackensack University Medical Center-Palisades, North Bergen, New Jersey, USA
| | - George Crowley
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University, School of Medicine, New York, USA
| | - Syed Hissam Haider
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University, School of Medicine, New York, USA
| | - Liqun Zhang
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University, School of Medicine, New York, USA;; Department of Respiratory Medicine, PLA, Army General Hospital, Beijing 100853, China
| | - Anna Nolan
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University, School of Medicine, New York, USA;; Department of Environmental Medicine, New York University, School of Medicine, New York, USA
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Morin L, Ray S, Wilson C, Remy S, Benissa MR, Jansen NJG, Javouhey E, Peters MJ, Kneyber M, De Luca D, Nadel S, Schlapbach LJ, Maclaren G, Tissieres P. Refractory septic shock in children: a European Society of Paediatric and Neonatal Intensive Care definition. Intensive Care Med 2016; 42:1948-1957. [PMID: 27709263 PMCID: PMC5106490 DOI: 10.1007/s00134-016-4574-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 09/22/2016] [Indexed: 12/31/2022]
Abstract
Purpose Although overall paediatric septic shock mortality is decreasing, refractory septic shock (RSS) is still associated with high mortality. A definition for RSS is urgently needed to facilitate earlier identification and treatment. We aim to establish a European society of paediatric and neonatal intensive care (ESPNIC) experts’ definition of paediatric RSS. Methods We conducted a two-round Delphi study followed by an observational multicentre retrospective study. One hundred and fourteen paediatric intensivists answered a clinical case-based, two-round Delphi survey, identifying clinical items consistent with RSS. Multivariate analysis of these items in a development single-centre cohort (70 patients, 30 % mortality) facilitated development of RSS definitions based on either a bedside or computed severity score. Both scores were subsequently tested in a validation cohort (six centres, 424 patients, 11.6 % mortality). Results From the Delphi process, the draft definition included evidence of myocardial dysfunction and high blood lactate levels despite high vasopressor treatment. When assessed in the development population, each item was independently associated with the need for extracorporeal life support (ECLS) or death. Resultant bedside and computed septic shock scores had high discriminative power against the need for ECLS or death, with areas under the receiver operating characteristics curve of 0.920 (95 % CI 0.89–0.94), and 0.956 (95 % CI 0.93–0.97), respectively. RSS defined by a bedside score equal to or higher than 2 and a computed score equal to or higher than 3.5 was associated with a significant increase in mortality. Conclusions This ESPNIC definition of RSS accurately identifies children with the most severe form of septic shock. Electronic supplementary material The online version of this article (doi:10.1007/s00134-016-4574-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Luc Morin
- Paediatric Intensive Care Unit, Paris South University Hospitals, AP-HP, 78 Rue du General Leclerc, 94275, Le Kremlin-Bicêtre, France
| | - Samiran Ray
- Paediatric Intensive Care Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Clare Wilson
- Paediatric Intensive Care Unit, Saint-Mary's Hospital, London, UK
| | - Solenn Remy
- Paediatric Intensive Care Unit, Lyon University Hospitals, Bron, France
| | - Mohamed Rida Benissa
- Paediatric Intensive Care Unit, Paris South University Hospitals, AP-HP, 78 Rue du General Leclerc, 94275, Le Kremlin-Bicêtre, France
| | - Nicolaas J G Jansen
- Paediatric Intensive Care Unit, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Etienne Javouhey
- Paediatric Intensive Care Unit, Lyon University Hospitals, Bron, France
| | - Mark J Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Martin Kneyber
- Paediatric Intensive Care Unit, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands.,Critical care, Anesthesiology, Peri-operative and Emergency medicine (CAPE), The University of Groningen, Groningen, The Netherlands
| | - Daniele De Luca
- Neonatal Intensive Care Unit, Paris South University Hospitals, AP-HP, Clamart, France
| | - Simon Nadel
- Paediatric Intensive Care Unit, Saint-Mary's Hospital, London, UK
| | - Luregn Jan Schlapbach
- Paediatric Intensive Care Unit, Lady Cilento Children's Hospital, Children's Health Queensland, Brisbane, Australia.,Paediatric Critical Care Research Group, Mater Research, The University of Queensland, Brisbane, Australia.,Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Graeme Maclaren
- Department of Paediatrics, Royal Children's Hospital, University of Melbourne, Melbourne, Australia.,Cardiothoracic Intensive Care Unit, National University Health System, Singapore, Singapore
| | - Pierre Tissieres
- Paediatric Intensive Care Unit, Paris South University Hospitals, AP-HP, 78 Rue du General Leclerc, 94275, Le Kremlin-Bicêtre, France. .,Institute of Integrative Biology of the Cell, Paris Saclay University, Saint-Aubin, France.
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Bomberg H, Groesdonk HV, Raffel M, Minko P, Schmied W, Klingele M, Schäfers HJ. Vasopressin as Therapy During Nonocclusive Mesenteric Ischemia. Ann Thorac Surg 2016; 102:813-819. [DOI: 10.1016/j.athoracsur.2016.03.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 01/11/2016] [Accepted: 03/07/2016] [Indexed: 01/24/2023]
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