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González R, Urbano J, López-Herce J. Resuscitating the macro- vs. microcirculation in septic shock. Curr Opin Pediatr 2024; 36:274-281. [PMID: 38446225 DOI: 10.1097/mop.0000000000001345] [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] [Indexed: 03/07/2024]
Abstract
PURPOSE OF REVIEW This review summarizes current literature about the relationships between macro and microcirculation and their practical clinical implications in children with septic shock. RECENT FINDINGS Current evidence from experimental and clinical observational studies in children and adults with septic shock reveals that the response to treatment and resuscitation is widely variable. Furthermore, there is a loss of hemodynamic coherence, as resuscitation-induced improvement in macrocirculation (systemic hemodynamic parameters) does not necessarily result in a parallel improvement in the microcirculation. Therefore, patient-tailored monitoring is essential in order to adjust treatment requirements during resuscitation in septic shock. Optimal monitoring must integrate macrocirculation (heart rate, blood pressure, cardiac output, and ultrasound images), microcirculation (videomicroscopy parameters and capillary refill time) and cellular metabolism (lactic acid, central venous blood oxygen saturation, and difference of central venous to arterial carbon dioxide partial pressure). SUMMARY There is a dire need for high-quality studies to assess the relationships between macrocirculation, microcirculation and tissue metabolism in children with septic shock. The development of reliable and readily available microcirculation and tissue perfusion biomarkers (other than lactic acid) is also necessary to improve monitoring and treatment adjustment in such patients.
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Affiliation(s)
- Rafael González
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón
- Health Research Institute of the Gregorio Marañón Hospital
- Maternal and Child Public Health Department. School of Medicine, Complutense University of Madrid
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - Javier Urbano
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón
- Health Research Institute of the Gregorio Marañón Hospital
- Maternal and Child Public Health Department. School of Medicine, Complutense University of Madrid
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - Jesús López-Herce
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón
- Health Research Institute of the Gregorio Marañón Hospital
- Maternal and Child Public Health Department. School of Medicine, Complutense University of Madrid
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
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Nakamura K, Nakano H, Ikechi D, Mochizuki M, Takahashi Y, Koyama Y, Hashimoto H, Abe T, Hayakawa M, Yamakawa K. The Vasopressin Loading for Refractory septic shock (VALOR) study: a prospective observational study. Crit Care 2023; 27:294. [PMID: 37480126 PMCID: PMC10362561 DOI: 10.1186/s13054-023-04583-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 07/17/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Vasopressin is a second-line vasoactive agent for refractory septic shock. Vasopressin loading is not generally performed because of the lack of evidence for its effects and safety. However, based on our previous findings, we hypothesized it can predict the responsibility to vasopressin infusion with safety, and prospectively examined it in the present study. METHODS Vasopressin loading was performed via the intravenous administration of a bolus of 1 U, followed by its continuous infusion at 1U/h in patients with septic shock treated with ≥ 0.2 μg/kg/min noradrenaline. An arterial pressure wave analysis was conducted, and endocrinological tests were performed immediately prior to vasopressin loading. We classified patients into responders/non-responders based on mean arterial pressure (MAP) changes after vasopressin loading. Based on our previous findings, the lower tertile of MAP changes was selected as the cut-off. The change in the catecholamine index (CAI) after 6 h was assigned as the primary outcome. Digital ischemia, mesenteric ischemia, and myocardial ischemia during the admission period were prospectively and systematically recorded as adverse events. RESULTS Ninety-two patients were registered during the study period and examined. Sixty-two patients with a MAP change > 22 mmHg were assigned as responders and the others as non-responders. Blood adrenocorticotropic hormone levels were significantly higher in non-responders. Stroke volume variations were higher in responders before loading, while stroke volume and dP/dtmax were higher in responders after loading. Median CAI changes were - 10 in responders and 0 in non-responders, which was significantly lower in the former (p < 0.0001). AUROC of MAP change with vasopressin loading to predict CAI change < 0 after continuous infusion was 0.843 with sensitivity of 0.92 and specificity of 0.77. Ischemia events were observed in 5 cases (5.4%). CONCLUSIONS Vasopressin loading may be safely introduced for septic shock. Vasopressin loading may be used to predict responses to its continuous infusion and select appropriate strategies to increase blood pressure.
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Affiliation(s)
- Kensuke Nakamura
- Department of Critical Care Medicine, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004 Japan
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki 317-0077 Japan
| | - Hidehiko Nakano
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki 317-0077 Japan
| | - Daisuke Ikechi
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki 317-0077 Japan
| | - Masaki Mochizuki
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki 317-0077 Japan
| | - Yuji Takahashi
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki 317-0077 Japan
| | - Yasuaki Koyama
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki 317-0077 Japan
| | - Hideki Hashimoto
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki 317-0077 Japan
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, 1187-299, Kaname, Tsukuba, Ibaraki 300-2622 Japan
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki 305-8575 Japan
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Kita 14-jo Nishi 5-chome, Kita-ku, Sapporo-shi, Hokkaido 060-8648 Japan
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical College Hospital, 2-7, Daigakumachi, Takatsuki, Osaka 569-8686 Japan
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Wang J, Shi M, Huang L, Li Q, Meng S, Xu J, Xue M, Xie J, Liu S, Huang Y. Addition of terlipressin to norepinephrine in septic shock and effect of renal perfusion: a pilot study. Ren Fail 2022; 44:1207-1215. [PMID: 35856162 PMCID: PMC9307113 DOI: 10.1080/0886022x.2022.2095286] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Purpose Terlipressin improves renal function in patients with septic shock. However, the mechanism remains unclear. Here, we aimed to evaluate the effects of terlipressin on renal perfusion in patients with septic shock. Materials and Methods This pilot study enrolled patients with septic shock in the intensive care unit of the tertiary hospital from September 2019 to May 2020. We randomly assigned patients to terlipressin and usual care groups using a 1:1 ratio. Terlipressin was intravenously pumped at a rate of 1.3 μg/kg/hour for 24 h. We monitored renal perfusion using renal contrast-enhanced ultrasound (CEUS). The primary outcome was peak sonographic signal intensity (a renal perfusion parameter monitored by CEUS) at 24 h after enrollment. Results 22 patients were enrolled in this study with 10 in the terlipressin group and 12 in the usual care group. The baseline characteristics of patients between the two groups were comparable. The peak sonographic signal intensity at 24 h after enrollment in the terlipressin group (60.5 ± 8.6 dB) was significantly higher than that in the usual care group (52.4 ± 7.0 dB; mean difference, 7.1 dB; 95% CI, 0.4–13.9; adjusted p = .04). Patients in the terlipressin group had a lower time to peak, heart rates, norepinephrine dose, and a higher stroke volume at 24 h after enrollment. No significant difference in the urine output within 24 h and incidence of acute kidney injury within 28 days was found between the two groups. Conclusions Terlipressin improves renal perfusion, increases stroke volume, and decreases norepinephrine dose and heart rates in patients with septic shock.
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Affiliation(s)
- Jinlong Wang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Mengjuan Shi
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Lili Huang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Qing Li
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Shanshan Meng
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jingyuan Xu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Ming Xue
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Songqiao Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yingzi Huang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
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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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Manipulating the Microcirculation in Sepsis - the Impact of Vasoactive Medications on Microcirculatory Blood Flow: A Systematic Review. Shock 2020; 52:5-12. [PMID: 30102639 DOI: 10.1097/shk.0000000000001239] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Sepsis is life-threatening organ dysfunction because of a dysregulated host response to infection. Disturbed microvascular blood flow is associated with excess mortality and is a potential future target for interventions. This review addresses the evidence for pharmacological manipulation of the microcirculation in sepsis assessed by techniques that evaluate the sublingual microvasculature. METHODS Systematic review using a published protocol. Eligibility criteria were studies of septic patients published from January 2000 to February 2018. Interventions were drugs aimed at improving perfusion. Outcome was improvement in microvascular flow using orthogonal polarization spectral, sidestream dark field, or incident dark field imaging (Grades of Recommendation, Assessment, Development, and Evaluation criteria used). RESULTS Two thousand six hundred and six articles were screened and 22 included. (6 randomized controlled trials, 12 interventional, 3 observational, and 1 pilot, n = 572 participants). Multiple measurement techniques were described, including: automated analyses, subjective, and composite scoring systems. Norepinephrine was not found to improve microvascular flow (low-grade evidence, n = 6 studies); except in chronic hypertension (low, n = 1 study). Addition of arginine vasopressin or terlipressin to norepinephrine maintained flow while decreasing norepinephrine requirements (high, n = 2 studies). Neither dobutamine nor glyceryl trinitrate consistently improved flow (low, n = 6 studies). A single study (n = 40 participants) demonstrated improved flow with levosimendan (high). In a risk of bias assessment 16/16 interventional, pilot and observational studies were found to be high risk. CONCLUSIONS There is no robust evidence to date that any one agent can reproducibly lead to improved microvascular flow. Furthermore, no study demonstrated outcome benefit of one therapeutic agent over another. Updated consensus guidelines could improve comparable reporting of measurements and reduce bias, to enable meaningful comparisons around the effects of individual pharmacological agents.
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Dilken O, Ergin B, Ince C. Assessment of sublingual microcirculation in critically ill patients: consensus and debate. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:793. [PMID: 32647718 PMCID: PMC7333125 DOI: 10.21037/atm.2020.03.222] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The main concern in shock and resuscitation is whether the microcirculation can carry adequate oxygen to the tissues and remove waste. Identification of an intact coherence between macro- and microcirculation during states of shock and resuscitation shows a functioning regulatory mechanism. However, loss of hemodynamic coherence between the macro and microcirculation can be encountered frequently in sepsis, cardiogenic shock, or any hemodynamically compromised patient. This loss of hemodynamic coherence results in an improvement in macrohemodynamic parameters following resuscitation without a parallel improvement in microcirculation resulting in tissue hypoxia and tissue compromise. Hand-held vital microscopes (HVMs) can visualize the microcirculation and help to diagnose the nature of microcirculatory shock. Although treatment with the sole aim of recruiting the microcirculation is as yet not realized, interventions can be tailored to the needs of the patient while monitoring sublingual microcirculation. With the help of the newly introduced software, called MicroTools, we believe sublingual microcirculation monitoring and diagnosis will be an essential point-of-care tool in managing shock patients.
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Affiliation(s)
- Olcay Dilken
- Department of Intensive Care Med, Laboratory of Translational Intensive Care Med, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Intensive Care, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Bulent Ergin
- Department of Intensive Care Med, Laboratory of Translational Intensive Care Med, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care Med, Laboratory of Translational Intensive Care Med, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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7
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Annane D, Ouanes-Besbes L, de Backer D, DU B, Gordon AC, Hernández G, Olsen KM, Osborn TM, Peake S, Russell JA, Cavazzoni SZ. A global perspective on vasoactive agents in shock. Intensive Care Med 2018; 44:833-846. [PMID: 29868972 DOI: 10.1007/s00134-018-5242-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/22/2018] [Indexed: 01/09/2023]
Abstract
PURPOSE We set out to summarize the current knowledge on vasoactive drugs and their use in the management of shock to inform physicians' practices. METHODS This is a narrative review by a multidisciplinary, multinational-from six continents-panel of experts including physicians, a pharmacist, trialists, and scientists. RESULTS AND CONCLUSIONS Vasoactive drugs are an essential part of shock management. Catecholamines are the most commonly used vasoactive agents in the intensive care unit, and among them norepinephrine is the first-line therapy in most clinical conditions. Inotropes are indicated when myocardial function is depressed and dobutamine remains the first-line therapy. Vasoactive drugs have a narrow therapeutic spectrum and expose the patients to potentially lethal complications. Thus, these agents require precise therapeutic targets, close monitoring with titration to the minimal efficacious dose and should be weaned as promptly as possible. Moreover, the use of vasoactive drugs in shock requires an individualized approach. Vasopressin and possibly angiotensin II may be useful owing to their norepinephrine-sparing effects.
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Affiliation(s)
- Djillali Annane
- General ICU, Raymond Poincaré Hospital (APHP), School of Medicine Simone Veil U1173 Laboratory of Infection and Inflammation (University of Versailles SQY, University Paris Saclay/INSERM), CRICS-TRIGERSEP Network (F-CRIN), 104 boulevard Raymond Poincaré, 92380, Garches, France.
| | | | - Daniel de Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Bin DU
- Medical ICU, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, 100730, Beijing, China
| | - Anthony C Gordon
- Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Tiffany M Osborn
- Section of Acute Care Surgical Services, Surgical/Trauma Critical Care, Barnes Jewish Hospital, St. Louis, MI, USA
| | - Sandra Peake
- Department of Intensive Care, The Queen Elizabeth Hospital School of Medicine, University of Adelaide, Adelaide, SA, Australia.,School of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
| | - James A Russell
- Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC, Canada
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Kampmeier TG, Arnemann PH, Hessler M, Seidel LM, Becker K, Morelli A, Rehberg SW, Ertmer C. Comparison of first-line and second-line terlipressin versus sole norepinephrine in fulminant ovine septic shock. Sci Rep 2018; 8:7105. [PMID: 29740065 PMCID: PMC5940827 DOI: 10.1038/s41598-018-25570-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 04/23/2018] [Indexed: 12/31/2022] Open
Abstract
The Surviving Sepsis Guidelines suggest the use of vasopressin in case of catecholamine-refractory septic shock. Terlipressin (TP) as a V1-selective AVP analogue is a potential alternative, though data regarding the first-line administration in septic shock are scarce. The present study explored and compared the effects of first-line vs. second-line infusion of TP or sole norepinephrine regarding organ function, fluid and norepinephrine requirements and survival in fulminant ovine septic shock. Peritoneal sepsis was induced in 23 ewes after laparotomy and faecal withdrawal from the caecum. After onset of shock, causal and supportive sepsis therapy (antibiotics, peritoneal lavage, fluids and open-label norepinephrine) was performed in all animals. Concurrently, animals were randomized to receive 0.9% sodium chloride (control group) or TP (2 µg∙kg-1∙h-1, first-line group) after shock onset. In the second-line TP group, TP (2 µg∙kg-1∙h-1) was started once norepinephrine requirements exceeded 0.5 µg∙kg-1∙min-1. No significant differences were found between groups regarding survival, haemodynamics as well as fluid- and catecholamine-requirements. Kidney function and electron microscopic kidney injury were comparable between groups. In the present model of fulminant ovine septic shock, first-line TP infusion had no significant effect on fluid and norepinephrine requirements or organ dysfunction as compared to second-line TP infusion or placebo.
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Affiliation(s)
- Tim G Kampmeier
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany.
| | - Philip H Arnemann
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | - Michael Hessler
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | - Laura M Seidel
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | - Karsten Becker
- Institute of Medical Microbiology, University Hospital of Muenster, Muenster, Germany
| | - Andrea Morelli
- Department of Anaesthesiology and Intensive Care, University of Rome, "La Sapienza", Rome, Italy
| | - Sebastian W Rehberg
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital of Greifswald, Greifswald, Germany
| | - Christian Ertmer
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
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9
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Sharawy N, Mahrous R, Whynot S, George R, Lehmann C. Clinical relevance of early sublingual microcirculation monitoring in septic shock patients. Clin Hemorheol Microcirc 2018; 68:347-359. [DOI: 10.3233/ch-170244] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Nivin Sharawy
- Department of Anaesthesia, Surgical Intensive Care Trauma Center, Faculty of Medicine, Cairo University, Cairo, Egypt
- Department of Physiology, Faculty of Medicine, Cairo University, Cairo, Egypt
- Department of Anaesthesia, Pain Management and Perioperative Medicine’s, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Reham Mahrous
- Department of Anaesthesia, Surgical Intensive Care Trauma Center, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sara Whynot
- Department of Anaesthesia, Pain Management and Perioperative Medicine’s, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Ronald George
- Department of Anaesthesia, Pain Management and Perioperative Medicine’s, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Christian Lehmann
- Department of Anaesthesia, Pain Management and Perioperative Medicine’s, Faculty of Medicine, Dalhousie University, Halifax, Canada
- Department of Pharmacology, Faculty of Medicine, Dalhousie University, Halifax, Canada
- Department of Immunology, Faculty of Medicine, Dalhousie University, Halifax, Canada
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10
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Vincent JL, Taccone FS. Microvascular monitoring – Do ‘global’ markers help? Best Pract Res Clin Anaesthesiol 2016; 30:399-405. [DOI: 10.1016/j.bpa.2016.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 10/27/2016] [Indexed: 12/19/2022]
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11
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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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12
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Hemodynamic coherence in sepsis. Best Pract Res Clin Anaesthesiol 2016; 30:453-463. [PMID: 27931649 DOI: 10.1016/j.bpa.2016.10.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Accepted: 10/31/2016] [Indexed: 12/26/2022]
Abstract
Microvascular alterations are a hallmark of sepsis and play a crucial role in its pathophysiology. Such alterations are the result of overwhelming inflammation, which negatively affects all the components of the microcirculation. As the severity of microvascular alterations is associated with organ dysfunction and mortality, several strategies have been tested for improving microcirculation. Nevertheless, they are mainly based on the conventional manipulation of systemic hemodynamics to increase the total flow to the organs and tissues. Other therapeutic interventions are still being investigated. In this review, we discuss the pathophysiology of septic microcirculatory dysfunction and its implications for possible treatments.
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Abstract
BACKGROUND Initial goal-directed resuscitation for hypotensive shock usually includes administration of intravenous fluids, followed by initiation of vasopressors. Despite obvious immediate effects of vasopressors on haemodynamics, their effect on patient-relevant outcomes remains controversial. This review was published originally in 2004 and was updated in 2011 and again in 2016. OBJECTIVES Our objective was to compare the effect of one vasopressor regimen (vasopressor alone, or in combination) versus another vasopressor regimen on mortality in critically ill participants with shock. We further aimed to investigate effects on other patient-relevant outcomes and to assess the influence of bias on the robustness of our effect estimates. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015 Issue 6), MEDLINE, EMBASE, PASCAL BioMed, CINAHL, BIOSIS and PsycINFO (from inception to June 2015). We performed the original search in November 2003. We also asked experts in the field and searched meta-registries to identify ongoing trials. SELECTION CRITERIA Randomized controlled trials (RCTs) comparing various vasopressor regimens for hypotensive shock. DATA COLLECTION AND ANALYSIS Two review authors abstracted data independently. They discussed disagreements between them and resolved differences by consulting with a third review author. We used a random-effects model to combine quantitative data. MAIN RESULTS We identified 28 RCTs (3497 participants) with 1773 mortality outcomes. Six different vasopressors, given alone or in combination, were studied in 12 different comparisons.All 28 studies reported mortality outcomes; 12 studies reported length of stay. Investigators reported other morbidity outcomes in a variable and heterogeneous way. No data were available on quality of life nor on anxiety and depression outcomes. We classified 11 studies as having low risk of bias for the primary outcome of mortality; only four studies fulfilled all trial quality criteria.In summary, researchers reported no differences in total mortality in any comparisons of different vasopressors or combinations in any of the pre-defined analyses (evidence quality ranging from high to very low). More arrhythmias were observed in participants treated with dopamine than in those treated with norepinephrine (high-quality evidence). These findings were consistent among the few large studies and among studies with different levels of within-study bias risk. AUTHORS' CONCLUSIONS We found no evidence of substantial differences in total mortality between several vasopressors. Dopamine increases the risk of arrhythmia compared with norepinephrine and might increase mortality. Otherwise, evidence of any other differences between any of the six vasopressors examined is insufficient. We identified low risk of bias and high-quality evidence for the comparison of norepinephrine versus dopamine and moderate to very low-quality evidence for all other comparisons, mainly because single comparisons occasionally were based on only a few participants. Increasing evidence indicates that the treatment goals most often employed are of limited clinical value. Our findings suggest that major changes in clinical practice are not needed, but that selection of vasopressors could be better individualised and could be based on clinical variables reflecting hypoperfusion.
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Affiliation(s)
- Gunnar Gamper
- Department of Cardiology, Universitätsklinikum Sankt Pölten, Sankt Pölten, Austria
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El Kalioubie A, Overtchouk P, Ledoux G, Lawson R, Favory R. Effets des vasoconstricteurs sur la microcirculation. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1050-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Damiani E, Pierpaoli E, Orlando F, Donati A, Provinciali M. Sidestream dark field videomicroscopy forin vivoevaluation of vascularization and perfusion of mammary tumours in HER2/neu transgenic mice. Clin Exp Pharmacol Physiol 2015; 42:225-9. [DOI: 10.1111/1440-1681.12343] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 11/11/2014] [Accepted: 11/12/2014] [Indexed: 12/23/2022]
Affiliation(s)
- Elisa Damiani
- Anaesthesia and Intensive Care Unit; Department of Biomedical Sciences and Public Health; Polytechnic University of Marche; Ancona Italy
| | - Elisa Pierpaoli
- Advanced Technology Center for Ageing Research; Scientific Technological Area; Italian National Research Centre on Aging (INRCA-IRCCS); Ancona Italy
| | - Fiorenza Orlando
- Advanced Technology Center for Ageing Research; Scientific Technological Area; Italian National Research Centre on Aging (INRCA-IRCCS); Ancona Italy
| | - Abele Donati
- Anaesthesia and Intensive Care Unit; Department of Biomedical Sciences and Public Health; Polytechnic University of Marche; Ancona Italy
| | - Mauro Provinciali
- Advanced Technology Center for Ageing Research; Scientific Technological Area; Italian National Research Centre on Aging (INRCA-IRCCS); Ancona Italy
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Sharawy N, Lehmann C. New directions for sepsis and septic shock research. J Surg Res 2014; 194:520-527. [PMID: 25596653 DOI: 10.1016/j.jss.2014.12.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 11/19/2014] [Accepted: 12/04/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND Septic shock is a frequent complication in intensive care unit that can result in multiple organ failure and death. In addition, recent data suggested that severe sepsis and septic shock represent an economic burden. Therefore, septic shock is an important public health problem. METHOD In this review, we will focus on the recent evidences concerning the stages of septic shock, the complex macrocirculation and microcirculation relationship, and the importance of those evidences for future resuscitation goals and therapeutic strategies during late septic shock. RESULT Recently, two stages of septic shock are suggested. In early stage, hypovolemia is the main contributing factor. During this stage, macrocirculatory and microcirculatory changes run parallel, and fluid resuscitation seems to be effective in restoring the hemodynamic parameters. Late stage of septic shock is characterized by complex microcirculation and macrocirculation relationship. CONCLUSIONS Although early goal-directed therapy is a stepwise approach in the treatment of septic shock, tissue perfusion remains an important factor that contributes to septic shock outcome. Because appropriate monitoring of tissue perfusion is a matter of debt, the ideal therapeutic strategy remains a controversial issue that needs further investigations.
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Affiliation(s)
- Nivin Sharawy
- Department of Anesthesia, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Christian Lehmann
- Department of Anesthesia, Dalhousie University, Halifax, Nova Scotia, Canada
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Qiu X, Huang Y, Xu J, Qiu H, Yang Y. Effects of terlipressin on microcirculation of small bowel mesentery in rats with endotoxic shock. J Surg Res 2014; 188:503-9. [PMID: 24582066 DOI: 10.1016/j.jss.2014.01.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 01/28/2014] [Accepted: 01/30/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Septic shock is still related to unacceptably high morbidity and mortality. Microcirculatory alteration has been demonstrated to be one important reason associated with this evolution. Vasoactive drugs are often used to restore adequate arterial pressure and tissue perfusion in septic shock. To define the roles of different drugs, the effects of terlipressin (TP) on the microcirculation of small bowel mesentery in rats with endotoxic shock were evaluated and compared with those of norepinephrine (NE). METHODS Twenty-five adult male Wistar rats were randomized to the control (n = 5), TP (n = 10), and NE (n = 10) groups. After endotoxic shock was induced by intravenous lipopolysaccharide administration for 30 min, rats in the NE and TP groups were infused with saline 5 mL/kg/h and simultaneously given NE 4 μg/kg/min or TP 8 μg/kg/h. The mean arterial pressure, heart rate, blood gas analysis, and microvascular blood flow images of small bowel mesentery were recorded. RESULTS After fluid resuscitation and vasopressor infusion, the mean arterial pressure was restored to the baseline values in the NE and TP groups. In the TP group, the heart rate was significantly lower compared with the NE group (P = 0.013). The proportion of perfused vessels and the microvascular flow index (MFI) were significantly increased; furthermore, the heterogeneity index of small vessels was markedly decreased in both the interventional groups with respect to the control group. Compared with the NE group, the MFI was significantly higher (P < 0.05) and the heterogeneity index was significantly lower (P < 0.05) in the TP group. CONCLUSIONS Both TP and NE improved hemodynamic and microcirculatory alterations in rats with endotoxic shock. Compared with NE, TP was more effective in promoting MFI and improving the heterogeneity of small bowel mesentery in rats.
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Affiliation(s)
- Xiaohua Qiu
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Yanxia Huang
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Jingyuan Xu
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Haibo Qiu
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Yi Yang
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, China.
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Buijs EAB, Verboom EM, Top APC, Andrinopoulou ER, Buysse CMP, Ince C, Tibboel D. Early microcirculatory impairment during therapeutic hypothermia is associated with poor outcome in post-cardiac arrest children: a prospective observational cohort study. Resuscitation 2013; 85:397-404. [PMID: 24200889 DOI: 10.1016/j.resuscitation.2013.10.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 09/22/2013] [Accepted: 10/22/2013] [Indexed: 12/21/2022]
Abstract
AIMS OF THE STUDY This study aimed to evaluate if the microcirculation is impaired during and after therapeutic hypothermia (TH) in children with return of spontaneous circulation after cardiac arrest (CA) and to assess if microcirculatory impairment predicts mortality. This has been reported for post-CA adults, but results might be different for children because etiology, pathophysiology, and mortality rate differ. METHODS This prospective observational cohort study included consecutive, non-neonatal post-CA children receiving TH upon intensive care admission between June 2008 and June 2012. Also included were gender-matched and age-matched normothermic, control children without cardiorespiratory disease. The buccal microcirculation was non-invasively assessed with Sidestream Dark Field Imaging at the start of TH, halfway during TH, at the start of re-warming, and at normothermia. Macrocirculatory, respiratory, and biochemical parameters were also collected. RESULTS Twenty post-CA children were included of whom 9 died. During hypothermia, the microcirculation was impaired in the post-CA patients and did not change over time. At normothermia, the core body temperature and the microcirculation had increased and no longer differed from the controls. Microcirculatory deterioration was associated with mortality in the post-CA patients. In particular, the microcirculation was more severely impaired at TH start in the non-survivors than in the survivors - positive predictive value: 73-83, negative predictive value: 75-100, sensitivity: 63-100%, and specificity: 70-90%. CONCLUSIONS The microcirculation is impaired in post-CA children during TH and more severe impairment at TH start was associated with mortality. After the stop of TH, the microcirculation improves rapidly irrespective of outcome.
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Affiliation(s)
- Erik A B Buijs
- Intensive Care and Department of Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Centre, Rotterdam, The Netherlands.
| | - Elyse M Verboom
- Intensive Care and Department of Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Centre, Rotterdam, The Netherlands.
| | - Anke P C Top
- Paediatric Intensive Care Unit, Birmingham Children's Hospital, Birmingham, United Kingdom.
| | | | - Corinne M P Buysse
- Intensive Care and Department of Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Centre, Rotterdam, The Netherlands.
| | - Can Ince
- Intensive Care, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands.
| | - Dick Tibboel
- Intensive Care and Department of Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Centre, Rotterdam, The Netherlands.
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From macrohemodynamic to the microcirculation. Crit Care Res Pract 2013; 2013:892710. [PMID: 23509621 PMCID: PMC3600213 DOI: 10.1155/2013/892710] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 01/22/2013] [Accepted: 01/28/2013] [Indexed: 01/20/2023] Open
Abstract
ICU patients need a prompt normalization of macrohemodynamic parameters. Unfortunately, this optimization sometimes does not protect patients from organ failure development. Prevention or treatment of organ failure needs another target to be pursued: the microcirculatory restoration. Microcirculation is the ensemble of vessels of maximum 100 μm in diameter. Nowadays the Sidestream Dark Field (SDF) imaging technique allows its bedside investigation and a recent round-table conference established the criteria for its evaluation. First, microcirculatory derangements have been studied in sepsis: they are mainly characterized by a reduction of vessel density, an alteration of flow, and a heterogeneous distribution of perfusion. Endothelial malfunction and glycocalyx rupture were proved to be the main reasons for the observed microthrombi, capillary leakage, leukocyte rolling, and rouleaux phenomenon, even if further studies are necessary for a better explanation. Therapeutic approaches targeting microcirculation are under investigation. Microcirculatory alterations have been recently demonstrated in other diseases such as hypovolemia and cardiac failure but this issue still needs to be explored. The aim of this paper is to gather the already known information, focus the reader's attention on the importance of microvascular physiopathology in critical illness, and prompt him to actively participate to achieve a more comprehensive understanding of the issue.
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Vellinga NAR, Boerma EC, Koopmans M, Donati A, Dubin A, Shapiro NI, Pearse RM, Bakker J, Ince C. Study Design of the Microcirculatory Shock Occurrence in Acutely Ill Patients (microSOAP): an International Multicenter Observational Study of Sublingual Microcirculatory Alterations in Intensive Care Patients. Crit Care Res Pract 2012; 2012:121752. [PMID: 22666566 PMCID: PMC3359769 DOI: 10.1155/2012/121752] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Accepted: 03/02/2012] [Indexed: 11/17/2022] Open
Abstract
Objective. Sublingual microcirculatory alterations are associated with an adverse prognosis in several critical illness subgroups. Up to now, single-center studies have reported on sublingual microcirculatory alterations in ICU patient subgroups, but an extensive evaluation of the prevalence of these alterations is lacking. We present the study design of an international multicenter observational study to investigate the prevalence of microcirculatory alterations in critically ill: the Microcirculatory Shock Occurrence in Acutely ill Patients (microSOAP). Methods. 36 ICU's worldwide have participated in this study aiming for inclusion of over 500 evaluable patients. To enable communication and data collection, a website, an Open Clinica 3.0 database, and image uploading software have been designed. A one-session assessment of the sublingual microcirculation using Sidestream Dark Field imaging and data collection on patient characteristics has been performed in every ICU patient >18 years, regardless of underlying disease. Statistical analysis will provide insight in the prevalence and severity of sublingual alterations, its relation to systemic hemodynamic variables, disease, therapy, and outcome. Conclusion. This study will be the largest microcirculation study ever performed. It is expected that this study will also establish a basis for future studies related to the microcirculation in critically ill.
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Affiliation(s)
- Namkje A. R. Vellinga
- Erasmus MC University Medical Center, Department of Intensive Care Adults, P.O. Box 2040–Room H625, 3000 CA Rotterdam, The Netherlands
- Medical Center Leeuwarden, Department of Intensive Care, P.O. Box 888, 8901 BR Leeuwarden, The Netherlands
| | - E. Christiaan Boerma
- Medical Center Leeuwarden, Department of Intensive Care, P.O. Box 888, 8901 BR Leeuwarden, The Netherlands
| | - Matty Koopmans
- Medical Center Leeuwarden, Department of Intensive Care, P.O. Box 888, 8901 BR Leeuwarden, The Netherlands
| | - Abele Donati
- Università Politecnica delle Marche, Department of Biomedical Science and Public Health, 60126 Ancona, Italy
| | - Arnaldo Dubin
- Sanatorio Otamendi y Miroli, Servicio de Terapia Intensiva, Azcuénaga 870, C1115AAB, Buenos Aires, Argentina
| | - Nathan I. Shapiro
- Beth Isreal Deaconess Medical Center, Department of Emergency Medicine and Center for Vascular Biology Research, 1 Deaconess Road, CC2-W, Boston, MA 02115, USA
| | - Rupert M. Pearse
- Barts and The London School of Medicine and Dentistry, London, EC1M 6BQ, London, UK
| | - Jan Bakker
- Erasmus MC University Medical Center, Department of Intensive Care Adults, P.O. Box 2040–Room H625, 3000 CA Rotterdam, The Netherlands
| | - Can Ince
- Erasmus MC University Medical Center, Department of Intensive Care Adults, P.O. Box 2040–Room H625, 3000 CA Rotterdam, The Netherlands
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Year in review in Intensive Care Medicine 2011. II. Cardiovascular, infections, pneumonia and sepsis, critical care organization and outcome, education, ultrasonography, metabolism and coagulation. Intensive Care Med 2012; 38:345-58. [PMID: 22270471 PMCID: PMC3291826 DOI: 10.1007/s00134-012-2467-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Accepted: 01/02/2012] [Indexed: 12/14/2022]
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Morelli A, Donati A, Ertmer C, Rehberg S, Kampmeier T, Orecchioni A, Di Russo A, D'Egidio A, Landoni G, Lombrano MR, Botticelli L, Valentini A, Zangrillo A, Pietropaoli P, Westphal M. Effects of vasopressinergic receptor agonists on sublingual microcirculation in norepinephrine-dependent septic shock. Crit Care 2011; 15:R217. [PMID: 21929764 PMCID: PMC3334762 DOI: 10.1186/cc10453] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Revised: 07/28/2011] [Accepted: 09/19/2011] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION The present study was designed to determine the effects of continuously infused norepinephrine (NE) plus (1) terlipressin (TP) or (2) arginine vasopressin (AVP) or (3) placebo on sublingual microcirculation in septic shock patients. The primary study end point was a difference of ≥ 20% in the microvascular flow index of small vessels among groups. METHODS The design of the study was a prospective, randomized, double-blind clinical trial. NE was titrated to maintain mean arterial pressure (MAP) between 65 and 75 mmHg after establishment of normovolemia in 60 septic shock patients. Thereafter patients (n = 20 per group) were randomized to receive continuous infusions of either TP (1 μg/kg/hour), AVP (0.04 U/minute) or placebo (isotonic saline). In all groups, open-label NE was adjusted to maintain MAP within threshold values if needed. The sublingual microcirculatory blood flow of small vessels was assessed by sidestream dark-field imaging. All measurements, including data from right heart catheterization and norepinephrine requirements, were obtained at baseline and 6 hours after randomization. RESULTS TP and AVP decreased NE requirements at the end of the 6-hour study period. The data are medians (25th and 75th interquartile ranges (IQRs)): 0.57 μg/kg/minute (0.29 to 1.04) vs. 0.16 μg/kg/minute (0.03 to 0.37) for TP and 0.40 μg/kg/minute (0.20 to 1.05) vs. 0.23 μg/kg/minute (0.03 to 0.77) for AVP, with statistical significance of P < 0.05 vs. baseline and vs. placebo. There were no differences in sublingual microcirculatory variables, systemic hemodynamics, oxygen transport and acid-base homeostasis among the three study groups during the entire observation period. The proportions of perfused vessels increased in relation to baseline within all study groups, and there were no significant differences between groups. The specific data were as follows (median (IQR)): 9.7% (2.6 to 19.8) for TP, 8.9% (0.0 to 17.8) for AVP, and 6.9% (3.5 to 10.1) for placebo (P < 0.05 vs. baseline for each comparison), as well as perfused vessel density 18.6% (8.6 to 36.9) for TP, 20.2% (-3.0 to 37.2) for AVP, and 11.4% (-3.0 to 19.4) for placebo (P < 0.05 vs. baseline for each comparison). CONCLUSIONS The present study suggests that to achieve a MAP of 65 to 75 mmHg in septic patients treated with NE, the addition of continuously infused low-dose TP or AVP does not affect sublingual microcirculatory blood flow. In addition, our results suggest that microcirculatory flow abnormalities are mainly related to other factors (for example, volume status, timing, hemodynamics and progression of the disease) rather than to the vasopressor per se. TRIAL REGISTRATION ClinicalTrial.gov NCT00995839.
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Affiliation(s)
- Andrea Morelli
- Department of Anesthesiology and Intensive Care, University of Rome, "La Sapienza," Viale del Policlinico 155, Rome I-00161, Italy
| | - Abele Donati
- Department of Neuroscience-Anesthesia and Intensive Care Unit, Università Politecnica delle Marche, Via Tronto 10, Torrette di Ancona I-60020, Italy
| | - Christian Ertmer
- Department of Anesthesiology and Intensive Care, University Hospital of Muenster, Albert-Schweitzer-Strasse 33, Muenster D-48149, Germany
| | - Sebastian Rehberg
- Department of Anesthesiology and Intensive Care, University Hospital of Muenster, Albert-Schweitzer-Strasse 33, Muenster D-48149, Germany
| | - Tim Kampmeier
- Department of Anesthesiology and Intensive Care, University Hospital of Muenster, Albert-Schweitzer-Strasse 33, Muenster D-48149, Germany
| | - Alessandra Orecchioni
- Department of Anesthesiology and Intensive Care, University of Rome, "La Sapienza," Viale del Policlinico 155, Rome I-00161, Italy
| | - Alessandro Di Russo
- Department of Anesthesiology and Intensive Care, University of Rome, "La Sapienza," Viale del Policlinico 155, Rome I-00161, Italy
| | - Annalia D'Egidio
- Department of Anesthesiology and Intensive Care, University of Rome, "La Sapienza," Viale del Policlinico 155, Rome I-00161, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, Università Vita-Salute San Raffaele, Via Olgettina 60, Milan I-20132, Italy
| | - Maria Rita Lombrano
- Department of Neuroscience-Anesthesia and Intensive Care Unit, Università Politecnica delle Marche, Via Tronto 10, Torrette di Ancona I-60020, Italy
| | - Laura Botticelli
- Department of Neuroscience-Anesthesia and Intensive Care Unit, Università Politecnica delle Marche, Via Tronto 10, Torrette di Ancona I-60020, Italy
| | - Agnese Valentini
- Department of Neuroscience-Anesthesia and Intensive Care Unit, Università Politecnica delle Marche, Via Tronto 10, Torrette di Ancona I-60020, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, Università Vita-Salute San Raffaele, Via Olgettina 60, Milan I-20132, Italy
| | - Paolo Pietropaoli
- Department of Anesthesiology and Intensive Care, University of Rome, "La Sapienza," Viale del Policlinico 155, Rome I-00161, Italy
| | - Martin Westphal
- Department of Anesthesiology and Intensive Care, University Hospital of Muenster, Albert-Schweitzer-Strasse 33, Muenster D-48149, Germany
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