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Peng H, Liang Z, Zhang S, Yang Y. Optimal target mean arterial pressure for patients with sepsis-associated encephalopathy: a retrospective cohort study. BMC Infect Dis 2024; 24:902. [PMID: 39223467 DOI: 10.1186/s12879-024-09789-w] [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: 05/29/2024] [Accepted: 08/21/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Sepsis-associated encephalopathy (SAE) patients often experience changes in intracranial pressure and impaired cerebral autoregulation. Mean arterial pressure (MAP) plays a crucial role in cerebral perfusion pressure, but its relationship with mortality in SAE patients remains unclear. This study aims to investigate the relationship between MAP and the risk of 28-day and in-hospital mortality in SAE patients, providing clinicians with the optimal MAP target. METHODS We retrospectively collected clinical data of patients diagnosed with SAE on the first day of ICU admission from the MIMIC-IV (v2.2) database. Patients were divided into four groups based on MAP quartiles. Kruskal-Wallis H test and Chi-square test were used to compare clinical characteristics among the groups. Restricted cubic spline and segmented Cox regression models, both unadjusted and adjusted for multiple variables, were employed to elucidate the relationship between MAP and the risk of 28-day and in-hospital mortality in SAE patients and to identify the optimal MAP. Subgroup analyses were conducted to assess the stability of the results. RESULTS A total of 3,816 SAE patients were included. The Q1 group had higher rates of acute kidney injury and vasoactive drug use on the first day of ICU admission compared to other groups (P < 0.01). The Q1 and Q4 groups had longer ICU and hospital stays (P < 0.01). The 28-day and in-hospital mortality rates were highest in the Q1 group and lowest in the Q3 group. Multivariable adjustment restricted cubic spline curves indicated a nonlinear relationship between MAP and mortality risk (P for nonlinearity < 0.05). The MAP ranges associated with HRs below 1 for 28-day and in-hospital mortality were 74.6-90.2 mmHg and 74.6-89.3 mmHg, respectively.The inflection point for mortality risk, determined by the minimum hazard ratio (HR), was identified at a MAP of 81.5 mmHg. The multivariable adjusted segmented Cox regression models showed that for MAP < 81.5 mmHg, an increase in MAP was associated with a decreased risk of 28-day and in-hospital mortality (P < 0.05). In Model 4, each 5 mmHg increase in MAP was associated with a 15% decrease in 28-day mortality risk (HR: 0.85, 95% CI: 0.79-0.91, p < 0.05) and a 14% decrease in in-hospital mortality risk (HR: 0.86, 95% CI: 0.80-0.93, p < 0.05). However, for MAP ≥ 81.5 mmHg, there was no significant association between MAP and mortality risk (P > 0.05). Subgroup analyses based on age, congestive heart failure, use of vasoactive drugs, and acute kidney injury showed consistent results across different subgroups.Subsequent analysis of SAE patients with septic shock also showed results similar to those of the original cohort.However, for comatose SAE patients (GCS ≤ 8), there was a negative correlation between MAP and the risk of 28-day and in-hospital mortality when MAP was < 81.5 mmHg, but a positive correlation when MAP was ≥ 81.5 mmHg in adjusted models 2 and 4. CONCLUSION There is a nonlinear relationship between MAP and the risk of 28-day and in-hospital mortality in SAE patients. The optimal MAP target for SAE patients in clinical practice appears to be 81.5 mmHg.
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Affiliation(s)
- Hongyan Peng
- Department of Pediatric Intensive Care Unit, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 318 Renmin Middle Road, Yuexiu District, Guangzhou, 510120, China
- Department of Intensive Care Medicine, Liuzhou Affiliated Guangzhou Women and Children's Medical Center, No. 50 Boyuan Avenue, Liudong New District, Yufeng District, Liuzhou, 545005, China
| | - Zhuoxin Liang
- Department of Intensive Care Medicine, Liuzhou Affiliated Guangzhou Women and Children's Medical Center, No. 50 Boyuan Avenue, Liudong New District, Yufeng District, Liuzhou, 545005, China
| | - Senxiong Zhang
- Department of Intensive Care Medicine, Liuzhou Affiliated Guangzhou Women and Children's Medical Center, No. 50 Boyuan Avenue, Liudong New District, Yufeng District, Liuzhou, 545005, China
| | - Yiyu Yang
- Department of Pediatric Intensive Care Unit, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 318 Renmin Middle Road, Yuexiu District, Guangzhou, 510120, China.
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2
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Orso D, Federici N, Lio C, Mearelli F, Bove T. Hemodynamic goals in sepsis and septic shock resuscitation: An umbrella review of systematic reviews and meta-analyses with trial sequential analysis. Aust Crit Care 2024; 37:818-826. [PMID: 38609748 DOI: 10.1016/j.aucc.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 03/03/2024] [Accepted: 03/18/2024] [Indexed: 04/14/2024] Open
Abstract
OBJECTIVE The objective of this study was to verify whether any parameter among those used as the target for haemodynamic optimisation (e.g., mean arterial pressure, central venous oxygen saturation, systolic or diastolic dysfunction, CO2 gap, lactates, right ventricular dysfunction, and PvaCO2/CavO2 ratio) is correlated with mortality in an undifferentiated population with sepsis or septic shock. METHODS An umbrella review, searching MEDLINE, the Cochrane Database of Systematic Reviews, Health Technology Assessment Database, and the JBI Database of Systematic Reviews and Implementation Reports, was performed. We included systematic reviews and meta-analyses enrolling a population of unselected patients with sepsis or septic shock. The main outcome was mortality. Two authors conducted data extraction and risk-of-bias assessments independently. We used a random-effects model to pool binary and continuous data and summarised estimates of effect using equivalent odds ratios (eORs). We used the ROBIS tool to assess risk of bias and the assessment of multiple systematic reviews 2 score to assess global quality. DATA SYNTHESIS 17 systematic reviews and meta-analyses (15 828 patients) were included in the quantitative analysis. Diastolic dysfunction (eOR: 1.42; 95% confidence interval [CI]: 1.14-1.76), PvaCO2/CavO2 ratio (eOR: 2.15; 95% CI: 1.37-3.37), and CO2 gap (eOR: 1.86; 95% CI: 1.07-3.25) showed a significant correlation with mortality. Lactates were the parameter with highest inconsistency (I2 = 92%). Central venous oxygen saturation and right ventricle dysfunction showed significant statistical excess test of significance (p-value = 0.009 and 0.005, respectively). None of the considered parameters showed statistically significant publication bias. CONCLUSIONS According to this umbrella review, diastolic dysfunction is the haemodynamic variable that is most closely linked to the prognosis of septic patients. The PvaCO2/CavO2 ratio and the CO2gap are significantly related to the mortality of septic patients, but the poor quality of evidence or the low number of cases, studied so far, limit their clinical applicability. CLINICAL TRIAL REGISTRATION PROSPERO: International prospective register of systematic reviews, 2023, CRD42023432813 (Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023432813).
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Affiliation(s)
- Daniele Orso
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy.
| | - Nicola Federici
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | - Cristina Lio
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy; Department of Medical Sciences (DAME), University of Udine, Udine, Italy
| | - Filippo Mearelli
- Department of Internal Medicine, ASUGI University Hospital of Trieste, Trieste, Italy
| | - Tiziana Bove
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy; Department of Medical Sciences (DAME), University of Udine, Udine, Italy
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D'Amico F, Pruna A, Putowski Z, Dormio S, Ajello S, Scandroglio AM, Lee TC, Zangrillo A, Landoni G. Low Versus High Blood Pressure Targets in Critically Ill and Surgical Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2024; 52:1427-1438. [PMID: 38656245 DOI: 10.1097/ccm.0000000000006314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
OBJECTIVES Hypotension is associated with adverse outcomes in critically ill and perioperative patients. However, these assumptions are supported by observational studies. This meta-analysis of randomized controlled trials aims to compare the impact of lower versus higher blood pressure targets on mortality. DATA SOURCES We searched PubMed, Cochrane, and Scholar from inception to February 10, 2024. STUDY SELECTION Randomized trials comparing lower versus higher blood pressure targets in the management of critically ill and perioperative settings. DATA EXTRACTION The primary outcome was all-cause mortality at the longest follow-up available. This review was registered in the Prospective International Register of Systematic Reviews, CRD42023452928. DATA SYNTHESIS Of 2940 studies identified by the search string, 28 (12 in critically ill and 16 in perioperative settings) were included totaling 15,672 patients. Patients in the low blood pressure target group had lower mortality (23 studies included: 1019/7679 [13.3%] vs. 1103/7649 [14.4%]; relative risk 0.93; 95% CI, 0.87-0.99; p = 0.03; I2 = 0%). This corresponded to a 97.4% probability of any increase in mortality with a Bayesian approach. These findings were mainly driven by studies performed in the ICU setting and with treatment lasting more than 24 hours; however, the magnitude and direction of the results were similar in the majority of sensitivity analyses including the analysis restricted to low risk of bias studies. We also observed a lower rate of atrial fibrillation and fewer patients requiring transfusion in low-pressure target groups. No differences were found in the other secondary outcomes. CONCLUSIONS Based on pooled randomized trial evidence, a lower compared with a higher blood pressure target results in a reduction of mortality, atrial fibrillation, and transfusion requirements. Lower blood pressure targets may be beneficial but there is ongoing uncertainty. However, the present meta-analysis does not confirm previous findings and recommendations. These results might inform future guidelines and promote the study of the concept of protective hemodynamics.
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Affiliation(s)
- Filippo D'Amico
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Pruna
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Zbigniew Putowski
- Department of Intensive Care and Perioperative Medicine, Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Sara Dormio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Ajello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, QC, Canada
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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4
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Darnell R, Brown A, Laing E, Edwards J, Harrison DA, Manning JC, Peters MJ, Ramnarayan P, Ray S, Sadique Z, Scholefield BR, Shortt D, Lampro L, Au C, Rowan KM, Mouncey P, Inwald DP. Protocol for a Randomized Controlled Trial to Evaluate a Permissive Blood Pressure Target Versus Usual Care in Critically Ill Children with Hypotension (PRESSURE). Pediatr Crit Care Med 2024; 25:629-637. [PMID: 38629915 PMCID: PMC11216373 DOI: 10.1097/pcc.0000000000003516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
OBJECTIVES Management of hypotension is a fundamental part of pediatric critical care, with cardiovascular support in the form of fluids or vasoactive drugs offered to every hypotensive child. However, optimal blood pressure (BP) targets are unknown. The PRotocolised Evaluation of PermiSSive BP Targets Versus Usual CaRE (PRESSURE) trial aims to evaluate the clinical and cost-effectiveness of a permissive mean arterial pressure (MAP) target of greater than a fifth centile for age compared with usual care. DESIGN Pragmatic, open, multicenter, parallel-group randomized control trial (RCT) with integrated economic evaluation. SETTING Eighteen PICUs across the United Kingdom. PATIENTS Infants and children older than 37 weeks corrected gestational age to 16 years accepted to a participating PICU, on mechanical ventilation and receiving vasoactive drugs for hypotension. INTERVENTIONS Adjustment of hemodynamic support to achieve a permissive MAP target greater than fifth centile for age during invasive mechanical ventilation. MEASUREMENTS AND MAIN RESULTS Randomization is 1:1 to a permissive MAP target or usual care, stratified by site and age group. Due to the emergency nature of the treatment, approaching patients for written informed consent will be deferred until after randomization. The primary clinical outcome is a composite of death and days of ventilatory support at 30 days. Baseline demographics and clinical status will be recorded as well as daily measures of BP and organ support, and discharge outcomes. This RCT received Health Research Authority approval (reference 289545), and a favorable ethical opinion from the East of England-Cambridge South Research Ethics Committee on May 10, 2021 (reference number 21/EE/0084). The trial is registered and has an International Standard RCT Number (reference 20609635). CONCLUSIONS Trial findings will be disseminated in U.K. national and international conferences and in peer-reviewed journals.
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Affiliation(s)
- Robert Darnell
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - Alanna Brown
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - Emma Laing
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - Julia Edwards
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - Joseph C Manning
- School of Healthcare, College of Life Sciences, University of Leicester, Leicester, United Kingdom
| | - Mark J Peters
- Infection, Immunity and Inflammation, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Padmanabhan Ramnarayan
- Department of Surgery and Cancer, Imperial College London, St Mary's Campus, London, United Kingdom
| | - Samiran Ray
- Infection, Immunity and Inflammation, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Zia Sadique
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Barnaby R Scholefield
- Department of Paediatric Critical Care Medicine, Hospital for Sick Children, University Avenue, Toronto, ON, Canada
| | - Dermot Shortt
- Patient representative, c/o Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - Lamprini Lampro
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - Carly Au
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - Kathy M Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - David P Inwald
- Paediatric Intensive Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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5
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Fernando SM, Tran A, Soliman K, Flynn B, Oommen T, Wenzhe L, Adhikari NK, Kanji S, Seely AJ, Fox-Robichaud AE, Wax RS, Cook DJ, Lamontagne F, Rochwerg B. Methylene Blue in Septic Shock: A Systematic Review and Meta-Analysis. Crit Care Explor 2024; 6:e1110. [PMID: 38904978 PMCID: PMC11196076 DOI: 10.1097/cce.0000000000001110] [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: 06/22/2024] Open
Abstract
OBJECTIVES Although clinicians may use methylene blue (MB) in refractory septic shock, the effect of MB on patient-important outcomes remains uncertain. We conducted a systematic review and meta-analysis to investigate the benefits and harms of MB administration in patients with septic shock. DATA SOURCES We searched six databases (including PubMed, Embase, and Medline) from inception to January 10, 2024. STUDY SELECTION We included randomized clinical trials (RCTs) of critically ill adults comparing MB with placebo or usual care without MB administration. DATA EXTRACTION Two reviewers performed screening, full-text review, and data extraction. We pooled data using a random-effects model, assessed the risk of bias using the modified Cochrane tool, and used Grading of Recommendations Assessment, Development, and Evaluation to rate certainty of effect estimates. DATA SYNTHESIS We included six RCTs (302 patients). Compared with placebo or no MB administration, MB may reduce short-term mortality (RR [risk ratio] 0.66 [95% CI, 0.47-0.94], low certainty) and hospital length of stay (mean difference [MD] -2.1 d [95% CI, -1.4 to -2.8], low certainty). MB may also reduce duration of vasopressors (MD -31.1 hr [95% CI, -16.5 to -45.6], low certainty), and increase mean arterial pressure at 6 hours (MD 10.2 mm Hg [95% CI, 6.1-14.2], low certainty) compared with no MB administration. The effect of MB on serum methemoglobin concentration was uncertain (MD 0.9% [95% CI, -0.2% to 2.0%], very low certainty). We did not find any differences in adverse events. CONCLUSIONS Among critically ill adults with septic shock, based on low-certainty evidence, MB may reduce short-term mortality, duration of vasopressors, and hospital length of stay, with no evidence of increased adverse events. Rigorous randomized trials evaluating the efficacy of MB in septic shock are needed. REGISTRATION Center for Open Science (https://osf.io/hpy4j).
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Affiliation(s)
- Shannon M. Fernando
- Department of Critical Care, Lakeridge Health Corporation, Oshawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alexandre Tran
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Karim Soliman
- Department of Critical Care, Lakeridge Health Corporation, Oshawa, ON, Canada
- Department of Critical Care Medicine, Queen’s University, Kingston, ON, Canada
| | - Barbara Flynn
- Department of Critical Care, Lakeridge Health Corporation, Oshawa, ON, Canada
| | - Thomas Oommen
- Department of Critical Care, Lakeridge Health Corporation, Oshawa, ON, Canada
| | - Li Wenzhe
- Department of Critical Care Medicine, First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Neill K.J. Adhikari
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Salmaan Kanji
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Andrew J.E. Seely
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Alison E. Fox-Robichaud
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Randy S. Wax
- Department of Critical Care, Lakeridge Health Corporation, Oshawa, ON, Canada
- Department of Critical Care Medicine, Queen’s University, Kingston, ON, Canada
| | - Deborah J. Cook
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - François Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de Recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Hernández G, Valenzuela ED, Kattan E, Castro R, Guzmán C, Kraemer AE, Sarzosa N, Alegría L, Contreras R, Oviedo V, Bravo S, Soto D, Sáez C, Ait-Oufella H, Ospina-Tascón G, Bakker J. Capillary refill time response to a fluid challenge or a vasopressor test: an observational, proof-of-concept study. Ann Intensive Care 2024; 14:49. [PMID: 38558268 PMCID: PMC10984906 DOI: 10.1186/s13613-024-01275-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/10/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Several studies have validated capillary refill time (CRT) as a marker of tissue hypoperfusion, and recent guidelines recommend CRT monitoring during septic shock resuscitation. Therefore, it is relevant to further explore its kinetics of response to short-term hemodynamic interventions with fluids or vasopressors. A couple of previous studies explored the impact of a fluid bolus on CRT, but little is known about the impact of norepinephrine on CRT when aiming at a higher mean arterial pressure (MAP) target in septic shock. We designed this observational study to further evaluate the effect of a fluid challenge (FC) and a vasopressor test (VPT) on CRT in septic shock patients with abnormal CRT after initial resuscitation. Our purpose was to determine the effects of a FC in fluid-responsive patients, and of a VPT aimed at a higher MAP target in chronically hypertensive fluid-unresponsive patients on the direction and magnitude of CRT response. METHODS Thirty-four septic shock patients were included. Fluid responsiveness was assessed at baseline, and a FC (500 ml/30 mins) was administered in 9 fluid-responsive patients. A VPT was performed in 25 patients by increasing norepinephrine dose to reach a MAP to 80-85 mmHg for 30 min. Patients shared a multimodal perfusion and hemodynamic monitoring protocol with assessments at at least two time-points (baseline, and at the end of interventions). RESULTS CRT decreased significantly with both tests (from 5 [3.5-7.6] to 4 [2.4-5.1] sec, p = 0.008 after the FC; and from 4.0 [3.3-5.6] to 3 [2.6 -5] sec, p = 0.03 after the VPT. A CRT-response was observed in 7/9 patients after the FC, and in 14/25 pts after the VPT, but CRT deteriorated in 4 patients on this latter group, all of them receiving a concomitant low-dose vasopressin. CONCLUSIONS Our findings support that fluid boluses may improve CRT or produce neutral effects in fluid-responsive septic shock patients with persistent hypoperfusion. Conversely, raising NE doses to target a higher MAP in previously hypertensive patients elicits a more heterogeneous response, improving CRT in the majority, but deteriorating skin perfusion in some patients, a fact that deserves further research.
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Affiliation(s)
- Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile.
| | - Emilio Daniel Valenzuela
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Camila Guzmán
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Alicia Elzo Kraemer
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Nicolás Sarzosa
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Leyla Alegría
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Roberto Contreras
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Vanessa Oviedo
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Sebastián Bravo
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Dagoberto Soto
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Claudia Sáez
- Departamento de Hematología Oncología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Hafid Ait-Oufella
- Medical Intensive Care Unit, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Gustavo Ospina-Tascón
- Cardiovascular Research Center, INSERM U970, Université de Paris, Paris, France
- Department of Intensive Care Medicine, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Jan Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, Netherlands
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7
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Wang G, Jiang X, Fu Y, Gao Y, Jiang Q, Guo E, Huang H, Liu X. Development and validation of a nomogram to predict the risk of sepsis-associated encephalopathy for septic patients in PICU: a multicenter retrospective cohort study. J Intensive Care 2024; 12:8. [PMID: 38378667 PMCID: PMC10877756 DOI: 10.1186/s40560-024-00721-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/08/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Patients with sepsis-associated encephalopathy (SAE) have higher mortality rates and longer ICU stays. Predictors of SAE are yet to be identified. We aimed to establish an effective and simple-to-use nomogram for the individual prediction of SAE in patients with sepsis admitted to pediatric intensive care unit (PICU) in order to prevent early onset of SAE. METHODS In this retrospective multicenter study, we screened 790 patients with sepsis admitted to the PICU of three hospitals in Shandong, China. Least absolute shrinkage and selection operator regression was used for variable selection and regularization in the training cohort. The selected variables were used to construct a nomogram to predict the risk of SAE in patients with sepsis in the PICU. The nomogram performance was assessed using discrimination and calibration. RESULTS From January 2017 to May 2022, 613 patients with sepsis from three centers were eligible for inclusion in the final study. The training cohort consisted of 251 patients, and the two independent validation cohorts consisted of 193 and 169 patients. Overall, 237 (38.7%) patients developed SAE. The morbidity of SAE in patients with sepsis is associated with the respiratory rate, blood urea nitrogen, activated partial thromboplastin time, arterial partial pressure of carbon dioxide, and pediatric critical illness score. We generated a nomogram for the early identification of SAE in the training cohort (area under curve [AUC] 0.82, 95% confidence interval [CI] 0.76-0.88, sensitivity 65.6%, specificity 88.8%) and validation cohort (validation cohort 1: AUC 0.80, 95% CI 0.74-0.86, sensitivity 75.0%, specificity 74.3%; validation cohort 2: AUC 0.81, 95% CI 0.73-0.88, sensitivity 69.1%, specificity 83.3%). Calibration plots for the nomogram showed excellent agreement between SAE probabilities of the observed and predicted values. Decision curve analysis indicated that the nomogram conferred a high net clinical benefit. CONCLUSIONS The novel nomogram and online calculator showed performance in predicting the morbidity of SAE in patients with sepsis admitted to the PICU, thereby potentially assisting clinicians in the early detection and intervention of SAE.
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Affiliation(s)
- Guan Wang
- Department of Pediatrics, Qilu Hospital of Shandong University, No. 107 West Wenhua Road, Jinan, 250012, Shandong, China
| | - Xinzhu Jiang
- Qilu Hospital of Shandong University, No. 107 West Wenhua Road, Jinan, 250012, Shandong, China
| | - Yanan Fu
- Department of Medical Engineering, Qilu Hospital of Shandong University, No. 107 West Wenhua Road, Jinan, 250012, Shandong, China
| | - Yan Gao
- Qilu Hospital of Shandong University, No. 107 West Wenhua Road, Jinan, 250012, Shandong, China
| | - Qin Jiang
- Department of Pediatrics, Jinan Children's Hospital of Shandong University, No. 23976 Jingshi Road, Jinan, 250000, Shandong, China
| | - Enyu Guo
- Department of Pediatrics, Jining First People's Hospital, No. 6 JianKang Road, Jining, 272000, Shandong, China
| | - Haoyang Huang
- School of Public Health of Shandong University, No. 44 West Wenhua Road, Jinan, 250000, Shandong, China
| | - Xinjie Liu
- Department of Pediatrics, Qilu Hospital of Shandong University, No. 107 West Wenhua Road, Jinan, 250012, Shandong, China.
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8
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Ramasco F, Aguilar G, Aldecoa C, Bakker J, Carmona P, Dominguez D, Galiana M, Hernández G, Kattan E, Olea C, Ospina-Tascón G, Pérez A, Ramos K, Ramos S, Tamayo G, Tuero G. Towards the personalization of septic shock resuscitation: the fundamentals of ANDROMEDA-SHOCK-2 trial. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:112-124. [PMID: 38244774 DOI: 10.1016/j.redare.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/04/2023] [Indexed: 01/22/2024]
Abstract
Septic shock is a highly lethal and prevalent disease. Progressive circulatory dysfunction leads to tissue hypoperfusion and hypoxia, eventually evolving to multiorgan dysfunction and death. Prompt resuscitation may revert these pathogenic mechanisms, restoring oxygen delivery and organ function. High heterogeneity exists among the determinants of circulatory dysfunction in septic shock, and current algorithms provide a stepwise and standardized approach to conduct resuscitation. This review provides the pathophysiological and clinical rationale behind ANDROMEDA-SHOCK-2, an ongoing multicenter randomized controlled trial that aims to compare a personalized resuscitation strategy based on clinical phenotyping and peripheral perfusion assessment, versus standard of care, in early septic shock resuscitation.
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Affiliation(s)
- F Ramasco
- Hospital Universitario de La Princesa, Madrid, Spain.
| | - G Aguilar
- Hospital Clínico Universitario de Valencia, Spain
| | - C Aldecoa
- Hospital Universitario Río Hortega, Valladolid, Spain
| | - J Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile; The Latin American Intensive Care Network (LIVEN); Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, Netherlands; Division of Pulmonary Critical Care, and Sleep Medicine, New York University and Columbia University, New York, USA
| | - P Carmona
- Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - D Dominguez
- Hospital Universitario Ntra. Sra. de Candelaria, Santa Cruz de Tenerife, Spain
| | - M Galiana
- Hospital General Universitario Doctor Balmis, Alicante, Spain
| | - G Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile; The Latin American Intensive Care Network (LIVEN)
| | - E Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile; The Latin American Intensive Care Network (LIVEN)
| | - C Olea
- Hospital Universitario 12 de Octubre, Madrid. Spain
| | - G Ospina-Tascón
- The Latin American Intensive Care Network (LIVEN); Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia; Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - A Pérez
- Hospital General Universitario de Elche, Spain
| | - K Ramos
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile; The Latin American Intensive Care Network (LIVEN)
| | - S Ramos
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - G Tamayo
- Hospital Universitario de Cruces, Baracaldo, Vizcaya, Spain
| | - G Tuero
- Hospital Can Misses, Ibiza, Spain
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9
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Dari MA, Fayaz A, Sharif S, Hernandez Galaviz S, Hernandez Galaviz E, Bataineh SM, Wei CR, Allahwala D. Comparison of High-Normal Versus Low-Normal Mean Arterial Pressure at Target on Outcomes in Sepsis or Shock Patients: A Meta-Analysis of Randomized Control Trials. Cureus 2024; 16:e52258. [PMID: 38352092 PMCID: PMC10863627 DOI: 10.7759/cureus.52258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2024] [Indexed: 02/16/2024] Open
Abstract
The objective of this meta-analysis was to compare the impact of a high-normal and a low-normal mean arterial pressure (MAP) target on outcomes in patients with sepsis or shock. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, two investigators conducted a thorough literature search across online databases, including PubMed, Cochrane Library, Web of Science, and EMBASE, spanning from inception to December 10, 2023. The assessed outcomes encompassed all-cause mortality, the need for renal replacement therapy, and the length of intensive care unit (ICU) stay. A total of four randomized controlled trials (RCTs) were included, involving 3507 participants with individual study participant counts ranging from 118 to 2463. The pooled analysis revealed no statistically significant difference in the risk of all-cause mortality between the two groups (Risk Ratio (RR): 0.94, 95% Confidence Interval (CI): 0.87 to 1.01). Furthermore, there was no disparity in the rates of renal replacement therapy and the duration of ICU stay between the high-normal and low-normal MAP groups. Our findings indicate no significant distinctions in mortality, rates of renal replacement therapy, or ICU stay duration between the two groups. However, future trials with larger sample sizes are warranted to comprehensively understand the nuanced effects of different MAP settings on outcomes in patients with sepsis and shock.
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Affiliation(s)
- Mohammedsefa A Dari
- Otolaryngology - Head and Neck Surgery, Addis Ababa University, Addis Ababa, ETH
| | - Azrung Fayaz
- Internal Medicine, College of Physicians and Surgeons, Peshawar, PAK
- Internal Medicine, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Shazia Sharif
- Gastroenterology, Lahore General Hospital, Lahore, PAK
| | | | | | | | - Calvin R Wei
- Research and Development, Shing Huei Group, Taipei, TWN
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10
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Murgolo F, Mussi RD, Messina A, Pisani L, Dalfino L, Civita A, Stufano M, Gianluca A, Staffieri F, Bartolomeo N, Spadaro S, Brienza N, Grasso S. Subclinical cardiac dysfunction may impact on fluid and vasopressor administration during early resuscitation of septic shock. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2023; 3:29. [PMID: 37641139 PMCID: PMC10463881 DOI: 10.1186/s44158-023-00117-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND According to the Surviving Sepsis Campaign (SSC) fluids and vasopressors are the mainstays of early resuscitation of septic shock while inotropes are indicated in case of tissue hypoperfusion refractory to fluids and vasopressors, suggesting severe cardiac dysfunction. However, septic cardiac disfunction encompasses a large spectrum of severities and may remain "subclinical" during early resuscitation. We hypothesized that "subclinical" cardiac dysfunction may nevertheless influence fluid and vasopressor administration during early resuscitation. We retrospectively reviewed prospectically collected data on fluids and vasoconstrictors administered outside the ICU in patients with septic shock resuscitated according to the SSC guidelines that had reached hemodynamic stability without the use of inotropes. All the patients were submitted to transpulmonary thermodilution (TPTD) hemodynamic monitoring at ICU entry. Subclinical cardiac dysfunction was defined as a TPTD-derived cardiac function index (CFI) ≤ 4.5 min-1. RESULTS At ICU admission, subclinical cardiac dysfunction was present in 17/40 patients (42%; CFI 3.6 ± 0.7 min-1 vs 6.6 ± 1.9 min-1; p < 0.01). Compared with patients with normal CFI, these patients had been resuscitate with more fluids (crystalloids 57 ± 10 vs 47 ± 9 ml/kg PBW; p < 0.01) and vasopressors (norepinephrine 0.65 ± 0.25 vs 0.43 ± 0.29 mcg/kg/min; p < 0.05). At ICU admission these patients had lower cardiac index (2.2 ± 0.6 vs 3.6 ± 0.9 L/min/m2, p < 0.01) and higher systemic vascular resistances (2721 ± 860 vs 1532 ± 480 dyn*s*cm-5/m2, p < 0.01). CONCLUSIONS In patients with septic shock resuscitated according to the SSC, we found that subclinical cardiac dysfunction may influence the approach to fluids and vasopressor administration during early resuscitation. Our data support the implementation of early, bedside assessment of cardiac function during early resuscitation of septic shock.
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Affiliation(s)
- Francesco Murgolo
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Rossella di Mussi
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Antonio Messina
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Humanitas University, Pieve Emanuele-Milano, Italy
| | - Luigi Pisani
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Lidia Dalfino
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Antonio Civita
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Monica Stufano
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Altamura Gianluca
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Francesco Staffieri
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Nicola Bartolomeo
- Interdisciplinary department of medicine, University of Bari, Bari, Italy
| | - Savino Spadaro
- Department of translation medicine, University of Ferrara, Ferrara, Italy
| | - Nicola Brienza
- Interdisciplinary department of medicine, University of Bari, Bari, Italy
| | - Salvatore Grasso
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy.
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11
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Scott MJ, Aggarwal G, Aitken RJ, Anderson ID, Balfour A, Foss NB, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Johnston C, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Sharoky C, Urman RD, Wick E, Wu CL, Young-Fadok T, Peden CJ. Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS ®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care. World J Surg 2023; 47:1850-1880. [PMID: 37277507 PMCID: PMC10241558 DOI: 10.1007/s00268-023-07020-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. METHODS Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. RESULTS Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. CONCLUSIONS These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.
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Affiliation(s)
- Michael J. Scott
- Department of Anesthesiology and Critical Care Medicine, Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
- University College London, London, UK
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey UK
| | - Robert J. Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Iain D. Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD UK
- University of Manchester, Manchester, UK
| | - Angie Balfour
- Western General Hospital, NHS Lothian, Edinburgh, EH4 2XU Scotland
| | | | - Zara Cooper
- Harvard Medical School, Kessler Director, Center for Surgery and Public Health, Brigham and Women’s Hospital and Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA 02120 USA
| | - Jugdeep K. Dhesi
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, Guy’s and St Thomas’ NHS Foundation Trust, King’s College London, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - W. Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA 23298 USA
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital Huddinge, Hälsovägen 3. B85, 141 86 Stockholm, Sweden
| | - Sarah P. Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY UK
| | - Joaquim M. Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel N. Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Carolyn Johnston
- Department of Anesthesia, St George’s Hospital, Tooting, London, UK
| | - Jeniffer S. Kim
- Department of Research and Evaluation, Kaiser Permanente Research, Pasadena, CA 9110 USA
| | - Nicholas P. Lees
- Department of General and Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD UK
| | - Olle Ljungqvist
- Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, 701 85 Orebro, Sweden
| | - Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 – 49, 760032 Cali, Colombia
- Sección de Cirugía de Trauma y Emergencias, Universidad del Valle – Hospital Universitario del Valle, Cl 5 No. 36-08, 760032 Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Catherine Sharoky
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Richard D. Urman
- Department of Anesthesiology, The Ohio State University and Wexner Medical Center, 410 West 10Th Ave, Columbus, OH 43210 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA 94143 USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Medicine-Hospital for Special Surgery, Department of Anesthesiology-Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021 USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 e. Mayo Blvd., Phoenix, AZ 85054 USA
| | - Carol J. Peden
- Department of Anesthesiology Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104 USA
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12
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Rikhraj KJK, Ronsley C, Sekhon MS, Mitra AR, Griesdale DEG. High-normal versus low-normal mean arterial pressure thresholds in critically ill patients: a systematic review and meta-analysis of randomized trials. Can J Anaesth 2023; 70:1244-1254. [PMID: 37268800 DOI: 10.1007/s12630-023-02494-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 06/04/2023] Open
Abstract
PURPOSE Targeted blood pressure thresholds remain unclear in critically ill patients. Two prior systematic reviews have not shown differences in mortality with a high mean arterial pressure (MAP) threshold, but there have been new studies published since. Thus, we conducted an updated systematic review and meta-analysis of randomized controlled trials (RCTs) that compared the effect of a high-normal vs low-normal MAP on mortality, favourable neurologic outcome, need for renal replacement therapy, and adverse vasopressor-induced events in critically ill patients. SOURCE We searched six databases from inception until 1 October 2022 for RCTs of critically ill patients targeted to either a high-normal vs a low-normal MAP threshold for at least 24 hr. We assessed study quality using the revised Cochrane risk-of-bias 2 tool and the risk ratio (RR) was used as the summary measure of association. We used the Grading of Recommendations Assessment, Development, and Evaluation framework to assess the certainty of evidence. PRINCIPAL FINDINGS We included eight RCTs with 4,561 patients. Four trials were conducted in patients following out-of-hospital cardiac arrest, two in patients with distributive shock requiring vasopressors, one in patients with septic shock, and one in patients with hepatorenal syndrome. The pooled RRs for mortality (eight RCTs; 4,439 patients) and favourable neurologic outcome (four RCTs; 1,065 patients) were 1.06 (95% confidence interval [CI], 0.99 to 1.14; moderate certainty) and 0.99 (95% CI, 0.90 to 1.08; moderate certainty), respectively. The RR for the need for renal replacement therapy (four RCTs; 4,071 patients) was 0.97 (95% CI, 0.87 to 1.08; moderate certainty). There was no statistical between-study heterogeneity across all outcomes. CONCLUSION This updated systematic review and meta-analysis of RCTs found no differences in mortality, favourable neurologic outcome, or the need for renal replacement therapy between critically ill patients assigned to a high-normal vs low-normal MAP target. STUDY REGISTRATION PROSPERO (CRD42022307601); registered 28 February 2022.
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Affiliation(s)
- Kiran J K Rikhraj
- Department of Emergency Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada.
- Department of Emergency Medicine, Vancouver General Hospital, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.
| | - Claire Ronsley
- Department of Emergency Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Anish R Mitra
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Donald E G Griesdale
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
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13
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Niemelä V, Siddiqui F, Ameloot K, Reinikainen M, Grand J, Hästbacka J, Hassager C, Kjaergard J, Åneman A, Tiainen M, Nielsen N, Harboe Olsen M, Kamp Jorgensen C, Juul Petersen J, Dankiewicz J, Saxena M, Jakobsen JC, Skrifvars MB. Higher versus lower blood pressure targets after cardiac arrest: systematic review with individual patient data meta-analysis. Resuscitation 2023:109862. [PMID: 37295549 DOI: 10.1016/j.resuscitation.2023.109862] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/23/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE Guidelines recommend targeting mean arterial pressure (MAP) > 65 mmHg in patients after cardiac arrest (CA). Recent trials have studied the effects of targeting a higher MAP as compared to a lower MAP after CA. We performed a systematic review and individual patient data meta-analysis to investigate the effects of higher versus lower MAP targets on patient outcome. METHOD We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, LILACS, BIOSIS, CINAHL, Scopus, the Web of Science Core Collection, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry, Google Scholar and the Turning Research into Practice database to identify trials randomizing patients to higher (≥ 71 mmHg) or lower (≤70 mmHg) MAP targets after CA and resuscitation. We used the Cochrane Risk of Bias tool, version 2 (RoB 2) to assess for risk of bias. The primary outcomes were 180-day all-cause mortality and poor neurologic recovery defined by a modified Rankin score of 4-6 or a cerebral performance category score of 3-5. RESULTS Four eligible clinical trials were identified, randomizing a total of 1,087 patients. All the included trials were assessed as having a low risk for bias. The risk ratio (RR) with 95% confidence interval for 180-day all-cause mortality for a higher versus a lower MAP target was 1.08 (0.92-1.26) and for poor neurologic recovery 1.01 (0.86-1.19). Trial sequential analysis showed that a 25% or higher treatment effect, i.e., RR<0.75, can be excluded. No difference in serious adverse events was found between the higher and lower MAP groups. CONCLUSIONS Targeting a higher MAP compared to a lower MAP is unlikely to reduce mortality or improve neurologic recovery after CA. Only a large treatment effect above 25% (RR<0.75) could be excluded, and future studies are needed to investigate if relevant but lower treatment effect exists. Targeting a higher MAP was not associated with any increase in adverse effects.
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Affiliation(s)
- Ville Niemelä
- Department of Anaesthesia and Intensive Care, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Faiza Siddiqui
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Department of Cardiology, University Hospitals Leuven, Leuven, Belgium; Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Johannes Grand
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Johanna Hästbacka
- Department of Anaesthesiology and Intensive Care, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jesper Kjaergard
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anders Åneman
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, South Western Clinical School, University of New South Wales, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Marjaana Tiainen
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Niklas Nielsen
- Lund University and Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Helsingborg Hospital, Lund, Sweden; Skåne University Hospital, Clinical Studies Sweden - Forum South, Lund, Sweden; Anaesthesia and Intensive Care, Helsingborg Hospital, Lund, Sweden
| | - Markus Harboe Olsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Caroline Kamp Jorgensen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Denmark
| | - Johanne Juul Petersen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Manoj Saxena
- South Western Clinical School, University of New South Wales, Sydney, Australia; Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Denmark
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
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Munroe ES, Hyzy RC, Semler MW, Shankar-Hari M, Young PJ, Zampieri FG, Prescott HC. Evolving Management Practices for Early Sepsis-induced Hypoperfusion: A Narrative Review. Am J Respir Crit Care Med 2023; 207:1283-1299. [PMID: 36812500 PMCID: PMC10595457 DOI: 10.1164/rccm.202209-1831ci] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/22/2023] [Indexed: 02/24/2023] Open
Abstract
Sepsis causes significant morbidity and mortality worldwide. Resuscitation is a cornerstone of management. This review covers five areas of evolving practice in the management of early sepsis-induced hypoperfusion: fluid resuscitation volume, timing of vasopressor initiation, resuscitation targets, route of vasopressor administration, and use of invasive blood pressure monitoring. For each topic, we review the seminal evidence, discuss the evolution of practice over time, and highlight questions for additional research. Intravenous fluids are a core component of early sepsis resuscitation. However, with growing concerns about the harms of fluid, practice is evolving toward smaller-volume resuscitation, which is often paired with earlier vasopressor initiation. Large trials of fluid-restrictive, vasopressor-early strategies are providing more information about the safety and potential benefit of these approaches. Lowering blood pressure targets is a means to prevent fluid overload and reduce exposure to vasopressors; mean arterial pressure targets of 60-65 mm Hg appear to be safe, at least in older patients. With the trend toward earlier vasopressor initiation, the need for central administration of vasopressors has been questioned, and peripheral vasopressor use is increasing, although it is not universally accepted. Similarly, although guidelines suggest the use of invasive blood pressure monitoring with arterial catheters in patients receiving vasopressors, blood pressure cuffs are less invasive and often sufficient. Overall, the management of early sepsis-induced hypoperfusion is evolving toward fluid-sparing and less-invasive strategies. However, many questions remain, and additional data are needed to further optimize our approach to resuscitation.
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Affiliation(s)
- Elizabeth S. Munroe
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Robert C. Hyzy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Matthew W. Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Manu Shankar-Hari
- Centre for Inflammation Research, The University of Edinburgh, Edinburgh, United Kingdom
- Department of Intensive Care Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Paul J. Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Fernando G. Zampieri
- Hospital do Coração (HCor) Research Institute, São Paulo, Brazil
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; and
| | - Hallie C. Prescott
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Ann Arbor, Michigan
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15
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Gao Q, Lin Y, Xu R, Zhang Y, Luo F, Chen R, Li P, Nie S, Li Y, Su L. Association between mean arterial pressure and clinical outcomes among patients with heart failure. ESC Heart Fail 2023. [PMID: 37177860 PMCID: PMC10375101 DOI: 10.1002/ehf2.14401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/12/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
AIMS Mean arterial pressure (MAP) is widely used for evaluating organ perfusion, but its impact on clinical outcomes in patients with heart failure (HF) remains poorly understood. The aim of this study is to investigate the relationship between MAP and all-cause mortality and readmission in patients with HF. METHODS AND RESULTS We retrospectively analysed data from PhysioNet, involving 2005 patients with HF admitted to Zigong Fourth People's Hospital between 2016 and 2019. The primary outcomes were composite outcomes of all-cause mortality and readmission at 3 and 6 months. The secondary outcomes were readmission at 3 and 6 months. Multivariate-adjusted Cox regression models, restricted cubic spline curves (RCS), and propensity score matching (PSM) were used to explore the relationship between MAP and clinical outcomes. Among 2005 patients with HF [≥70 years, 1460 (72.8%); male, 843 (42.0%)], the incidence of primary outcome at 3 months was 33.4% (223/668), 24.4% (163/668), and 22.7% (152/669), and at 6 months, it was 47.5% (317/668), 38.5% (257/668), and 38.0% (254/669) across MAP tertiles [from Tertile 1 (T1) to Tertile 3 (T3)], respectively. The RCS showed an 'L-shaped' relationship between MAP and primary or secondary endpoints. Multivariate-adjusted Cox models showed that a higher MAP was significantly associated with a lower risk of composite endpoints at 3 months [adjusted hazard ratio (aHR) 0.75, 95% confidence interval (CI) 0.61-0.92, P = 0.006, Tertile 2 (T2); aHR 0.69, 95% CI 0.56-0.86, P = 0.001, T3] and 6 months (aHR 0.79, 95% CI 0.67-0.93, P = 0.005, T2; aHR 0.77, 95% CI 0.64-0.91, P = 0.003, T3) compared with T1. After 1:1 PSM, the effect of maintaining a relatively higher MAP was slightly attenuated. Threshold analyses indicated that per 10 mmHg increase in MAP, there was a 21% and 14% decrease in composite endpoints at 3 and 6 months, respectively (aHR 0.79, 95% CI 0.69-0.91, P = 0.001), and 6 months (aHR 0.86, 95% CI 0.77-0.97, P = 0.013) in patients with MAP ≤ 93 mmHg. The associations were consistent in readmission (secondary outcomes), various subgroups, and sensitivity analysis. CONCLUSIONS A higher MAP was associated with a lower risk of a composite of all-cause mortality and readmission. Maintaining a relatively higher MAP could potentially improve the clinical prognosis for patients with HF.
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Affiliation(s)
- Qi Gao
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, 1838 N Guangzhou Ave, Guangzhou, 510515, China
| | - Yuxin Lin
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, 1838 N Guangzhou Ave, Guangzhou, 510515, China
| | - Ruqi Xu
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, 1838 N Guangzhou Ave, Guangzhou, 510515, China
| | - Yuping Zhang
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, 1838 N Guangzhou Ave, Guangzhou, 510515, China
| | - Fan Luo
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, 1838 N Guangzhou Ave, Guangzhou, 510515, China
| | - Ruixuan Chen
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, 1838 N Guangzhou Ave, Guangzhou, 510515, China
| | - Pingping Li
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, 1838 N Guangzhou Ave, Guangzhou, 510515, China
| | - Sheng Nie
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, 1838 N Guangzhou Ave, Guangzhou, 510515, China
| | - Yanqin Li
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, 1838 N Guangzhou Ave, Guangzhou, 510515, China
| | - Licong Su
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, 1838 N Guangzhou Ave, Guangzhou, 510515, China
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16
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Jain S, Witt LJ, Ferrante LE. Clin-STAR corner: Recent practice-changing studies at the interface of pulmonary and critical care medicine and geriatrics. J Am Geriatr Soc 2023; 71:705-710. [PMID: 36536494 PMCID: PMC10023292 DOI: 10.1111/jgs.18196] [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: 10/27/2022] [Accepted: 11/18/2022] [Indexed: 12/24/2022]
Abstract
Older adults suffering from chronic pulmonary diseases, such as chronic obstructive pulmonary disease and interstitial lung disease, and critical illnesses, such as sepsis and acute respiratory failure, are more vulnerable to adverse outcomes like disability and greater side effects from treatments. In this update, we discuss recent practice-changing clinical trials and observational studies in Pulmonary & Critical Care Medicine that have advanced our understanding of the diagnosis or management of older adults with chronic lung diseases or critical illnesses.
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Affiliation(s)
- Snigdha Jain
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT
| | - Leah J. Witt
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, CA
| | - Lauren E. Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT
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Teja B, Bosch NA, Walkey AJ. How We Escalate Vasopressor and Corticosteroid Therapy in Patients With Septic Shock. Chest 2023; 163:567-574. [PMID: 36162481 DOI: 10.1016/j.chest.2022.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 11/21/2022] Open
Abstract
Septic shock is defined by the need for vasopressor agents to correct hypotension and lactic acidosis resulting from infection, with 30%-40% case fatality rates. The care of patients with worsening septic shock involves multiple treatment decisions involving vasopressor choices and adjunctive treatments. In this edition of "How I Do It", we provide a case-based discussion of common clinical decisions regarding choice of first-line vasopressor, BP targets, route of vasopressor delivery, use of secondary vasopressors, and adjunctive medications. We also consider diagnostic approaches, treatment, and monitoring strategies for the patient with worsening shock, as well as approaches to difficult weaning of vasopressors.
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Affiliation(s)
- Bijan Teja
- Interdepartmental Division of Critical Care Medicine, University of Toronto, St. Michael's Hospital, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, St. Michael's Hospital, Toronto, ON, Canada; Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
| | - Nicholas A Bosch
- The Pulmonary Center, Section of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Department of Medicine, Boston University, Boston, MA
| | - Allan J Walkey
- The Pulmonary Center, Section of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Department of Medicine, Boston University, Boston, MA.
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18
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Carayannopoulos KL, Pidutti A, Upadhyaya Y, Alshamsi F, Basmaji J, Granholm A, Alhazzani W, Lewis K. Mean Arterial Pressure Targets and Patient-Important Outcomes in Critically Ill Adults: A Systematic Review and Meta-Analysis of Randomized Trials. Crit Care Med 2023; 51:241-253. [PMID: 36661452 DOI: 10.1097/ccm.0000000000005726] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To conduct a systematic review and meta-analysis to determine whether targeting a higher mean arterial pressure (MAP) compared with a lower MAP in adults with shock results in differences in patient important outcomes. DATA SOURCES We searched MEDLINE, EMBASE, the Cochrane Library, and ClinicalTrials.gov through May 2021. STUDY SELECTION Titles and abstracts were screened independently and in duplicate to identify potentially eligible studies, then full text for final eligibility. We included parallel-group randomized controlled trials in adult patients with a diagnosis of shock requiring vasoactive medications. The higher MAP group was required to receive vasoactive medications to target a higher MAP as established by study authors, whereas the lower MAP group received vasoactive medications to target lower MAP. DATA EXTRACTION In triplicate, reviewers independently extracted data using a prepiloted abstraction form. Statistical analyses were conducted using the RevMan software Version 5.3. DATA SYNTHESIS Six randomized controlled trials (n = 3,690) met eligibility criteria. Targeting a higher MAP (75-85 mm Hg) compared with lower MAP of 65 mm Hg resulted in no difference in mortality (relative risk [RR], 1.06; 95% CI, 0.98-1.15; I2 = 0%; p = 0.12; moderate certainty. Targeting a higher MAP resulted in no difference in the risk of undergoing renal replacement therapy (RR, 0.96; 95% CI, 0.83-1.11; I2 = 24%; p = 0.57; moderate certainty); however, a subgroup analysis comparing patients with and without chronic hypertension demonstrated that a higher MAP may reduce the risk of undergoing renal replacement therapy (RR, 0.83; 95% CI, 0.71-0.98; I2 = 0%; p = 0.02). CONCLUSIONS In conclusion, our systematic review and meta-analysis demonstrated with moderate certainty that there is no difference in mortality when a higher MAP is targeted in critically ill adult patients with shock. Further studies are needed to determine the impact of mean arterial pressure on need for renal replacement therapy in this population.
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Affiliation(s)
| | - Andrew Pidutti
- Department of Medicine, Virginia Commonwealth University, Richmond, VA
| | | | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - John Basmaji
- Department of Medicine & Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Impact and Evidence, McMaster University, Hamilton, ON, Canada
| | - Kimberley Lewis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Impact and Evidence, McMaster University, Hamilton, ON, Canada
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Tran PNT, Kusirisin P, Kaewdoungtien P, Phannajit J, Srisawat N. Higher blood pressure versus normotension targets to prevent acute kidney injury: a systematic review and meta-regression of randomized controlled trials. Crit Care 2022; 26:364. [PMID: 36434726 PMCID: PMC9700976 DOI: 10.1186/s13054-022-04236-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/10/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Renal hypoperfusion is one of the most common causes of acute kidney injury (AKI), especially in shock and perioperative patients. An optimal blood pressure (BP) target to prevent AKI remains undetermined. We conducted a systematic review and meta-analysis of available randomized clinical trial (RCT) results to address this knowledge gap. METHODS From inception to May 13, 2022, we searched Ovid Medline, EMBASE, Cochrane Library, SCOPUS, clinicaltrials.gov, and WHO ICTRP for RCTs comparing higher BP target versus normotension in hemodynamically unstable patients (shock, post-cardiac arrest, or surgery patients). The outcomes of interest were post-intervention AKI rate and renal replacement therapy (RRT) rate. Two investigators independently screened the citations and reviewed the full texts for eligible studies according to a predefined form. RESULTS Twelve trials were included, enrolling a total of 5759 participants, with shock, non-cardiac, and cardiac surgery patients accounting for 3282 (57.0%), 1687 (29.3%) and 790 (13.7%) patients, respectively. Compared to lower mean arterial blood pressure (MAP) targets that served as normotension, targeting higher MAP had no significant effect on AKI rates in shock (RR [95% CI] = 1.10 [0.93, 1.29]), in cardiac-surgery (RR [95% CI] = 0.87 [0.73, 1.03]) and non-cardiac surgery patients (RR [95% CI] = 1.25 [0.98, 1.60]) using random-effects meta-analyses. In shock patients with premorbid hypertension, however, targeting MAP above 70 mmHg resulted in significantly lower RRT risks, RR [95%CI] = 1.20 [1.03, 1.41], p < 0.05. CONCLUSIONS Targeting a higher MAP in shock or perioperative patients may not be superior to normotension, except in shock patients with premorbid hypertension. Further studies are needed to assess the effects of a high MAP target to preventing AKI in hypertensive patients across common settings of hemodynamic instability. Trial registration This systematic review has been registered on PROSPERO ( CRD42021286203 ) on November 19, 2021, prior to data extraction and analysis.
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Affiliation(s)
- Phu Nguyen Trong Tran
- grid.7922.e0000 0001 0244 7875Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.411628.80000 0000 9758 8584Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand ,grid.413054.70000 0004 0468 9247Department of Internal Medicine, Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Cantho, Vietnam
| | - Prit Kusirisin
- grid.7922.e0000 0001 0244 7875Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.411628.80000 0000 9758 8584Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand ,grid.7922.e0000 0001 0244 7875Center of Excellence in Critical Care Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.7132.70000 0000 9039 7662Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Piyanut Kaewdoungtien
- grid.7922.e0000 0001 0244 7875Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.411628.80000 0000 9758 8584Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand ,grid.7922.e0000 0001 0244 7875Center of Excellence in Critical Care Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.415092.b0000 0004 0576 2645Division of Nephrology, Police General Hospital, Royal Thai Police Headquarters, Bangkok, Thailand
| | - Jeerath Phannajit
- grid.7922.e0000 0001 0244 7875Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.7922.e0000 0001 0244 7875Division of Clinical Epidemiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Nattachai Srisawat
- grid.7922.e0000 0001 0244 7875Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.411628.80000 0000 9758 8584Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand ,grid.7922.e0000 0001 0244 7875Center of Excellence in Critical Care Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.512985.2Academy of Science, Royal Society of Thailand, Bangkok, Thailand
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20
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Cereuil A, Ronflé R, Culver A, Boucekine M, Papazian L, Lefebvre L, Leone M. Septic Shock: Phenotypes and Outcomes. Adv Ther 2022; 39:5058-5071. [PMID: 36050614 DOI: 10.1007/s12325-022-02280-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 07/21/2022] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Sepsis is a heterogeneous syndrome that results in life-threatening organ dysfunction. Our goal was to determine the relevant variables and patient phenotypes to use in predicting sepsis outcomes. METHODS We performed an ancillary study concerning 119 patients with septic shock at intensive care unit (ICU) admittance (T0). We defined clinical worsening as having an increased sequential organ failure assessment (SOFA) score of ≥ 1, 48 h after admission (ΔSOFA ≥ 1). We performed univariate and multivariate analyses based on the 28-day mortality rate and ΔSOFA ≥ 1 and determined three patient phenotypes: safe, intermediate and unsafe. The persistence of the intermediate and unsafe phenotypes after T0 was defined as a poor outcome. RESULTS At T0, the multivariate analysis showed two variables associated with 28-day mortality rate: norepinephrine dose and serum lactate concentration. Regarding ΔSOFA ≥ 1, we identified three variables at T0: norepinephrine dose, lactate concentration and venous-to-arterial carbon dioxide difference (P(v-a)CO2). At T0, the three phenotypes (safe, intermediate and unsafe) were found in 28 (24%), 70 (59%) and 21 (18%) patients, respectively. We thus suggested using an algorithm featuring norepinephrine dose, lactate concentration and P(v-a)CO2 to predict patient outcomes and obtained an area under the curve (AUC) of 74% (63-85%). CONCLUSION Our findings highlight the fact that identifying relevant variables and phenotypes may help physicians predict patient outcomes.
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Affiliation(s)
- Alexandre Cereuil
- Réanimation et Surveillance Continue Médico-Chirurgicales Polyvalentes, Hôpital Nord, Service d'Anesthésie et de Réanimation, Aix Marseille Université, APHM, Avenue des tamaris, 13100, Marseille, Aix-en-Provence, France
| | - Romain Ronflé
- Réanimation et Surveillance Continue Médico-Chirurgicales Polyvalentes, Centre Hospitalier du Pays d'Aix, Marseille, Aix-en-Provence, France.
| | - Aurélien Culver
- Réanimation et Surveillance Continue Médico-Chirurgicales Polyvalentes, Centre Hospitalier du Pays d'Aix, Marseille, Aix-en-Provence, France
| | - Mohamed Boucekine
- EA 3279 CEReSS, School of Medicine - La Timone Medical Campus, Health Service Research and Quality of Life Center, Aix Marseille Université, APHM, Marseille, France
| | - Laurent Papazian
- Hôpital Nord, Médecine Intensive - Réanimation, Aix Marseille Université, APHM, Marseille, France
| | - Laurent Lefebvre
- Réanimation et Surveillance Continue Médico-Chirurgicales Polyvalentes, Centre Hospitalier du Pays d'Aix, Marseille, Aix-en-Provence, France
| | - Marc Leone
- Réanimation et Surveillance Continue Médico-Chirurgicales Polyvalentes, Hôpital Nord, Service d'Anesthésie et de Réanimation, Aix Marseille Université, APHM, Avenue des tamaris, 13100, Marseille, Aix-en-Provence, France.,Centre d'Investigation Clinique, Hôpital Nord, Aix Marseille Université, APHM, Marseille, France
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21
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Murphy KM, Rishniw M, Silverstein DC. Use of vasopressors for treatment of vasodilatory hypotension in dogs and cats by Diplomates of the American College of Veterinary Emergency and Critical Care. J Vet Emerg Crit Care (San Antonio) 2022; 32:714-722. [PMID: 35829666 DOI: 10.1111/vec.13230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 04/30/2021] [Accepted: 06/20/2021] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To identify the most common practices of Diplomates of the American College of Veterinary Emergency and Critical Care (DACVECCs) as they relate to the recognition and treatment of hypotension in dogs and cats, particularly concerning the use of vasopressors in vasodilatory shock states. DESIGN A survey regarding vasopressor use was sent to all active DACVECCs using the Veterinary Information Network. Questions focused on respondent characteristics, method of recognition of hypotension, triggers for initiation of vasopressor therapy, first- and second-line vasopressor choice, and methods of determining response to therapy. SUBJECTS A total of 734 DACVECCs were invited to participate, and 203 Diplomates (27.7%) completed the survey. RESULTS For both dogs and cats, the most common first-line vasopressor was norepinephrine (87.9% in dogs and 83.1% in cats). The most common second-choice vasopressor was vasopressin (44.2% in dogs and 39.0% in cats). Cutoff values for initiating vasopressor therapy varied between species and modality used for blood pressure measurement. In general, most DACVECCs chose to initiate vasopressor therapy at a Doppler blood pressure <90 mm Hg or a mean arterial pressure of <60 or <65 mm Hg when using oscillometric or direct arterial blood pressure measurements in dogs and cats. CONCLUSIONS Most DACVECCs adhere to published human guidelines when choosing a first-line vasopressor. However, there is significant variability in blood pressure measurement technique, cutoffs for initiation of vasopressor use, and choice of second-line vasopressors.
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Affiliation(s)
- Kellyann M Murphy
- Department of Clinical Studies and Advanced Medicine, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania, USA
| | - Mark Rishniw
- Veterinary Information Network, Davis, California, USA
| | - Deborah C Silverstein
- Department of Clinical Studies and Advanced Medicine, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania, USA
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22
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Kulkarni AP, Govil D, Samavedam S, Srinivasan S, Ramasubban S, Venkataraman R, Pichamuthu K, Jog SA, Divatia JV, Myatra SN. ISCCM Guidelines for Hemodynamic Monitoring in the Critically Ill. Indian J Crit Care Med 2022; 26:S66-S76. [PMID: 36896359 PMCID: PMC9989872 DOI: 10.5005/jp-journals-10071-24301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/26/2022] [Indexed: 11/09/2022] Open
Abstract
Hemodynamic assessment along with continuous monitoring and appropriate therapy forms an integral part of management of critically ill patients with acute circulatory failure. In India, the infrastructure in ICUs varies from very basic facilities in smaller towns and semi-urban areas, to world-class, cutting-edge technology in corporate hospitals, in metropolitan cities. Surveys and studies from India suggest a wide variation in clinical practices due to possible lack of awareness, expertise, high costs, and lack of availability of advanced hemodynamic monitoring devices. We, therefore, on behalf of the Indian Society of Critical Care Medicine (ISCCM), formulated these evidence-based guidelines for optimal use of various hemodynamic monitoring modalities keeping in mind the resource-limited settings and the specific needs of our patients. When enough evidence was not forthcoming, we have made recommendations after achieving consensus amongst members. Careful integration of clinical assessment and critical information obtained from laboratory data and monitoring devices should help in improving outcomes of our patients. How to cite this article Kulkarni AP, Govil D, Samavedam S, Srinivasan S, Ramasubban S, Venkataraman R, et al. ISCCM Guidelines for Hemodynamic Monitoring in the Critically Ill. Indian J Crit Care Med 2022;26(S2):S66-S76.
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Affiliation(s)
- Atul Prabhakar Kulkarni
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Deepak Govil
- Institute of Critical Care and Anesthesia, Medanta - The Medicity, Gurugram, Haryana, India
| | - Srinivas Samavedam
- Department of Critical Care, Virinchi Hospital, Hyderabad, Telangana, India
| | | | | | - Ramesh Venkataraman
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Kishore Pichamuthu
- Department of Medical Intensive Care Unit, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Sameer Arvind Jog
- Department of Critical Care Medicine, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra India
| | - Jigeeshu V Divatia
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra India
| | - Sheila Nainan Myatra
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Endo A, Yamakawa K, Tagami T, Umemura Y, Takahashi K, Nagasawa H, Araki Y, Kojima M, Sera T, Yagi M, Yamamoto R, Takahashi J, Nakane M, Takeda C, Narita C, Kazuma S, Okura H, Takahashi H, Wada T, Tahara S, Matsuoka A, Masaki T, Shiraishi A, Shimoyama K, Yokokawa Y, Nakamura R, Sageshima H, Yanagida Y, Takahashi K, Otomo Y. Optimal target blood pressure in elderly with septic shock (OPTPRESS) trial: study protocol for a randomized controlled trial. Trials 2022; 23:799. [PMID: 36153530 PMCID: PMC9509562 DOI: 10.1186/s13063-022-06732-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Hemodynamic stabilization is a core component in the resuscitation of septic shock. However, the optimal target blood pressure remains debatable. Previous randomized controlled trials suggested that uniformly adopting a target mean arterial pressure (MAP) higher than 65 mmHg for all adult septic shock patients would not be beneficial; however, it has also been proposed that higher target MAP may be beneficial for elderly patients, especially those with arteriosclerosis.
Methods
A multicenter, pragmatic single-blind randomized controlled trial will be conducted to compare target MAP of 80–85 mmHg (high-target) and 65–70 mmHg (control) in the resuscitation of septic shock patients admitted to 28 hospitals in Japan. Patients with septic shock aged ≥65 years are randomly assigned to the high-target or control groups. The target MAP shall be maintained for 72 h after randomization or until vasopressors are no longer needed to improve patients’ condition. To minimize the adverse effects related to catecholamines, if norepinephrine dose of ≥ 0.1 μg/kg/min is needed to maintain the target MAP, vasopressin will be initiated. Other therapeutic approaches, including fluid administration, hydrocortisone use, and antibiotic choice, will be determined by the physician in charge based on the latest clinical guidelines. The primary outcome is all-cause mortality at 90 days after randomization.
Discussion
The result of this trial will provide great insight on the resuscitation strategy for septic shock in the era of global aged society. Also, it will provide the better understanding on the importance of individualized treatment strategy in hemodynamic management in critically ill patients.
Trial registration
UMIN Clinical Trials Registry; UMIN000041775. Registered 13 September 2020.
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Yoshimoto H, Fukui S, Higashio K, Endo A, Takasu A, Yamakawa K. Optimal target blood pressure in critically ill adult patients with vasodilatory shock: A systematic review and meta-analysis. Front Physiol 2022; 13:962670. [PMID: 36051909 PMCID: PMC9424848 DOI: 10.3389/fphys.2022.962670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
While the Surviving Sepsis Campaign guidelines recommend an initial target value of 65 mmHg as the mean arterial pressure (MAP) in patients with septic shock, the optimal MAP target for improving outcomes remains controversial. We performed a meta-analysis to evaluate the optimal MAP for patients with vasodilatory shock, which included three randomized controlled trials that recruited 3,357 patients. Between the lower (60–70 mmHg) and higher (>70 mmHg) MAP target groups, there was no significant difference in all-cause mortality (risk ratio [RR], 1.06; 95% confidence intervals [CI], 0.98–1.16) which was similar in patients with chronic hypertension (RR, 1.10; 95% CI, 0.98–1.24) and patients aged ≥65 years (RR, 1.10; 95% CI, 0.99–1.21). No significant difference in adverse events was observed between the different MAP groups (RR, 1.04; 95% CI, 0.87–1.24); however, supraventricular arrhythmia was significantly higher in the higher MAP group (RR, 1.73; 95% CI, 1.15–2.60). Renal replacement therapy was reduced in the higher MAP group of patients with chronic hypertension (RR, 0.83; 95% CI, 0.71–0.98). Though the higher MAP control did not improve the mortality rate, it may be beneficial in reducing renal replacement therapy in patients with chronic hypertension. Systematic review registration: UMIN Clinical Trials Registry, identifier UMIN000042624
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Affiliation(s)
- Hidero Yoshimoto
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
- Department of Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Satoshi Fukui
- Faculty of Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Koki Higashio
- Faculty of Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Akira Endo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital, Bunkyo-ku, Tokyo, Japan
| | - Akira Takasu
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Kazuma Yamakawa
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
- *Correspondence: Kazuma Yamakawa,
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25
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Sadique Z, Grieve R, Diaz-Ordaz K, Mouncey P, Lamontagne F, O’Neill S. A Machine-Learning Approach for Estimating Subgroup- and Individual-Level Treatment Effects: An Illustration Using the 65 Trial. Med Decis Making 2022; 42:923-936. [PMID: 35607982 PMCID: PMC9459357 DOI: 10.1177/0272989x221100717] [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: 11/15/2022]
Abstract
Personalizing treatment recommendations or guidelines requires evidence about the
heterogeneity of treatment effects (HTE). Machine-learning (ML) approaches can
explore HTE by considering many covariates, including complex interactions
between them. Causal ML approaches can avoid overfitting, which arises when the
same dataset is used to select covariate by treatment interaction terms as to
make inferences and reduce reliance on the correct specification of fixed
parametric models. We investigate causal forests (CF), a ML method based on
modified decision trees that can estimate subgroup- and individual-level
treatment effects, without requiring correct prespecification of the effect
model. We consider CF alongside parametric approaches for estimating HTE, within
the 65 Trial, which evaluates the effect of a permissive hypotension strategy
versus usual care on 90-d mortality for critically ill patients aged 65 y or
older with vasodilatory hypotension. Here, the CF approach provides similar
estimates of treatment effectiveness for prespecified and post hoc subgroups to
the parametric approach, and the results of a test for overall HTE show weak
evidence of heterogeneity. The CF estimates of individual-level treatment
effects, the expected effects of treatment for individuals in subpopulations
defined by their covariates, suggest that the permissive hypotension strategy is
expected to reduce 90-d mortality for 98.7% of patients but with 95% confidence
intervals that include zero for 71.6% of patients. A ML approach is then used to
assess the patient characteristics associated with these individual-level
effects, and to help target future research that can identify those patient
subgroups for whom the intervention is most effective.
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Affiliation(s)
- Zia Sadique
- Department of Health Services Research and
Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard Grieve
- R. Grieve, Department of Health Services
Research and Policy, London School of Hygiene and Tropical Medicine, 15-17
Tavistock Place, WC1H 9SH, London;
()
| | - Karla Diaz-Ordaz
- Department of Medical Statistics, London School
of Hygiene & Tropical Medicine, London, UK
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National
Audit & Research Centre (ICNARC), London, UK
| | - Francois Lamontagne
- Université de Sherbrooke, Quebec, Canada
- Centre de Recherche du Centre Hospitalier
Universitaire de Sherbrooke, Quebec, Canada
| | - Stephen O’Neill
- Department of Health Services Research and
Policy, London School of Hygiene & Tropical Medicine, London, UK
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26
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McEwen CC, Amir T, Qiu Y, Young J, Kennedy K, Grocott HP, Kessani H, Mazer D, Brudney S, Kavosh M, Jacobsohn E, Vedel A, Wang E, Whitlock RP, Belley-Coté EP, Spence J. Morbidity and mortality in patients managed with high compared with low blood pressure targets during on-pump cardiac surgery: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth 2022; 69:374-386. [PMID: 35014001 DOI: 10.1007/s12630-021-02171-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 11/02/2021] [Accepted: 11/02/2021] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Many believe that blood pressure management during cardiac surgery is associated with postoperative outcomes. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the impact of high compared with low intraoperative blood pressure targets on postoperative morbidity and mortality in adults undergoing cardiac surgery on cardiopulmonary bypass (CPB). Our primary objective was to inform the design of a future large RCT. SOURCE We searched MEDLINE, EMBASE, Web of Science, CINAHL, and CENTRAL for RCTs comparing high with low intraoperative blood pressure targets in adult patients undergoing any cardiac surgical procedure on CPB. We screened reference lists, grey literature, and conference proceedings. PRINCIPAL FINDINGS We included eight RCTs (N =1,116 participants); all examined the effect of blood pressure management only during the CPB. Trial definitions of high compared with low blood pressure varied and, in some, there was a discrepancy between the target and achieved mean arterial pressure. We observed no difference in delirium, cognitive decline, stroke, acute kidney injury, or mortality between high and low blood pressure targets (very-low to low quality evidence). Higher blood pressure targets may have increased the risk of requiring a blood transfusion (three trials; n = 456 participants; relative risk, 1.4; 95% confidence interval, 1.1 to 1.9; P = 0.01; moderate quality evidence) but this finding was based on a small number of trials. CONCLUSION Individual trial definitions of high and low blood pressure targets varied, limiting inferences. The effect of high (compared with low) blood pressure targets on other morbidity and mortality after cardiac surgery remains unclear because of limitations with the body of existing evidence. Research to determine the optimal management of blood pressure during cardiac surgery is required. STUDY REGISTRATION PROSPERO (CRD42020177376); registered: 5 July 2020.
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Affiliation(s)
- Charlotte C McEwen
- Department of Surgery (Cardiac Surgery), McMaster University, Hamilton, ON, Canada
| | - Takhliq Amir
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Yuan Qiu
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Jack Young
- Health Sciences Library, McMaster University, Hamilton, ON, Canada
| | - Kevin Kennedy
- Department of Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada
| | - Hilary P Grocott
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Hesham Kessani
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - David Mazer
- Department of Anesthesia, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Scott Brudney
- Departments of Medicine (Critical Care) and Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Morvarid Kavosh
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Eric Jacobsohn
- Departments of Medicine (Critical Care) and Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Anne Vedel
- Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Eugene Wang
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Richard P Whitlock
- Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada.,Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada
| | - Emilie P Belley-Coté
- Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada.,Departments of Medicine (Cardiology and Critical Care) and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jessica Spence
- Perioperative Research Division, Population Health Research Institute, Hamilton, ON, Canada. .,Departments of Anesthesia and Critical Care and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada.
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27
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Hu AM, Hai C, Wang HB, Zhang Z, Sun LB, Zhang ZJ, Li HP. Associations Between Elevated Systolic Blood Pressure and Outcomes in Critically Ill Patients: A Retrospective Cohort Study and Propensity Analysis. Shock 2021; 56:557-563. [PMID: 33756503 DOI: 10.1097/shk.0000000000001774] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Studies have shown nonlinear relationships between systolic blood pressure (SBP) and outcomes, with increased risk observed at both low and high blood pressure levels. However, the relationships between cumulative times at different SBP levels and outcomes in critically ill patients remain unclear. We hypothesized that an appropriate SBP level is associated with a decrease in adverse outcomes after intensive care unit (ICU) admission. METHODS This study was a retrospective analysis of data from the Medical Information Mart for Intensive Care (MIMIC) III database, which includes more than 1,000,000 SBP records from 12,820 patients. Associations of cumulative times at four SBP ranges (<100 mm Hg, 100-120 mm Hg, 120-140 mm Hg, and ≥140 mm Hg) with mortality (12-, 3-, 1-month mortality and in-hospital mortality) were evaluated. Restricted cubic splines and multivariable Cox regression models were employed to assess associations between mortality and cumulative times at SBP levels (4 levels: <2, 2-12, 12-36, and ≥36 h) over 72 h of ICU admission. Additionally, 120 mm Hg to 140 mm Hg was subdivided into <12 h (Group L) and ≥12 h (Group M) subsets and subjected to propensity-score matching and subgroup analyses. RESULTS At 120 mm Hg to 140 mm Hg, level-4 SBP was associated with lower adjusted risks of mortality at 12 months (OR, 0.71; CI, 0.61-0.81), 3 months (OR, 0.72; CI, 0.61-0.85), and 1 month (OR, 0.61; CI, 0.48-0.79) and in the hospital (OR, 0.71; CI, 0.58-0.88) than level-1 SBP. The cumulative times at the other 3 SBP ranges (<100 mm Hg, 100-120 mm Hg, and ≥140 mm Hg) were not independent risk predictors of prognosis. Furthermore, Group M had lower 12-month mortality than Group L, which remained in the propensity-score matched and subgroup analyses. CONCLUSIONS SBP at 120 mm Hg to 140 mm Hg was associated with decreased adverse outcomes. Randomized trials are required to determine whether the outcomes in critically ill patients improve with early maintenance of a SBP level at 120 mm Hg to 140 mm Hg.
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Affiliation(s)
- An-Min Hu
- Department of Anesthesiology, Shenzhen People's Hospital, Shenzhen, China
- First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
- The Second Clinical Medical College, Jinan University, Shenzhen, China
| | - Chao Hai
- Department of Anesthesiology, Shenzhen People's Hospital, Shenzhen, China
- First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
- The Second Clinical Medical College, Jinan University, Shenzhen, China
| | - Hai-Bo Wang
- Peking University Clinical Research Institute, Beijing, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Emergency and Trauma, Ministry of Education, College of Emergency and Trauma, Hainan Medical University, Haikou, China
| | - Ling-Bin Sun
- Department of Anesthesiology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Zhong-Jun Zhang
- Department of Anesthesiology, Shenzhen People's Hospital, Shenzhen, China
- First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
- The Second Clinical Medical College, Jinan University, Shenzhen, China
| | - Hui-Ping Li
- First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
- The Second Clinical Medical College, Jinan University, Shenzhen, China
- Department of Critical Care Medicine, Shenzhen People's Hospital, Shenzhen, China
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28
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Plata-Menchaca EP, Ruiz-Rodríguez JC, Ferrer R. Evidence for the Application of Sepsis Bundles in 2021. Semin Respir Crit Care Med 2021; 42:706-716. [PMID: 34544188 DOI: 10.1055/s-0041-1733899] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Sepsis represents a severe condition that predisposes patients to a high risk of death if its progression is not ended. As with other time-dependent conditions, the performance of determinant interventions has led to significant survival benefits and quality-of-care improvements in acute emergency care. Thus, the initial interventions in sepsis are a cornerstone for prognosis in most patients. Even though the evidence supporting the hour-1 bundle is perfectible, real-life application of thoughtful and organized sepsis care has improved survival and quality of care in settings promoting compliance to evidence-based treatments. Current evidence for implementing the Surviving Sepsis Campaign bundles for early sepsis management is moving forward to better approaches as more substantial evidence evolves.
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Affiliation(s)
- Erika P Plata-Menchaca
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Department of Intensive Care, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Juan Carlos Ruiz-Rodríguez
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital Universitari, Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autonoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Ricard Ferrer
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital Universitari, Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autonoma de Barcelona, Bellaterra, Barcelona, Spain
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29
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Valeanu L, Bubenek-Turconi SI, Ginghina C, Balan C. Hemodynamic Monitoring in Sepsis-A Conceptual Framework of Macro- and Microcirculatory Alterations. Diagnostics (Basel) 2021; 11:1559. [PMID: 34573901 PMCID: PMC8469937 DOI: 10.3390/diagnostics11091559] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/22/2021] [Accepted: 08/26/2021] [Indexed: 12/29/2022] Open
Abstract
Circulatory failure in sepsis is common and places a considerable burden on healthcare systems. It is associated with an increased likelihood of mortality, and timely recognition is a prerequisite to ensure optimum results. While there is consensus that aggressive source control, adequate antimicrobial therapy and hemodynamic management constitute crucial determinants of outcome, discussion remains about the best way to achieve each of these core principles. Sound cardiovascular support rests on tailored fluid resuscitation and vasopressor therapy. To this end, an overarching framework to improve cardiovascular dynamics has been a recurring theme in modern critical care. The object of this review is to examine the nature of one such framework that acknowledges the growing importance of adaptive hemodynamic support combining macro- and microhemodynamic variables to produce adequate tissue perfusion.
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Affiliation(s)
- Liana Valeanu
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (L.V.); (S.-I.B.-T.)
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Serban-Ion Bubenek-Turconi
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (L.V.); (S.-I.B.-T.)
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Carmen Ginghina
- 3rd Department of Cardiology, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania;
- Department of Cardiology, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Cosmin Balan
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (L.V.); (S.-I.B.-T.)
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30
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Initial Arterial Blood Pressure Targets in Patients With Septic Shock: One Size Fits All or Made to Measure? Crit Care Med 2021; 49:719-721. [PMID: 33731615 DOI: 10.1097/ccm.0000000000004900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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31
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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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32
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Kellum JA, Romagnani P, Ashuntantang G, Ronco C, Zarbock A, Anders HJ. Acute kidney injury. Nat Rev Dis Primers 2021; 7:52. [PMID: 34267223 DOI: 10.1038/s41572-021-00284-z] [Citation(s) in RCA: 519] [Impact Index Per Article: 173.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 02/06/2023]
Abstract
Acute kidney injury (AKI) is defined by a sudden loss of excretory kidney function. AKI is part of a range of conditions summarized as acute kidney diseases and disorders (AKD), in which slow deterioration of kidney function or persistent kidney dysfunction is associated with an irreversible loss of kidney cells and nephrons, which can lead to chronic kidney disease (CKD). New biomarkers to identify injury before function loss await clinical implementation. AKI and AKD are a global concern. In low-income and middle-income countries, infections and hypovolaemic shock are the predominant causes of AKI. In high-income countries, AKI mostly occurs in elderly patients who are in hospital, and is related to sepsis, drugs or invasive procedures. Infection and trauma-related AKI and AKD are frequent in all regions. The large spectrum of AKI implies diverse pathophysiological mechanisms. AKI management in critical care settings is challenging, including appropriate volume control, nephrotoxic drug management, and the timing and type of kidney support. Fluid and electrolyte management are essential. As AKI can be lethal, kidney replacement therapy is frequently required. AKI has a poor prognosis in critically ill patients. Long-term consequences of AKI and AKD include CKD and cardiovascular morbidity. Thus, prevention and early detection of AKI are essential.
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Affiliation(s)
- John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Paola Romagnani
- Nephrology and Dialysis Unit, Meyer Children's University Hospital, Florence, Italy
| | - Gloria Ashuntantang
- Faculty of Medicine and Biomedical Sciences, Yaounde General Hospital, University of Yaounde, Yaounde, Cameroon
| | - Claudio Ronco
- Department of Medicine, University of Padova, Padua, Italy.,Department of Nephrology, Dialysis and Kidney Transplant, International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Hans-Joachim Anders
- Division of Nephrology, Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany.
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33
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Lee SH, Kim YJ, Yu GN, Jeon JC, Kim WY. Pulse pressure during the initial resuscitative period in patients with septic shock treated with a protocol-driven resuscitation bundle therapy. Korean J Intern Med 2021; 36:924-931. [PMID: 32811131 PMCID: PMC8273825 DOI: 10.3904/kjim.2020.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/26/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS Maintaining a mean arterial pressure (MAP) ≥ 65 mmHg during septic shock should be based on individual circumstances, but specific target is poorly understood. We investigated associations between time-weighted average (TWA) hemodynamic parameters during the initial resuscitative period and 28-day mortality. METHODS Prospectively collected data were obtained from a septic shock patient registry, according to the Sepsis-3 definition, between 2016 and 2018. The TWA systolic blood pressure, diastolic blood pressure, MAP, shock index, and pulse pressure (PP) during the first 6 hours after shock recognition were compared. Multivariable regression analysis was performed to assess associations between these parameters and 28-day mortality. RESULTS Of 340 patients with septic shock, 92 died. Only the median TWA PP differed between the survivors and non-survivors (39.2 mmHg vs. 43.0 mmHg, p = 0.020), whereas the other indexes did not. When PP was divided into quartiles (< 34, 34 to 40, 40 to 48, and > 48 mmHg), the mortality rate was higher in the highest quartile (41.2%). Multivariable logistic analysis revealed that PP (odds ratio [OR], 1.28; 95% confidence interval [CI], 1.012 to 1.622; p = 0.039) and PP of > 48 mmHg (OR, 2.25; 95% CI, 1.272 to 3.981; p = 0.005) were independently associated with 28-day mortality. CONCLUSION PP was significantly associated with 28-day mortality in patients with septic shock and MAP maintained at > 65 mmHg during the first 6 hours. Further studies are warranted to optimize strategies for maintaining PP and MAP at > 65 mmHg during the early resuscitative period.
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Affiliation(s)
- Sang-Hun Lee
- Department of Emergency Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Youn-Jung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi Na Yu
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Cheon Jeon
- Department of Emergency Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Correspondence to Won Young Kim, M.D. Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: +82-2-3010-3350 Fax: +82-2-3010-3360 E-mail:
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Zimmerman DE, Sarangarm P, Brown CS, Faine B, Flack T, Gilbert BW, Howington GT, Kelly G, Laub J, Porter BA, Slocum GW, Rech MA. Staying InformED: Top emergency Medicine pharmacotherapy articles of 2020. Am J Emerg Med 2021; 49:200-205. [PMID: 34139435 PMCID: PMC8204853 DOI: 10.1016/j.ajem.2021.05.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/14/2021] [Accepted: 05/24/2021] [Indexed: 01/13/2023] Open
Abstract
The year 2020 was not easy for Emergency Medicine (EM) clinicians with the burden of tackling a pandemic. A large focus, rightfully so, was placed on the evolving diagnosis and management of patients with COVID-19 and, as such, the ability of clinicians to remain up to date on key EM pharmacotherapy literature may have been compromised. This article reviews the most important EM pharmacotherapy publications indexed in 2020. A modified Delphi approach was utilized for selected journals to identify the most impactful EM pharmacotherapy studies. A total of fifteen articles, eleven trials and four meta-analyses, were identified. This review provides a summary of each study, along with a commentary on the impact to the EM literature and EM clinician.
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Affiliation(s)
- David E Zimmerman
- Duquesne University School of Pharmacy, University of Pittsburgh Medical Center-Mercy Hospital, Room 311 Bayer Learning Center, 600 Forbes Avenue, Pittsburgh, PA 15282, United States of America.
| | - Preeyaporn Sarangarm
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM 87106, United States of America
| | - Caitlin S Brown
- Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Brett Faine
- Department of Emergency Medicine and Pharmacy Practice, University of Iowa, Iowa City, IA 52242, United States of America
| | - Tara Flack
- Department of Pharmacy, IU Health Methodist Hospital, Indianapolis, IN 46202, United States of America
| | - Brian W Gilbert
- Department of Pharmacy, Wesley Medical Center, Wichita, KS 67205, United States of America
| | - Gavin T Howington
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY 40506, United States of America; Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY 40536, United States of America
| | - Gregory Kelly
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America
| | - Jessica Laub
- Department of Pharmacy, New York-Presbyterian-Brooklyn Methodist Hospital, Brooklyn, NY 11215, United States of America
| | - Blake A Porter
- Department of Pharmacy, University of Vermont Medical Center, Burlington, VT 05401, United States of America
| | - Giles W Slocum
- Department of Emergency Medicine and Department of Pharmacy, Rush University Medical Center, Chicago, IL 60612, United States of America
| | - Megan A Rech
- Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Department of Emergency Medicine, S 1st Ave, Maywood 60153, IL, United States of America; Loyola University Medical Center, Department of Pharmacy, S 1st Ave, Maywood, IL 60153, United States of America
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Lat I, Coopersmith CM, De Backer D. The Surviving Sepsis Campaign: Fluid Resuscitation and Vasopressor Therapy Research Priorities in Adult Patients. Crit Care Med 2021; 49:623-635. [PMID: 33731607 PMCID: PMC7963440 DOI: 10.1097/ccm.0000000000004864] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Expand upon the priorities of fluid resuscitation and vasopressor therapy research priorities identified by a group of experts assigned by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. DATA SOURCES Original article, literature search. STUDY SELECTION Several members of the original task force with expertise specific to the area of fluid resuscitation and vasopressor therapy. DATA EXTRACTION None. DATA SYNTHESIS None. CONCLUSION In the second of a series of manuscripts subsequent to the original article, members with expertise in the subjects expound upon the three identified priorities related to fluid resuscitation and vasopressor therapies. This analysis summarizes what is known and what were identified as ongoing and future research.
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Affiliation(s)
- Ishaq Lat
- Department of Pharmacy, Shirley Ryan AbilityLab, Chicago, IL
| | - Craig M Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University, Atlanta, GA
| | - Daniel De Backer
- Department of Intensive Care, Chirec Hospitals, Université Libre de Bruxelles, Brussels, Belgium
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36
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Vasopressor Responsiveness Beyond Arterial Pressure: A Conceptual Systematic Review Using Venous Return Physiology. Shock 2021; 56:352-359. [PMID: 33756500 DOI: 10.1097/shk.0000000000001762] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT We performed a systematic review to investigate the effects of vasopressor-induced hemodynamic changes in adults with shock. We applied a physiological approach using the interacting domains of intravascular volume, heart pump performance, and vascular resistance to structure the interpretation of responses to vasopressors. We hypothesized that incorporating changes in determinants of cardiac output and vascular resistance better reflect the vasopressor responsiveness beyond mean arterial pressure alone.We identified 28 studies including 678 subjects in Pubmed, EMBASE, and CENTRAL databases.All studies demonstrated significant increases in mean arterial pressure (MAP) and systemic vascular resistance during vasopressor infusion. The calculated mean systemic filling pressure analogue increased (16 ± 3.3 mmHg to 18 ± 3.4 mmHg; P = 0.02) by vasopressors with variable effects on central venous pressure and the pump efficiency of the heart leading to heterogenous changes in cardiac output. Changes in the pressure gradient for venous return and cardiac output, scaled by the change in MAP, were positively correlated (r2 = 0.88, P < 0.001). Changes in the mean systemic filling pressure analogue and heart pump efficiency were negatively correlated (r2 = 0.57, P < 0.001) while no correlation was found between changes in MAP and heart pump efficiency.We conclude that hemodynamic changes induced by vasopressor therapy are inadequately represented by the change in MAP alone despite its common use as a clinical endpoint. The more comprehensive analysis applied in this review illustrates how vasopressor administration may be optimized.
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37
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Fukui S, Higashio K, Murao S, Endo A, Akira T, Yamakawa K. Optimal target blood pressure in critically ill adult patients with vasodilatory shock: a protocol for a systematic review and meta-analysis. BMJ Open 2021; 11:e048512. [PMID: 33741676 PMCID: PMC7986773 DOI: 10.1136/bmjopen-2020-048512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION The optimal target of mean arterial pressure (MAP) for better outcomes in patients with vasodilatory shock remains a matter of debate. Although catecholamines are generally used to maintain target blood pressure in hypotensive patients with vasodilatory shock, the adverse effects of catecholamines must also be considered. We will perform a systematic review and meta-analysis of randomised controlled trials (RCTs) to assess the certainty of evidence determining the optimal target of MAP control for patients with vasodilatory shock in critically ill settings. METHODS AND ANALYSIS This study protocol was registered in the University Hospital Medical Information Network Clinical Trials Registry. We will include only RCTs that evaluated the two different comparators for target MAP to be maintained for clinical outcomes of all-cause mortality: organ dysfunction and adverse events in critically ill adult patients with vasodilatory shock. We will search the electronic bibliographic databases of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials in November 2020. Two reviewers will independently screen titles and abstracts, perform full article reviews and extract study data. We will report study characteristics and assess methodological quality using the Cochrane Risk-of-Bias 2 tool. If pooling is appropriate, we will calculate relative risks with 95% CIs for all outcome measures. Clinical and methodological subgroup and sensitivity analyses will be performed to explore heterogeneity. Overall certainty of evidence will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION This study will not involve primary data collection, and formal ethics approval will therefore not be required. We aim to publish this systematic review in a peer-reviewed journal. TRIAL REGISTRATION NUMBER UMIN000042624.
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Affiliation(s)
- Satoshi Fukui
- Faculty of Medicine, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Koki Higashio
- Faculty of Medicine, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Shuhei Murao
- Department of Traumatology and Acute Critical Medicine, Osaka University School of Medicine Graduate School of Medicine, Suita, Osaka, Japan
| | - Akira Endo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Takasu Akira
- Department of Emergency Medicne, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Kazuma Yamakawa
- Department of Emergency Medicne, Osaka Medical College, Takatsuki, Osaka, Japan
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Lat I, Coopersmith CM, De Backer D, Coopersmith CM. The surviving sepsis campaign: fluid resuscitation and vasopressor therapy research priorities in adult patients. Intensive Care Med Exp 2021; 9:10. [PMID: 33644843 PMCID: PMC7917035 DOI: 10.1186/s40635-021-00369-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To expand upon the priorities of fluid resuscitation and vasopressor therapy research priorities identified by a group of experts assigned by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. DATA SOURCES Original paper and literature search. STUDY SELECTION Several members of the original task force with expertise specific to the area of fluid resuscitation and vasopressor therapy. DATA EXTRACTION None. DATA SYNTHESIS None. CONCLUSION In the second of a series of manuscripts subsequent to the original paper, members with expertise in the subjects expound upon the three identified priorities related to fluid resuscitation and vasopressor therapies. This analysis summarizes what is known and what were identified as ongoing and future research.
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Affiliation(s)
- Ishaq Lat
- Department of Pharmacy, Shirley Ryan Abilitylab, Chicago, IL, USA.
| | - Craig M Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University, Atlanta, GA, USA
| | - Daniel De Backer
- Department of Intensive Care, Chirec Hospitals, Université Libre de Bruxelles, Brussels, Belgium
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Nguyen M, Abou-Arab O, Bar S, Dupont H, Bouhemad B, Guinot PG. Echocardiographic measure of dynamic arterial elastance predict pressure response during norepinephrine weaning: an observational study. Sci Rep 2021; 11:2853. [PMID: 33531562 PMCID: PMC7854654 DOI: 10.1038/s41598-021-82408-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/20/2021] [Indexed: 01/27/2023] Open
Abstract
The purpose of this study was to determine whether dynamic elastance EAdyn derived from echocardiographic measurements of stroke volume variations can predict the success of a one-step decrease of norepinephrine dose. In this prospective single-center study, 39 patients with vasoplegic syndrome treated with norepinephrine and for whom the attending physician had decided to decrease norepinephrine dose and monitored by thermodilution were analyzed. EAdyn is the ratio of pulse pressure variation to stroke volume variation and was calculated from echocardiography stroke volume variations and from transpulmonary thermodilution. Pulse pressure variation was obtained from invasive arterial monitoring. Responders were defined by a decrease in mean arterial pressure (MAP) > 10% following norepinephrine decrease. The median decrease in norepinephrine was of 0.04 [0.03-0.05] µg kg-1 min-1. Twelve patients (31%) were classified as pressure responders with a median decrease in MAP of 13% [12-15%]. EAdyn was lower in pressure responders (0.40 [0.24-0.57] vs 0.95 [0.77-1.09], p < 0.01). EAdyn was able to discriminate between pressure responders and non-responders with an area under the curve of 0.86 (CI95% [0.71 to1.0], p < 0.05). The optimal cut-off was 0.8. EAdyn calculated from the echocardiographic estimation of the stroke volume variation and the invasive arterial pulse pressure variation can be used to discriminate pressure response to norepinephrine weaning. Agreement between EAdyn calculated from echocardiography and thermodilution was poor. Echocardiographic EAdyn might be used at bedside to optimize hemodynamic treatment.
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Affiliation(s)
- Maxime Nguyen
- Department of Anesthesiology and Intensive Care, C.H.U, Dijon, France. .,Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, France.
| | - Osama Abou-Arab
- Department of Anaesthesiology and Critical Care Medicine, Amiens University Hospital, 80054, Amiens, France
| | - Stéphane Bar
- Department of Anaesthesiology and Critical Care Medicine, Amiens University Hospital, 80054, Amiens, France
| | - Hervé Dupont
- Department of Anaesthesiology and Critical Care Medicine, Amiens University Hospital, 80054, Amiens, France
| | - Bélaïd Bouhemad
- Department of Anesthesiology and Intensive Care, C.H.U, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, France
| | - Pierre-Grégoire Guinot
- Department of Anesthesiology and Intensive Care, C.H.U, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, France
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40
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Mouncey PR, Richards-Belle A, Thomas K, Harrison DA, Sadique MZ, Grieve RD, Camsooksai J, Darnell R, Gordon AC, Henry D, Hudson N, Mason AJ, Saull M, Whitman C, Young JD, Lamontagne F, Rowan KM. Reduced exposure to vasopressors through permissive hypotension to reduce mortality in critically ill people aged 65 and over: the 65 RCT. Health Technol Assess 2021; 25:1-90. [PMID: 33648623 PMCID: PMC7957458 DOI: 10.3310/hta25140] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Vasopressors are administered to critical care patients to avoid hypotension, which is associated with myocardial injury, kidney injury and death. However, they work by causing vasoconstriction, which may reduce blood flow and cause other adverse effects. A mean arterial pressure target typically guides administration. An individual patient data meta-analysis (Lamontagne F, Day AG, Meade MO, Cook DJ, Guyatt GH, Hylands M, et al. Pooled analysis of higher versus lower blood pressure targets for vasopressor therapy septic and vasodilatory shock. Intensive Care Med 2018;44:12-21) suggested that greater exposure, through higher mean arterial pressure targets, may increase risk of death in older patients. OBJECTIVE To estimate the clinical effectiveness and cost-effectiveness of reduced vasopressor exposure through permissive hypotension (i.e. a lower mean arterial pressure target of 60-65 mmHg) in older critically ill patients. DESIGN A pragmatic, randomised clinical trial with integrated economic evaluation. SETTING Sixty-five NHS adult general critical care units. PARTICIPANTS Critically ill patients aged ≥ 65 years receiving vasopressors for vasodilatory hypotension. INTERVENTIONS Intervention - permissive hypotension (i.e. a mean arterial pressure target of 60-65 mmHg). Control (usual care) - a mean arterial pressure target at the treating clinician's discretion. MAIN OUTCOME MEASURES The primary clinical outcome was 90-day all-cause mortality. The primary cost-effectiveness outcome was 90-day incremental net monetary benefit. Secondary outcomes included receipt and duration of advanced respiratory and renal support, mortality at critical care and acute hospital discharge, and questionnaire assessment of cognitive decline and health-related quality of life at 90 days and 1 year. RESULTS Of 2600 patients randomised, 2463 (permissive hypotension, n = 1221; usual care, n = 1242) were analysed for the primary clinical outcome. Permissive hypotension resulted in lower exposure to vasopressors than usual care [mean duration 46.0 vs. 55.9 hours, difference -9.9 hours (95% confidence interval -14.3 to -5.5 hours); total noradrenaline-equivalent dose 31.5 mg vs. 44.3 mg, difference -12.8 mg (95% CI -18.0 mg to -17.6 mg)]. By 90 days, 500 (41.0%) patients in the permissive hypotension group and 544 (43.8%) patients in the usual-care group had died (absolute risk difference -2.85%, 95% confidence interval -6.75% to 1.05%; p = 0.154). Adjustment for prespecified baseline variables resulted in an odds ratio for 90-day mortality of 0.82 (95% confidence interval 0.68 to 0.98) favouring permissive hypotension. There were no significant differences in prespecified secondary outcomes or subgroups; however, patients with chronic hypertension showed a mortality difference favourable to permissive hypotension. At 90 days, permissive hypotension showed similar costs to usual care. However, with higher incremental life-years and quality-adjusted life-years in the permissive hypotension group, the incremental net monetary benefit was positive, but with high statistical uncertainty (£378, 95% confidence interval -£1347 to £2103). LIMITATIONS The intervention was unblinded, with risk of bias minimised through central allocation concealment and a primary outcome not subject to observer bias. The control group event rate was higher than anticipated. CONCLUSIONS In critically ill patients aged ≥ 65 years receiving vasopressors for vasodilatory hypotension, permissive hypotension did not significantly reduce 90-day mortality compared with usual care. The absolute treatment effect on 90-day mortality, based on 95% confidence intervals, was between a 6.8-percentage reduction and a 1.1-percentage increase in mortality. FUTURE WORK Future work should (1) update the individual patient data meta-analysis, (2) explore approaches for evaluating heterogeneity of treatment effect and (3) explore 65 trial conduct, including use of deferred consent, to inform future trials. TRIAL REGISTRATION Current Controlled Trials ISRCTN10580502. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 14. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Alvin Richards-Belle
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Karen Thomas
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - M Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard D Grieve
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Julie Camsooksai
- Critical Care, Research and Innovation, Poole Hospital NHS Foundation Trust, Poole, UK
| | - Robert Darnell
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
- Intensive Care Unit, Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | | | - Nicholas Hudson
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Alexina J Mason
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Michelle Saull
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | | | - J Duncan Young
- Kadoorie Centre for Critical Care Research and Education, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - François Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de Recherche du Centre Hospitalier, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
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41
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Durst MM, Eitzen EA, Benken ST. Comparison of Vasopressor Duration in Septic Shock Patients With and Without Cirrhosis. Ann Pharmacother 2020; 55:970-979. [PMID: 33327736 DOI: 10.1177/1060028020980727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Patients with cirrhosis have immune dysfunction, altered inflammatory response, and hemodynamic changes which increase risk of septic shock and potentially prolong management with fluids, vasopressors, and other therapies. Due to limited available guidance, this study aimed to characterize vasopressor use in patients with cirrhosis in relation to patients without cirrhosis in septic shock. METHODS This was a retrospective matched cohort analysis of 122 patients admitted to the intensive care unit (ICU) at an academic medical center from January 2015 to November 2017. Patients were grouped based on the presence or absence of cirrhosis and matched based on severity of illness scoring. The primary outcome was vasopressor duration. Secondary comparisons included total vasopressor requirement, length of hospital and ICU stay, in-hospital mortality, change in organ function, and discharge disposition. RESULTS The group with cirrhosis had significantly longer median (interquartile range [IQR]) durations of vasopressor therapy compared with the group without cirrhosis (86.0 [42.0-164.5] vs 39.0 [14.5-82.0] hours; P = 0.003) leading to increased median (IQR) vasopressor exposure (71.7 [15.5-239.5] vs 24.7 [5.3-77.9] mg norepinephrine [NE] equivalents; P = 0.003). No difference was found in in-hospital mortality between groups. However, regression analysis showed vasopressor exposure was associated with in-hospital mortality. CONCLUSION AND RELEVANCE Patients with cirrhosis in septic shock have increased vasopressor durations and overall requirements compared with patients without cirrhosis. Increased durations and requirements is associated with poorer outcomes independent of presence of cirrhosis. Future studies are needed to improve vasopressor treatment strategies and end points utilized in cirrhosis.
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Richards-Belle A, Mouncey PR, Grieve RD, Harrison DA, Sadique MZ, Henry D, Whitman C, Camsooksai J, Gordon AC, Young JD, Rowan KM, Lamontagne F. Evaluating the clinical and cost-effectiveness of permissive hypotension in critically ill patients aged 65 years or over with vasodilatory hypotension: Protocol for the 65 randomised clinical trial. J Intensive Care Soc 2020; 21:281-282. [PMID: 34093727 DOI: 10.1177/1751143720971433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Vasodilatory shock is common in critically ill patients and vasopressors are a mainstay of therapy. A meta-analysis suggested that use of a higher, as opposed to a lower, mean arterial pressure target to guide titration of vasopressor therapy, could be associated with a higher risk of death in older critically ill patients. The 65 trial is a pragmatic, multi-centre, parallel-group, open-label, randomised clinical trial of permissive hypotension (a mean arterial pressure target of 60 -65 mmHg during vasopressor therapy) versus usual care in critically ill patients aged 65 years or over with vasodilatory hypotension. The trial is conducted in 2600 patients from 65 United Kingdom adult, general critical care units. The primary outcome is all-cause mortality at 90 days. An economic evaluation is embedded. The 65 trial received favourable ethical opinion from the South Central - Oxford C Research Ethics Committee and approval from the Health Research Authority. The results will be presented at national and international conferences and published in peer-reviewed medical journals. Trial registration: ISRCTN10580502.
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Affiliation(s)
- Alvin Richards-Belle
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Richard D Grieve
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - M Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - Anthony C Gordon
- Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK.,Intensive Care Unit, Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - J Duncan Young
- Kadoorie Centre for Critical Care Research and Education, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - François Lamontagne
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke et Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Canada
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Mele TS, Kaafarani HMA, Guidry CA, Loor MM, Machado-Aranda D, Mendoza AE, Morris-Stiff G, Rattan R, Schubl SD, Barie PS. Surgical Infection Society Research Priorities: A Narrative Review of Fourteen Years of Progress. Surg Infect (Larchmt) 2020; 22:568-582. [PMID: 33275862 DOI: 10.1089/sur.2020.309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: In 2006, the Surgical Infection Society (SIS) utilized a modified Delphi approach to define 15 specific priority research questions that remained unanswered in the field of surgical infections. The aim of the current study was to evaluate the scientific progress achieved during the ensuing period in answering each of the 15 research questions and to determine if additional research in these fields is warranted. Methods: For each of the questions, a literature search using the National Center for Biotechnology Information (NCBI) was performed by the Scientific Studies Committee of the SIS to identify studies that attempted to address each of the defined questions. This literature was analyzed and summarized. The data on each question were evaluated by a surgical infections expert to determine if the question was answered definitively or remains unanswered. Results: All 15 priority research questions were studied in the last 14 years; six questions (40%) were definitively answered and 9 questions (60%) remain unanswered in whole or in part, mainly because of the low quality of the studies available on this topic. Several of the 9 unanswered questions were deemed to remain research priorities in 2020 and warrant further investigation. These included, for example, the role of empiric antimicrobial agents in nosocomial infections, the use of inotropes/vasopressors versus volume loading to raise the mean arterial pressure, and the role of increased antimicrobial dosing and frequency in the obese patient. Conclusions: Several surgical infection-related research questions prioritized in 2006 remain unanswered. Further high-quality research is required to provide a definitive answer to many of these priority knowledge gaps. An updated research agenda by the SIS is warranted at this time to define research priorities for the future.
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Affiliation(s)
- Tina S Mele
- Divisions of General Surgery and Critical Care, Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher A Guidry
- Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Michele M Loor
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - David Machado-Aranda
- Division of Acute Care Surgery, Michigan Medicine and Ann Arbor Veterans' Affairs Health System, Ann Arbor, Michigan, USA
| | - April E Mendoza
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gareth Morris-Stiff
- Department of Surgery, Case Western Reserve University, Cleveland, Ohio, USA
| | - Rishi Rattan
- Division of Trauma Surgery and Critical Care, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Sebastian D Schubl
- Department of Surgery, University of California, Irvine, California, USA
| | - Philip S Barie
- Division of Trauma Burns, Acute and Critical Care, Department of Surgery, and Division of Medical Ethics, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
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Masse MH, Battista MC, Wilcox ME, Pinto R, Marinoff N, D'Aragon F, St-Arnaud C, Mayette M, Leclair MA, Quiroz Martinez H, Grondin-Beaudoin B, Poulin Y, Carbonneau É, Seely AJE, Watpool I, Porteous R, Chassé M, Lebrasseur M, Lauzier F, Turgeon AF, Bellemare D, Mehta S, Charbonney E, Belley-Côté É, Botton É, Cohen D, Lamontagne F, Adhikari NKJ. Optimal VAsopressor TitraTION in patients 65 years and older (OVATION-65): protocol and statistical analysis plan for a randomised clinical trial. BMJ Open 2020; 10:e037947. [PMID: 33191251 PMCID: PMC7668371 DOI: 10.1136/bmjopen-2020-037947] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 07/25/2020] [Accepted: 07/28/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Vasodilatory hypotension is common among intensive care unit (ICU) patients; vasopressors are considered standard of care. However, optimal mean arterial pressure (MAP) targets for vasopressor titration are unknown. The objective of the Optimal VAsopressor TitraTION in patients 65 years and older (OVATION-65) trial is to ascertain the effect of permissive hypotension (vasopressor titration to achieve MAP 60-65 mm Hg) versus usual care on biomarkers of organ injury in hypotensive patients aged ≥65 years. METHODS AND ANALYSIS OVATION-65 is an allocation-concealed randomised trial in 7 Canadian hospitals. Eligible patients are ≥65 years of age, in an ICU with vasodilatory hypotension, receiving vasopressors for ≤12 hours to maintain MAP ≥65 mm Hg during or after adequate fluid resuscitation, and expected to receive vasopressors for ≥6 additional hours. Patients are excluded for any of the following: active treatment for spinal cord or acute brain injury; vasopressors given solely for bleeding, ventricular failure or postcardiopulmonary bypass vasoplegia; withdrawal of life-sustaining treatments expected within 48 hours; death perceived as imminent; previous enrolment in OVATION-65; organ transplant within the last year; receiving extracorporeal life support or lack of physician equipoise. Patients are randomised to permissive hypotension versus usual care for up to 28 days. The primary outcome is high-sensitivity troponin T, a biomarker of cardiac injury, on day 3. Secondary outcomes include biomarkers of injury to other organs (brain, liver, intestine, skeletal muscle); lactate (a biomarker of global tissue dysoxia); resource utilisation; adverse events; mortality (90 days and 6 months) and cognitive function (6 months). Assessors of biomarkers, mortality and cognitive function are blinded to allocation. ETHICS AND DISSEMINATION This protocol has been approved at all sites. Consent is obtained from the eligible patient, the substitute decision-maker if the patient is incapable, or in a deferred fashion where permitted. End-of-grant dissemination plans include presentations, publications and social media platforms and discussion forums. TRIAL REGISTRATION NUMBER NCT03431181.
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Affiliation(s)
- Marie-Hélène Masse
- Centre de recherche, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Marie-Claude Battista
- Centre de recherche, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Mary Elizabeth Wilcox
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Nicole Marinoff
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Frédérick D'Aragon
- Centre de recherche, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Charles St-Arnaud
- Centre de recherche, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Michael Mayette
- Centre de recherche, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Marc-André Leclair
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | | | - Yannick Poulin
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Élaine Carbonneau
- Centre de recherche, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Andrew J E Seely
- Departments of Surgery and Critical Care Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Irene Watpool
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Michaël Chassé
- Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
- Centre de recherche, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Martine Lebrasseur
- Centre de recherche, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Centre de recherche du CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit, Centre de recherche du CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - David Bellemare
- Population Health and Optimal Health Practices Research Unit, Centre de recherche du CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Emmanuel Charbonney
- Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
- Centre de recherche, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Émilie Belley-Côté
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
| | | | - Dian Cohen
- Patient partners, Sherbrooke, Quebec, Canada
| | - François Lamontagne
- Centre de recherche, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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45
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Affiliation(s)
- Fabrice Uhel
- Amsterdam University Medical Centers University of Amsterdam Amsterdam, the Netherlands
| | - Tom van der Poll
- Amsterdam University Medical Centers University of Amsterdam Amsterdam, the Netherlands
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46
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Kanji S, Burry L, Williamson D, Pittman M, Dubinsky S, Patel D, Natarajan S, MacLean R, Huh JH, Scales DC, Neilipovitz D. Therapeutic alternatives and strategies for drug conservation in the intensive care unit during times of drug shortage: a report of the Ontario COVID-19 ICU Drug Task Force. Can J Anaesth 2020; 67:1405-1416. [PMID: 32458267 PMCID: PMC8297429 DOI: 10.1007/s12630-020-01713-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/08/2020] [Accepted: 05/08/2020] [Indexed: 01/09/2023] Open
Abstract
During the coronavirus disease (COVID-19) global pandemic, urgent strategies to alleviate shortages are required. Evaluation of the feasibility, practicality, and value of drug conservation strategies and therapeutic alternatives requires a collaborative approach at the provincial level. The Ontario COVID-19 ICU Drug Task Force was directed to create recommendations suggesting drug conservation strategies and therapeutic alternatives for essential drugs at risk of shortage in the intensive care unit during the COVID-19 pandemic. Recommendations were rapidly developed using a modified Delphi method and evaluated on their ease of implementation, feasibility, and supportive evidence. This article describes the recommendations for drug conservation strategies and therapeutic alternatives for drugs at risk of shortage that are commonly used in the care of critically ill patients. Recommendations are identified as preferred and secondary ones that might be less desirable. Although the impetus for generating this document was the COVID-19 pandemic, recommendations should also be applicable for mitigating drug shortages outside of a pandemic. Proposed provincial strategies for drug conservation and therapeutic alternatives may not all be appropriate for every institution. Local implementation will require consultation from end-users and hospital administrators. Competing equipment shortages and available resources should be considered when evaluating the appropriateness of each strategy.
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Affiliation(s)
- Salmaan Kanji
- Department of Pharmacy, The Ottawa Hospital, The Ottawa Hospital Research Institute, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada.
| | - Lisa Burry
- Mount Sinai Hospital, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - David Williamson
- Sacré Coeur Hospital, Université de Montréal, Montreal, QC, Canada
| | | | | | | | | | | | | | - Damon C Scales
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Center, Toronto, ON, Canada
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47
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Aibar J, Schulman S. New-Onset Atrial Fibrillation in Sepsis: A Narrative Review. Semin Thromb Hemost 2020; 47:18-25. [PMID: 32968991 DOI: 10.1055/s-0040-1714400] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Atrial fibrillation (AF) is a frequently identified arrhythmia during the course of sepsis. The aim of this narrative review is to assess the characteristics of patients with new-onset AF related to sepsis and the risk of stroke and death, to understand if there is a need for anticoagulation. We searched for studies on AF and sepsis on PubMed, the Cochrane database, and Web of Science, and 17 studies were included. The mean incidence of new-onset AF in patients with sepsis was 20.6% (14.7% in retrospective studies and 31.6% in prospective). Risk factors for new-onset AF included advanced age, white race, male sex, obesity, history of cardiopulmonary disease, heart or respiratory failure, and higher disease severity score. In-hospital mortality was higher in patients with than in those without new-onset AF in 10 studies. In four studies the overall intensive care unit and hospital mortality rates were comparable between patients with and without new-onset AF, while three other studies did not provide mortality data. One study reported on the in-hospital incidence of stroke, which was 2.6 versus 0.69% in patients with or without new-onset AF, respectively. Seven of the studies provided follow-up data after discharge. In three studies, new-onset AF was associated with excess mortality at 28 days, 1 year, and 5 years after discharge of 34, 21, and 3% patients, respectively. In two studies, the mortality rate was comparable in patients with and without new-onset AF. Postdischarge stroke was reported in five studies, whereof two studies had no events after 30 and 90 days, one study showed a nonsignificant increase in stroke, and two studies demonstrated a significant increase in risk of stroke after new-onset AF. The absolute risk increase was 0.6 to 1.6%. Large prospective studies are needed to better understand the need for anticoagulation after new-onset AF in sepsis.
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Affiliation(s)
- Jesus Aibar
- Internal Medicine Department, Hospital Clínic, IDIBAPS - University of Barcelona, Spain.,Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada.,Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
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48
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Russell JA, Gordon AC, Williams MD, Boyd JH, Walley KR, Kissoon N. Vasopressor Therapy in the Intensive Care Unit. Semin Respir Crit Care Med 2020; 42:59-77. [PMID: 32820475 DOI: 10.1055/s-0040-1710320] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
After fluid administration for vasodilatory shock, vasopressors are commonly infused. Causes of vasodilatory shock include septic shock, post-cardiovascular surgery, post-acute myocardial infarction, postsurgery, other causes of an intense systemic inflammatory response, and drug -associated anaphylaxis. Therapeutic vasopressors are hormones that activate receptors-adrenergic: α1, α2, β1, β2; angiotensin II: AG1, AG2; vasopressin: AVPR1a, AVPR1B, AVPR2; dopamine: DA1, DA2. Vasopressor choice and dose vary widely because of patient and physician practice heterogeneity. Vasopressor adverse effects are excessive vasoconstriction causing organ ischemia/infarction, hyperglycemia, hyperlactatemia, tachycardia, and tachyarrhythmias. To date, no randomized controlled trial (RCT) of vasopressors has shown a decreased 28-day mortality rate. There is a need for evidence regarding alternative vasopressors as first-line vasopressors. We emphasize that vasopressors should be administered simultaneously with fluid replacement to prevent and decrease duration of hypotension in shock with vasodilation. Norepinephrine is the first-choice vasopressor in septic and vasodilatory shock. Interventions that decrease norepinephrine dose (vasopressin, angiotensin II) have not decreased 28-day mortality significantly. In patients not responsive to norepinephrine, vasopressin or epinephrine may be added. Angiotensin II may be useful for rapid resuscitation of profoundly hypotensive patients. Inotropic agent(s) (e.g., dobutamine) may be needed if vasopressors decrease ventricular contractility. Dopamine has fallen to almost no-use recommendation because of adverse effects; angiotensin II is available clinically; there are potent vasopressors with scant literature (e.g., methylene blue); and the novel V1a agonist selepressin missed on its pivotal RCT primary outcome. In pediatric septic shock, vasopressors, epinephrine, and norepinephrine are recommended equally because there is no clear evidence that supports the use of one vasoactive agent. Dopamine is recommended when epinephrine or norepinephrine is not available. New strategies include perhaps patients will be started on several vasopressors with complementary mechanisms of action, patients may be selected for particular vasopressors according to predictive biomarkers, and novel vasopressors may emerge with fewer adverse effects.
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Affiliation(s)
- James A Russell
- Department of Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anthony C Gordon
- Department of Surgery and Cancer, Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, United Kingdom.,Department of Surgery and Cancer, Intensive Care Unit, Imperial College Healthcare NHS Trust, St Mary's Hospital, London, United Kingdom
| | - Mark D Williams
- Department of Medicine, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - John H Boyd
- Department of Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Keith R Walley
- Department of Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Niranjan Kissoon
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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49
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Kow CS, Capstick T, Zaidi STR, Hasan SS. Consistency of recommendations from clinical practice guidelines for the management of critically ill COVID-19 patients. Eur J Hosp Pharm 2020; 28:42-46. [PMID: 32737069 PMCID: PMC7788212 DOI: 10.1136/ejhpharm-2020-002388] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/09/2020] [Accepted: 07/21/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND A significant knowledge gap exists for the management of critically ill patients with coronavirus disease 2019 (COVID-19). This study aimed to systematically investigate the consistency of recommendations from the available clinical practice guidelines (CPGs) to those of the WHO on the management of critically ill COVID-19 patients. METHODS We examined CPGs and UpToDate point-of-care resources on the management of critically ill COVID-19 patients that had been published as of 30 April 2020 and compared them against the CPG by the WHO. The main outcome was the rate of consistency among CPGs for the management of critically ill COVID-19 patients. Sensitivity analyses were conducted by excluding recommendation statements that were described as insufficient evidence and by excluding single CPGs one at a time. RESULTS Thirteen reference recommendations derived from the CPG of the WHO were generated using discrete and unambiguous specifications of the population, intervention, and comparison states. Across CPGs, the rate of consistency in direction with the WHO is 7.7%. When insufficient evidence codings were excluded, the rate of consistency increased substantially to 61.5%. The results of a leave-one-out sensitivity analysis suggested that the UpToDate recommendation source could explain the inconsistency. Consistency in direction rates changed by an absolute 23.1% (from 1/13 (7.7%) to 4/13 (30.8%)) if UpToDate was removed. CONCLUSIONS We observed inconsistencies between some recommendations of the CPGs and those of the WHO. These inconsistencies should best be addressed by consensus among the relevant bodies to avoid confusion in clinical practice while awaiting clinical trials to inform us of the best practice.
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Affiliation(s)
- Chia Siang Kow
- School of Postgraduate Studies, International Medical University, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Toby Capstick
- Department of Pharmacy, Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, UK
| | | | - Syed Shahzad Hasan
- Department of Pharmacy, University of Huddersfield, Huddersfield, West Yorkshire, UK
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50
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Wernly B, Heramvand N, Masyuk M, Rezar R, Bruno RR, Kelm M, Niederseer D, Lichtenauer M, Hoppe UC, Bakker J, Jung C. Acidosis predicts mortality independently from hyperlactatemia in patients with sepsis. Eur J Intern Med 2020; 76:76-81. [PMID: 32143899 DOI: 10.1016/j.ejim.2020.02.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 02/15/2020] [Accepted: 02/24/2020] [Indexed: 02/07/2023]
Abstract
RATIONALE AND OBJECTIVES Acidosis and hyperlactatemia predict outcome in critically ill patients. We assessed BE and pH for risk prediction capabilities in a sub-group of septic patients in the MIMIC-III database. METHODS Associations with mortality were assessed by logistic regression analysis in 5586 septic patients. Baseline parameters, lactate concentrations, pH, and BE were analyzed at baseline and after 6 hours. MEASUREMENTS AND MAIN RESULTS We combined acidosis (defined as either BE ≤-6 and/or pH ≤7.3) and hyperlactatemia and split the cohort into three subgroups: low-risk (no acidosis and lactate <2.3 mmol/L; n = 2294), medium-risk (either acidosis or lactate >2.3 mmol/L; n = 2125) and high-risk (both acidosis and lactate >2.3 mmol/L; n = 1167). Mortality was 14%, 20% and 38% (p<0.001) in low-risk, medium-risk and high-risk patients, respectively. The predictiveness of this model (AUC 0.63 95%CI 0.61-0.65) was higher compared to acidosis (AUC 0.59 95%CI 0.57-0.61; p<0.001) and lactate >2.3 mmol/L (AUC 0.60 95%CI 0.58-0.62; p<0.001) alone. Hyperlactatemia alone was only moderately predictive for acidosis (AUC 0.60 95%CI 0.59-0.62). CONCLUSIONS Acidosis and hyperlactatemia can occur independently to a certain degree. Combining acidosis and hyperlactatemia in a model yielded higher predictiveness for ICU-mortality. Septic patients with acidosis should be treated even more aggressively in the future.
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Affiliation(s)
- Bernhard Wernly
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria; Division of Cardiology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Nadia Heramvand
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Maryna Masyuk
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Richard Rezar
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Raphael Romano Bruno
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany; CARID, Cardiovascular Research Institute Düsseldorf, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - David Niederseer
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michael Lichtenauer
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Uta C Hoppe
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Jan Bakker
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands; Department of Pulmonology and Critical Care, New York University Medical Center, New York, USA; Department of Pulmonology and Critical Care, Columbia University Medical Center, New York, USA; Department of Intensive Care, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Christian Jung
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany.
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