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Pölkki A, Pekkarinen PT, Hess B, Blaser AR, Bachmann KF, Lakbar I, Hollenberg SM, Lobo SM, Rezende E, Selander T, Reinikainen M. Noradrenaline dose cutoffs to characterise the severity of cardiovascular failure: Data-based development and external validation. Acta Anaesthesiol Scand 2024. [PMID: 39210783 DOI: 10.1111/aas.14519] [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: 06/08/2024] [Revised: 08/16/2024] [Accepted: 08/19/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND The vasopressor dose needed is a common measure to assess the severity of cardiovascular failure, but there is no consensus on the ranges of vasopressor doses determining different levels of cardiovascular support. We aimed to identify cutoffs for determining low, intermediate and high doses of noradrenaline (norepinephrine), the primary vasopressor used in intensive care, based on association with hospital mortality. METHODS We conducted a binational registry study to determine cutoffs between low, intermediate and high noradrenaline doses. We required the cutoffs to be statistically rational and practical (rounded to the first decimal and easy to remember), and to result in increasing mortality with increasing doses. The highest noradrenaline dose in the first 24 h after intensive care unit (ICU) admission was used. The cutoffs were developed using data from 8079 ICU patients treated in the ICU at Kuopio University Hospital, Finland, between 2013 and 2019. Subsequently, the cutoffs were validated in the eICU database, including 39,007 ICU admissions to 29 ICUs in the United States of America in 2014-2015. The log-rank statistic, with the Contal and O'Quigley method, was used to determine the cutoffs resulting in the most significant split between the noradrenaline dose groups with regard to hospital mortality. RESULTS The two most prominent peaks in the log-rank statistic corresponded to noradrenaline doses 0.20 and 0.44 μg/kg/min. Accordingly, we determined three dose ranges: low (<0.2 μg/kg/min), intermediate (0.2-0.4 μg/kg/min) and high (>0.4 μg/kg/min). Mortality increased, whereas the number of patients decreased consistently with increasing noradrenaline doses in both cohorts. In the development cohort, hospital mortality was 6.5% in the group without noradrenaline administered and 14.0%, 26.4% and 40.2%, respectively, in the low-dose, intermediate-dose and high-dose groups. Compared to patients who received no noradrenaline, the hazard ratio for in-hospital death was 1.4 for the low-dose group, 4.0 for the intermediate-dose group and 7.5 for the high-dose group in the validation cohort (p < .001). CONCLUSIONS The highest noradrenaline dose is a useful measure for quantifying circulatory failure. Cutoffs 0.2 and 0.4 μg/kg/min seem to be suitable for defining low, intermediate and high doses.
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Affiliation(s)
- Anssi Pölkki
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Pirkka T Pekkarinen
- Division of Intensive Care Medicine, Department of Anaesthesiology and Intensive Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Benjamin Hess
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Annika Reintam Blaser
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
| | - Kaspar F Bachmann
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Inès Lakbar
- Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, University of Montpellier, Montpellier, France
| | - Steven M Hollenberg
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Suzana M Lobo
- Intensive Care Division, Hospital de Base, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, Brazil
| | - Ederlon Rezende
- Critical Care Department of The Hospital do Servidor Público Estadual - IAMSPE, Sao Paulo, Brazil
| | - Tuomas Selander
- Kuopio University Hospital, Science Service Center, Kuopio, Finland
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
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Drolz A. [Bleeding in liver diseases]. Med Klin Intensivmed Notfmed 2024:10.1007/s00063-024-01167-3. [PMID: 39138654 DOI: 10.1007/s00063-024-01167-3] [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: 06/12/2024] [Accepted: 07/08/2024] [Indexed: 08/15/2024]
Abstract
Bleeding events are feared complications in patients with advanced liver diseases and are associated with morbidity and mortality. In this context, gastrointestinal bleeding, particularly upper gastrointestinal bleeding, has a special clinical importance. In addition to endoscopic measures for hemostasis, reducing portal pressure in particular is a key component of treatment. Although the standard coagulation parameters are often altered in patients with liver diseases, optimizing coagulation plays a secondary role. Typically, a bundle of measures are employed in patients with portal hypertensive bleeding, which nowadays in most cases can halt the bleeding and stabilize the situation. The measures include endoscopy, antibiotic treatment, vasopressor treatment and, if necessary, shunt placement (transjugular intrahepatic portosystemic shunt).
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Affiliation(s)
- Andreas Drolz
- I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
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Li W, Deng J. Effect of Continuous Infusion Therapy With Low-dose Terlipressin Combined With Norepinephrine on Hemodynamics, Inflammatory Markers, and Prognosis in Patients With Severe Septic Shock. Mil Med 2024:usae369. [PMID: 39091078 DOI: 10.1093/milmed/usae369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/25/2024] [Accepted: 07/17/2024] [Indexed: 08/04/2024] Open
Abstract
OBJECTIVE The present study investigated the impact of continuous infusion therapy with low-dose terlipressin (TP) combined with norepinephrine on hemodynamics, inflammatory markers, and prognosis in patients with severe septic shock. MATERIALS AND METHODS Seventy-four patients with severe septic shock were randomly assigned to either a control group (n = 37) or an observation group (n = 37). Patients in the control group received norepinephrine alone, while those in the observation group received a continuous infusion of low-dose TP in addition to norepinephrine. To assess the effect of treatment, a set of clinical parameters was evaluated in both groups before and after treatment. These parameters included hemodynamic indicators (heart rate [HR], mean arterial pressure [MAP], central venous pressure [CVP], cardiac index [CI], and systemic vascular resistance index [SVRI]), levels of serum inflammatory markers (interleukin-8 [IL-8], tumor necrosis factor-α [TNF-α], and hypersensitivity C-reactive protein [hs-CRP]), renal function indicators (blood urea nitrogen [BUN], serum creatinine [SCr], and cystatin C [Cys-C]), serum procalcitonin (PCT), and lactate, as well as lactate clearance rate (LCR). Additionally, the acute physiology and chronic health evaluation II (APACHE II) score, 28-day mortality rate, multiple organ dysfunction syndrome (MODS) incidence rate, and adverse reaction incidence were also determined. RESULTS Compared to baseline values, MAP, CVP, CI, SVRI, and LCR increased in both groups after treatment, while HR, levels of IL-8, TNF-α, hs-CRP, BUN, SCr, PCT, and lactate all decreased. Additionally, APACHE II scores also decreased. Furthermore, the observation group exhibited higher MAP, CVP, CI, SVRI, and LCR, along with lower HR, levels of IL-8, TNF-α, hs-CRP, BUN, SCr, PCT, and lactate than the control group after treatment. The observation group also had lower APACHE II score, 28-day mortality rate, MODS incidence rate, and adverse reaction incidence than the control group after treatment (P < .05). CONCLUSION Continuous infusion therapy with low-dose TP combined with norepinephrine was effective in treating patients with severe septic shock, improving hemodynamic parameters, reducing the levels of inflammatory markers, promoting renal function recovery, and reducing the mortality rate.
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Affiliation(s)
- Wenlong Li
- Department of Emergency, Ganzhou People's Hospital, Ganzhou, Jiangxi 341000, China
| | - Jiaqian Deng
- Department of Cardiology, Ganzhou People's Hospital, Ganzhou, Jiangxi 341000, China
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Ley Greaves R, Bolot R, Holgate A, Gibbs C. Safety of pre-hospital peripheral vasopressors: The SPOTLESS study (Safety of PrehOspiTaL pEripheral vaSopreSsors). Emerg Med Australas 2024; 36:547-553. [PMID: 38423993 DOI: 10.1111/1742-6723.14396] [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: 09/14/2023] [Revised: 11/16/2023] [Accepted: 02/15/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVE To assess the safety and effectiveness of peripheral vasoactive drugs initiated during pre-hospital care and retrieval missions, in Queensland, Australia. METHODS Three years of retrospective data was gathered from two sources. Medical notes were reviewed using a search for any patient having 'inotrope' recorded on an electronic medical record. Each case was reviewed to include only peripheral infusions of adrenaline or noradrenaline. Clinical Governance records were searched for adverse events related to vasoactive drugs, alerted for review to ensure complete capture. RESULTS A total of 418 patients received peripheral infusions of adrenaline and noradrenaline over the 3-year period. No major complications were recorded either immediately or at Clinical Governance review. Minor complications were recorded in 4.7% of the cases, of which 3.5% occurred with peripheral vasoactives during the presence of the retrieval team. The frequency of use of peripheral vasoactives increased over the study period. CONCLUSIONS In this retrospective data set there were no major complications of peripheral vasoactive drugs. Minor complications were similar to in-hospital use and related to vascular access and drug delivery.
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Affiliation(s)
- Robbie Ley Greaves
- Lifeflight Retrieval Medicine, Brisbane, Queensland, Australia
- High Acuity Response Unit, Queensland Ambulance Service, Brisbane, Queensland, Australia
| | - Renee Bolot
- Lifeflight Retrieval Medicine, Brisbane, Queensland, Australia
| | - Andrew Holgate
- Lifeflight Retrieval Medicine, Brisbane, Queensland, Australia
- Emergency Department, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Clinton Gibbs
- Research and Evaluation, Retrieval Services Queensland, Brisbane, Queensland, Australia
- Emergency Department, Townsville University Hospital, Townsville, Queensland, Australia
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
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Huh J, Kwon H, Park H, Park SC, Yun SS, Chae MS. Impact of Norepinephrine and Dopamine Infusion on Renal Arterial Resistive Index during Pre-Emptive Living Donor Kidney Transplantation: Propensity Score Matching Analysis. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1066. [PMID: 39064495 PMCID: PMC11278998 DOI: 10.3390/medicina60071066] [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: 05/29/2024] [Revised: 06/26/2024] [Accepted: 06/26/2024] [Indexed: 07/28/2024]
Abstract
Background: Living donor kidney transplantation (LDKT) is a crucial treatment for end-stage renal disease, with pre-emptive LDKT (transplantation before dialysis initiation) offering significant benefits in graft function and patient survival. The selection of a vasopressor during LDKT, particularly between norepinephrine and dopamine, and its impact on renal arterial hemodynamics measured using the renal arterial resistive index (RARI) is poorly understood. Methods: This retrospective observational cohort study enrolled 347 eligible pre-emptive LDKT recipients from the Seoul St. Mary's Hospital between January 2019 and June 2023. Utilizing propensity score matching (PSM), the patients were categorized into dopamine and norepinephrine groups to compare the effects of these vasopressors on the intraoperative RARI, postoperative estimated glomerular filtration rate (eGFR), and hourly urine output. The RARI was measured via the Doppler ultrasonography of the renal hilum and parenchyma post-graft vascular and ureteral anastomoses. Results: The preoperative differences in the recipients' and donors' characteristics were mitigated following PSM. The dopamine group exhibited higher intraoperative RARI values at the renal hilum (0.77 ± 0.11 vs. 0.66 ± 0.13, p < 0.001) and parenchyma (0.71 ± 0.1 vs. 0.6 ± 0.1, p < 0.001) compared to those of the norepinephrine group. However, these differences were not statistically significant on postoperative day 7. The norepinephrine infusion adjusted for the propensity scores was associated with significantly lower odds of an RARI > 0.8 (hilum: OR = 0.214, 95% CI = 0.12-0.382, p < 0.001; parenchyma: OR = 0.1, 95% CI = 0.029-0.348, p < 0.001). The early postoperative outcomes showed a higher eGFR (day 1: 30.0 ± 13.3 vs. 25.1 ± 17.4 mL/min/1.73 m2, p = 0.004) and hourly urine output (day 1: 41.8 ± 16.9 vs. 36.5 ± 14.4 mL/kg/h, p = 0.002) in the norepinephrine group. Furthermore, the long-term outcomes were comparable between the groups. Conclusions: Norepinephrine infusion during pre-emptive LDKT is associated with more favorable intraoperative renal arterial hemodynamics, as evidenced by a lower RARI and improved early postoperative renal function compared to those of dopamine. These findings suggest a potential preferential role for norepinephrine in optimizing perioperative management and early graft functions in LDKT recipients. Given the retrospective nature of this study, further prospective studies are needed to confirm these observations. Additionally, the study limitations include the potential for unmeasured confounding factors and the inability to determine causality due to its observational design.
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Affiliation(s)
- Jaewon Huh
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Hyejin Kwon
- Department of Anesthesiology and Pain Medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Hunwoo Park
- Department of Anesthesiology and Pain Medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Sun Cheol Park
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Sang Seob Yun
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
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Khanna A, Vaidya K, Shah D, Ranjan AK, Gulati A. Centhaquine Increases Stroke Volume and Cardiac Output in Patients with Hypovolemic Shock. J Clin Med 2024; 13:3765. [PMID: 38999331 PMCID: PMC11242165 DOI: 10.3390/jcm13133765] [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: 05/08/2024] [Revised: 06/17/2024] [Accepted: 06/24/2024] [Indexed: 07/14/2024] Open
Abstract
Introduction: Centhaquine is a resuscitative agent that acts on α2B adrenergic receptors. Its effect on cardiac output in hypovolemic shock patients has not been reported. Methods: This pilot study was conducted in 12 hypovolemic shock patients treated with centhaquine who participated in an open-label phase IV study (NCT05956418). Echocardiography was utilized to measure stroke volume (SV), cardiac output (CO), left ventricular outflow tract velocity time integral (LVOT-VTI) and diameter (LVOTd), heart rate (HR), left ventricular ejection fraction (LVEF) and fractional shortening (LVFS), and inferior vena cava (IVC) diameter before (0 min) and 60, 120, and 300 min after centhaquine (0.01 mg/kg) iv infusion for 60 min. Results: SV was significantly increased after 60, 120, and 300 min. CO increased significantly after 120 and 300 min despite a decrease in HR. IVC diameter and LVOT-VTI at these time points significantly increased, indicating the increased venous return. LVEF and LVFS did not change, while the mean arterial pressure (MAP, mmHg) increased after 120 and 300 min. Positive correlations between IVC diameter and SV (R2 = 0.9556) and between IVC diameter and MAP (R2 = 0.8928) were observed, which indicated the effects of an increase in venous return on SV, CO, and MAP. Conclusions: Centhaquine-mediated increase in venous return is critical in enhancing SV, CO, and MAP in patients with hypovolemic shock; these changes could be pivotal for reducing shock-mediated circulatory failure, promoting tissue perfusion, and improving patient outcomes. Trial Registration: CTRI/2021/01/030263 and NCT05956418.
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Affiliation(s)
- Aman Khanna
- Aman Hospital and Research Centre Organization, Vadodara 390021, GJ, India
| | | | - Dharmesh Shah
- Pharmazz India Private Limited, Greater Noida 201307, UP, India
| | - Amaresh K Ranjan
- Pharmazz Inc., Research and Development, Willowbrook, IL 60527, USA
| | - Anil Gulati
- Pharmazz Inc., Research and Development, Willowbrook, IL 60527, USA
- Department of Bioengineering, The University of Illinois at Chicago, Chicago, IL 60607, USA
- College of Pharmacy Downers Grove, Midwestern University, Downers Grove, IL 60515, USA
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Ashine TM, Mekonnen MS, Heliso AZ, Wolde YD, Babore GO, Bushen ZD, Ereta EE, Saliya SA, Muluneh BB, Jemal SA. Incidence and predictors of acute kidney injury among adults admitted to the medical intensive care unit of a Comprehensive Specialized Hospital in Central Ethiopia. PLoS One 2024; 19:e0304006. [PMID: 38924008 PMCID: PMC11207181 DOI: 10.1371/journal.pone.0304006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/04/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Acute kidney injury is a prevalent complication in the Intensive Care Unit (ICU) and a significant global public health concern. It affects approximately 13 million individuals and contributes to nearly two million deaths worldwide. Acute kidney injury among Intensive Care Unit patients is closely associated with higher rates of morbidity and mortality. This study aims to assess the incidence of acute kidney injury and identify predictors among adult patients admitted to the medical Intensive Care Unit. METHOD A retrospective follow-up study was conducted by reviewing charts of 317 systematically selected patients admitted to the Intensive Care Unit from September 1, 2018, to August 30, 2022, in Wachemo University Nigist Ellen Mohammed Memorial Comprehensive Specialized Hospital. The extraction tool was used for the data collection, Epi-data version 4.6.0 for data entry, and STATA version 14 for data cleaning and analysis. The Kaplan-Meier, log-rank test, and life table were used to describe the data. The Cox proportional hazard regression model was used for analysis. RESULTS Among the total study participants, 128 (40.4%) developed Acute Kidney Injury (AKI). The incidence rate of Acute Kidney Injury was 30.1 (95% CI: 25.33, 35.8) per 1000 person-days of observation, with a median survival time of 23 days. It was found that patients with invasive mechanical ventilation (AHR = 2.64; 95% CI: 1.46-4.78), negative fluid balance (AHR = 2.00; 95% CI: 1.30-3.03), hypertension (AHR = 1.6; 95% CI: 1.05-2.38), and a vasopressor (AHR = 1.72; 95% CI: 1.10-2.63) were independent predictors of acute kidney injury. CONCLUSION The incidence of Acute Kidney Injury was a major concern in the ICU of the study area. In the intensive care unit (ICU), it was found that patients with vasopressors, invasive mechanical ventilation, negative fluid balance, and chronic hypertension were independent predictors of developing AKI. It would be better if clinicians in the ICU provided targeted interventions through close monitoring and evaluation of those patients with invasive ventilation, chronic hypertension, negative fluid balance, and vasopressors.
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Affiliation(s)
- Taye Mezgebu Ashine
- Department of Nursing, College of Medicine and Health Science, Wachemo University, Hosanna, Ethiopia
| | - Migbar Sibhat Mekonnen
- Department of Pediatric and Child Health Nursing, College of Medicine and Health Science, Dilla University, Dilla, Ethiopia
| | - Asnakech Zekiwos Heliso
- Department of Nursing, College of Medicine and Health Science, Wachemo University, Hosanna, Ethiopia
| | - Yesuneh Dejene Wolde
- Department of Midwifery, College of Medicine and Health Science, Wachemo University, Hosanna, Ethiopia
| | - Getachew Ossabo Babore
- Department of Nursing, College of Medicine and Health Science, Wachemo University, Hosanna, Ethiopia
| | - Zerihun Demisse Bushen
- Department of Pediatric and Child Health Nursing, College of Medicine and Health Science, Wachemo University, Hosanna, Ethiopia
| | - Elias Ezo Ereta
- Department of Nursing, College of Medicine and Health Science, Wachemo University, Hosanna, Ethiopia
| | - Sentayehu Admasu Saliya
- Department of Nursing, College of Medicine and Health Science, Wachemo University, Hosanna, Ethiopia
| | - Bethelhem Birhanu Muluneh
- Department of Pediatric and Child Health Nursing, College of Medicine and Health Science, Wachemo University, Hosanna, Ethiopia
| | - Samrawit Ali Jemal
- Department of Midwifery, College of Medicine and Health Science, Wachemo University, Hosanna, Ethiopia
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Roohani I, Moshal T, Boudiab EM, Stanton EW, Zachary P, Lo J, Carey JN, Daar DA. The Impact of Intraoperative Vasopressor Use and Fluid Status on Flap Survival in Traumatic Lower Extremity Reconstruction. J Reconstr Microsurg 2024. [PMID: 38782028 DOI: 10.1055/a-2331-8174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND Historically, the use of intraoperative vasopressors during free flap lower extremity (LE) reconstruction has been proposed to adversely affect flap survival due to concerns about compromising flap perfusion. This study aims to analyze the impact of intraoperative vasopressor use and fluid administration on postoperative outcomes in patients undergoing traumatic LE reconstruction. METHODS Patients who underwent LE free flap reconstruction between 2015 and 2023 at a Level I Trauma Center were retrospectively reviewed. Statistical analysis was conducted to evaluate the association between vasopressor use and intraoperative fluids with partial/complete flap necrosis, as well as the differential effect of vasopressor use on flap outcomes based on varying fluid levels. RESULTS A total of 105 LE flaps were performed over 8 years. Vasopressors were administered intraoperatively to 19 (18.0%) cases. Overall flap survival and limb salvage rates were 97.1 and 93.3%, respectively. Intraoperative vasopressor use decreased the overall risk of postoperative flap necrosis (OR 0.00005, 95% CI [9.11 × 10-9-0.285], p = 0.025), while a lower net fluid balance increased the risk of this outcome (OR 0.9985, 95% CI [0.9975-0.9996], p = 0.007). Further interaction analysis revealed that vasopressor use increased the risk of flap necrosis in settings with a higher net fluid balance (OR 1.0032, 95% CI [1.0008-1.0056], p-interaction =0.010). CONCLUSION This study demonstrated that intraoperative vasopressor use and adequate fluid status may be beneficial in improving flap outcomes in LE reconstruction. Vasopressor use with adequate fluid management can optimize hemodynamic stability when necessary during traumatic LE microvascular reconstruction without concern for increased risk of flap ischemia.
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Affiliation(s)
- Idean Roohani
- Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Tayla Moshal
- Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Elizabeth M Boudiab
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, California
| | - Eloise W Stanton
- Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Paige Zachary
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, California
| | - Jessica Lo
- Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Joseph N Carey
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, California
| | - David A Daar
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, California
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Chander S, Parkash O, Luhana S, Lohana AC, Sadarat F, Sapna F, Raja F, Rahaman Z, Mohammed YN, Shiwlani S, Kiran N, Wang HY, Tan S, Kumari R. Mortality, morbidity & clinical outcome with different types of vasopressors in out of hospital cardiac arrest patients- a systematic review and meta-analysis. BMC Cardiovasc Disord 2024; 24:283. [PMID: 38816786 PMCID: PMC11137957 DOI: 10.1186/s12872-024-03962-4] [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: 12/14/2023] [Accepted: 05/26/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND & OBJECTIVE Despite their continued use, the effectiveness and safety of vasopressors in post-cardiac arrest patients remain controversial. This study examined the efficacy of various vasopressors in cardiac arrest patients in terms of clinical, morbidity, and mortality outcomes. METHODS A comprehensive literature search was performed using online databases (MeSH terms: MEDLINE (Ovid), CENTRAL (Cochrane Library), Embase (Ovid), CINAHL, Scopus, and Google Scholar) from 1997 to 2023 for relevant English language studies. The primary outcomes of interest for this study included short-term survival leading to death, return of spontaneous circulation (ROSC), survival to hospital discharge, neurological outcomes, survival to hospital admission, myocardial infarction, and incidence of arrhythmias. RESULTS In this meta-analysis, 26 studies, including 16 RCTs and ten non-RCTs, were evaluated. The focus was on the efficacy of epinephrine, vasopressin, methylprednisolone, dopamine, and their combinations in medical emergencies. Epinephrine treatment was associated with better odds of survival to hospital discharge (OR = 1.52, 95%CI [1.20, 1.94]; p < 0.001) and achieving ROSC (OR = 3.60, 95% CI [3.45, 3.76], P < 0.00001)) over placebo but not in other outcomes of interest such as short-term survival/ death at 28-30 days, survival to hospital admission, or neurological function. In addition, our analysis indicates non-superiority of vasopressin or epinephrine vasopressin-plus-epinephrine therapy over epinephrine monotherapy except for survival to hospital admission where the combinatorial therapy was associated with better outcome (0.76, 95%CI [0.64, 0.92]; p = 0.004). Similarly, we noted the non-superiority of vasopressin-plus-methylprednisolone versus placebo. Finally, while higher odds of survival to hospital discharge (OR = 3.35, 95%CI [1.81, 6.2]; p < 0.001) and ROSC (OR = 2.87, 95%CI [1.97, 4.19]; p < 0.001) favoring placebo over VSE therapy were observed, the risk of lethal arrhythmia was not statistically significant. There was insufficient literature to assess the effects of dopamine versus other treatment modalities meta-analytically. CONCLUSION This meta-analysis indicated that only epinephrine yielded superior outcomes among vasopressors than placebo, albeit limited to survival to hospital discharge and ROSC. Additionally, we demonstrate the non-superiority of vasopressin over epinephrine, although vasopressin could not be compared to placebo due to the paucity of data. The addition of vasopressin to epinephrine treatment only improved survival to hospital admission.
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Affiliation(s)
- Subhash Chander
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Om Parkash
- Department of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Sindhu Luhana
- Department of Medicine, AGA khan University Hospital, Karachi, Pakistan
| | - Abhi Chand Lohana
- Department of Medicine, Western Michigan University, Kalamazoo, WV, USA
| | - Fnu Sadarat
- Department of Medicine, University at Buffalo, Buffalo, NY, USA
| | - Fnu Sapna
- Department of Pathology, Montefiore Medical Center, Bronx, NY, USA
| | - Fnu Raja
- Department of Pathology, MetroHealth Hospital, Cleveland, OH, USA
| | - Zubair Rahaman
- Department of Medicine, University at Buffalo, Buffalo, NY, USA
| | | | - Sheena Shiwlani
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nfn Kiran
- Department of Pathology, Northwell Health Hospital, New York, NY, USA
| | - Hong Yu Wang
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sam Tan
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Roopa Kumari
- Department of Pathology, Icahn School of Medicine, Mount Sinai, New York, NY, USA
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Bode C, Preissl S, Hein L, Lother A. Catecholamine treatment induces reversible heart injury and cardiomyocyte gene expression. Intensive Care Med Exp 2024; 12:48. [PMID: 38733526 PMCID: PMC11088585 DOI: 10.1186/s40635-024-00632-9] [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: 03/25/2024] [Accepted: 05/07/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Catecholamines are commonly used as therapeutic drugs in intensive care medicine to maintain sufficient organ perfusion during shock. However, excessive or sustained adrenergic activation drives detrimental cardiac remodeling and may lead to heart failure. Whether catecholamine treatment in absence of heart failure causes persistent cardiac injury, is uncertain. In this experimental study, we assessed the course of cardiac remodeling and recovery during and after prolonged catecholamine treatment and investigated the molecular mechanisms involved. RESULTS C57BL/6N wild-type mice were assigned to 14 days catecholamine treatment with isoprenaline and phenylephrine (IsoPE), treatment with IsoPE and subsequent recovery, or healthy control groups. IsoPE improved left ventricular contractility but caused substantial cardiac fibrosis and hypertrophy. However, after discontinuation of catecholamine treatment, these alterations were largely reversible. To uncover the molecular mechanisms involved, we performed RNA sequencing from isolated cardiomyocyte nuclei. IsoPE treatment resulted in a transient upregulation of genes related to extracellular matrix formation and transforming growth factor signaling. While components of adrenergic receptor signaling were downregulated during catecholamine treatment, we observed an upregulation of endothelin-1 and its receptors in cardiomyocytes, indicating crosstalk between both signaling pathways. To follow this finding, we treated mice with endothelin-1. Compared to IsoPE, treatment with endothelin-1 induced minor but longer lasting changes in cardiomyocyte gene expression. DNA methylation-guided analysis of enhancer regions identified immediate early transcription factors such as AP-1 family members Jun and Fos as key drivers of pathological gene expression following catecholamine treatment. CONCLUSIONS The results from this study show that prolonged catecholamine exposure induces adverse cardiac remodeling and gene expression before the onset of left ventricular dysfunction which has implications for clinical practice. The observed changes depend on the type of stimulus and are largely reversible after discontinuation of catecholamine treatment. Crosstalk with endothelin signaling and the downstream transcription factors identified in this study provide new opportunities for more targeted therapeutic approaches that may help to separate desired from undesired effects of catecholamine treatment.
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Affiliation(s)
- Christine Bode
- Institute of Experimental and Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sebastian Preissl
- Institute of Experimental and Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lutz Hein
- Institute of Experimental and Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- BIOSS Centre for Biological Signaling Studies, University of Freiburg, Freiburg, Germany
| | - Achim Lother
- Institute of Experimental and Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
- Interdisciplinary Medical Intensive Care, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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Derry KH, Rocks MC, Izard P, Nicholas RS, Sommer PM, Hacquebord JH. Limb Necrosis in the Setting of Vasopressor Use. Am J Crit Care 2024; 33:226-233. [PMID: 38688844 DOI: 10.4037/ajcc2024171] [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: 05/02/2024]
Abstract
BACKGROUND It remains poorly understood why only some hemodynamically unstable patients who receive aggressive treatment with vasopressor medications develop limb necrosis. OBJECTIVE To determine the incidence of limb necrosis and the factors associated with it following high-dose vasopressor therapy. METHODS A retrospective case-control medical records review was performed of patients aged 18 to 89 years who received vasopressor therapy between 2012 and 2021 in a single academic medical center. The study population was stratified by the development of limb necrosis following vasopressor use. Patients who experienced necrosis were compared with age- and sex-matched controls who did not experience necrosis. Demographic information, comorbidities, and medication details were recorded. RESULTS The incidence of limb necrosis following vasopressor administration was 0.25%. Neither baseline demographics nor medical comorbidities differed significantly between groups. Necrosis was present in the same limb as the arterial catheter most often for femoral catheters. The vasopressor dose administered was significantly higher in the necrosis group than in the control group for ephedrine (P = .02) but not for the other agents. The duration of therapy was significantly longer in the necrosis group than in the control group for norepinephrine (P = .001), epinephrine (P = .04), and ephedrine (P = .01). The duration of vasopressin administration did not differ significantly between groups. CONCLUSION The findings of this study suggest that medication-specific factors, rather than patient and disease characteristics, should guide clinical management of necrosis in the setting of vasopressor administration.
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Affiliation(s)
- Kendall H Derry
- Kendall H. Derry is a resident physician, Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Madeline C Rocks
- Madeline C. Rocks is a medical student, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Paul Izard
- Paul Izard is a medical student, Harvard Medical School, Boston, Massachusetts
| | - Rebecca S Nicholas
- Rebecca S. Nicholas is an attending physician, Division of Hand Surgery, Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Philip M Sommer
- Philip M. Sommer is an attending physician, Perioperative Care and Pain Medicine Division, Department of Anesthesiology, NYU Langone Health, New York, New York
| | - Jacques H Hacquebord
- Jacques H. Hacquebord is an attending physician and chief, Division of Hand Surgery, Department of Orthopedic Surgery, Hansjorg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
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Sanin GD, Cambronero GE, Wood EC, Patterson JW, Lane MR, Renaldo AC, Laingen BE, Rahbar E, Adams JY, Johnson A, Neff LP, Williams TK. MAN VERSUS MACHINE: PROVIDER DIRECTED VERSUS PRECISION AUTOMATED CRITICAL CARE MANAGEMENT IN A PORCINE MODEL OF DISTRIBUTIVE SHOCK. Shock 2024; 61:758-765. [PMID: 38526148 PMCID: PMC11328591 DOI: 10.1097/shk.0000000000002345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
ABSTRACT Background: Critical care management of shock is a labor-intensive process. Precision Automated Critical Care Management (PACC-MAN) is an automated closed-loop system incorporating physiologic and hemodynamic inputs to deliver interventions while avoiding excessive fluid or vasopressor administration. To understand PACC-MAN efficacy, we compared PACC-MAN to provider-directed management (PDM). We hypothesized that PACC-MAN would achieve equivalent resuscitation outcomes to PDM while maintaining normotension with lower fluid and vasopressor requirements. Methods : Twelve swine underwent 30% controlled hemorrhage over 30 min, followed by 45 min of aortic occlusion to generate a vasoplegic shock state, transfusion to euvolemia, and randomization to PACC-MAN or PDM for 4.25 h. Primary outcomes were total crystalloid volume, vasopressor administration, total time spent at hypotension (mean arterial blood pressure <60 mm Hg), and total number of interventions. Results : Weight-based fluid volumes were similar between PACC-MAN and PDM; median and IQR are reported (73.1 mL/kg [59.0-78.7] vs. 87.1 mL/kg [79.4-91.8], P = 0.07). There was no statistical difference in cumulative norepinephrine (PACC-MAN: 33.4 μg/kg [27.1-44.6] vs. PDM: 7.5 [3.3-24.2] μg/kg, P = 0.09). The median percentage of time spent at hypotension was equivalent (PACC-MAN: 6.2% [3.6-7.4] and PDM: 3.1% [1.3-6.6], P = 0.23). Urine outputs were similar between PACC-MAN and PDM (14.0 mL/kg vs. 21.5 mL/kg, P = 0.13). Conclusion : Automated resuscitation achieves equivalent resuscitation outcomes to direct human intervention in this shock model. This study provides the first translational experience with the PACC-MAN system versus PDM.
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Affiliation(s)
- Gloria D Sanin
- Department of General Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Gabriel E Cambronero
- Department of General Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Elizabeth C Wood
- Department of General Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - James W Patterson
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Magan R Lane
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Antonio C Renaldo
- Department of Biomedical Engineering, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Bonnie E Laingen
- Department of General Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Elaheh Rahbar
- Department of Biomedical Engineering, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Jason Y Adams
- Department of Pulmonary, Critical Care, and Sleep Medicine, University of California, Davis, California
| | - Austin Johnson
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Lucas P Neff
- Department of General Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Timothy K Williams
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
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Ballarin RS, Lazzarin T, Zornoff L, Azevedo PS, Pereira FWL, Tanni SE, Minicucci MF. Methylene blue in sepsis and septic shock: a systematic review and meta-analysis. Front Med (Lausanne) 2024; 11:1366062. [PMID: 38698779 PMCID: PMC11063345 DOI: 10.3389/fmed.2024.1366062] [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: 01/05/2024] [Accepted: 03/15/2024] [Indexed: 05/05/2024] Open
Abstract
Background Methylene blue is an interesting approach in reducing fluid overload and vasoactive drug administration in vasodilatory shock. The inhibition of guanylate cyclase induced by methylene blue infusion reduces nitric oxide production and improves vasoconstriction. This systematic review and meta-analysis aimed to assess the effects of methylene blue administration compared to placebo on the hemodynamic status and clinical outcomes in patients with sepsis and septic shock. Methods The authors specifically included randomized controlled trials that compared the use of methylene blue with placebo in adult patients with sepsis and septic shock. The outcomes were length of intensive care unit stay, hemodynamic parameters [vasopressor use], and days on mechanical ventilation. We also evaluated the abnormal levels of methemoglobinemia. This systematic review and meta-analysis were recorded in PROSPERO with the ID CRD42023423470. Results During the initial search, a total of 1,014 records were identified, out of which 393 were duplicates. Fourteen citations were selected for detailed reading, and three were selected for inclusion. The studies enrolled 141 patients, with 70 of them in the methylene blue group and 71 of them in the control group. Methylene blue treatment was associated with a lower length of intensive care unit stay (MD -1.58; 95%CI -2.97, -0.20; I2 = 25%; p = 0.03), decreased days on mechanical ventilation (MD -0.72; 95%CI -1.26, -0.17; I2 = 0%; p = 0.010), and a shorter time to vasopressor discontinuation (MD -31.49; 95%CI -46.02, -16.96; I2 = 0%; p < 0.0001). No association was found with methemoglobinemia. Conclusion Administering methylene blue to patients with sepsis and septic shock leads to reduced time to vasopressor discontinuation, length of intensive care unit stay, and days on mechanical ventilation. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023423470, CRD42023423470.
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Mergoum AM, Rhone AR, Larson NJ, Dries DJ, Blondeau B, Rogers FB. A Guide to the Use of Vasopressors and Inotropes for Patients in Shock. J Intensive Care Med 2024:8850666241246230. [PMID: 38613381 DOI: 10.1177/08850666241246230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
Shock is a life-threatening circulatory failure that results in inadequate tissue perfusion and oxygenation. Vasopressors and inotropes are vasoactive medications that are vital in increasing systemic vascular resistance and cardiac contractility, respectively, in patients presenting with shock. To be well versed in using these agents is an important skill to have in the critical care setting where patients can frequently exhibit symptoms of shock. In this review, we will discuss the pathophysiological mechanisms of shock and evaluate the current evidence behind the management of shock with an emphasis on vasopressors and inotropes.
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Affiliation(s)
| | | | | | - David J Dries
- Department of Surgery, Regions Hospital, Saint Paul, MN, USA
| | - Benoit Blondeau
- Department of Surgery, Regions Hospital, Saint Paul, MN, USA
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15
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Pansiritanachot W, Vathanavalun O, Chakorn T. Early post-resuscitation outcomes in patients receiving norepinephrine versus epinephrine for post-resuscitation shock in a non-trauma emergency department: A parallel-group, open-label, feasibility randomized controlled trial. Resusc Plus 2024; 17:100551. [PMID: 38313404 PMCID: PMC10834978 DOI: 10.1016/j.resplu.2024.100551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/22/2023] [Accepted: 01/08/2024] [Indexed: 02/06/2024] Open
Abstract
Background Post-resuscitation shock is the main cause of early death in post-cardiac arrest patients. To date, no randomized trial compares the efficacy between norepinephrine and epinephrine in post-resuscitation shock patients. Objectives This study aimed to assess the feasibility of the study protocol, and explore potential differences in efficacy and adverse events between norepinephrine and epinephrine in post-resuscitation shock patients. Methods This single-center, parallel-group, open-label, feasibility randomized controlled trial included adult non-traumatic cardiac arrest patients who had post-resuscitation shock within one hour after successful resuscitation. Patients were randomized to receive norepinephrine or epinephrine in a 1:1 ratio. Feasibility outcomes were reported descriptively and narratively. Exploratory analyses were performed to compare the efficacy and adverse events. Results A total of 40 patients were equally allocated. Most feasibility goals were achieved. All patients received the allocated intervention with no withdrawals. Ten (50%) patients in the norepinephrine group and 15 (75%) patients in the epinephrine group achieved the target blood pressure by the protocol with a median time of 42 and 39 min, respectively. However, the protocol deviated in 10 (25%) patients and the recruitment rate did not reach the acceptable threshold. The vasopressor dose to achieve the target blood pressure was significantly lower in the norepinephrine group. No significant differences in mortality rates and adverse outcomes were observed in the exploratory analyses. Conclusion It is feasible to conduct the definitive trial comparing early post-resuscitation outcomes in patients receiving NE versus EPI for post-resuscitation shock. Some protocol modifications are necessary.
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Affiliation(s)
- Wasin Pansiritanachot
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Siriraj, Bangkoknoi, Bangkok 10700, Thailand
| | - Orapim Vathanavalun
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Siriraj, Bangkoknoi, Bangkok 10700, Thailand
| | - Tipa Chakorn
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Siriraj, Bangkoknoi, Bangkok 10700, Thailand
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16
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Yang J, Zou X, Wang R, Kang Y, Ou X, Wang B. MEAN ARTERIAL PRESSURE/NOREPINEPHRINE EQUIVALENT DOSE INDEX AS AN EARLY MEASURE FOR MORTALITY RISK IN PATIENTS WITH SHOCK ON VASOPRESSORS. Shock 2024; 61:253-259. [PMID: 38157472 DOI: 10.1097/shk.0000000000002298] [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: 01/03/2024]
Abstract
ABSTRACT Purpose: We aimed to investigate the association between the early mean arterial pressure (MAP)/norepinephrine equivalent dose (NEQ) index and mortality risk in patients with shock on vasopressors and further identify the breakpoint value of the MAP/NEQ index for high mortality risk. Methods: Based on the Medical Information Mart for Intensive Care IV database, we conducted a retrospective cohort study involving 19,539 eligible intensive care unit records assigned to three groups (first tertile, second tertile, and third tertile) by different MAP/NEQ indexes within 24 h of intensive care unit admission. The study outcomes were 7-, 14-, 21-, and 28-day mortality. A Cox model was used to examine the risk of mortality following different MAP/NEQ indexes. The receiving operating characteristic curve was used to evaluate the predictive ability of the MAP/NEQ index. The restricted cubic spline was applied to fit the flexible correlation between the MAP/NEQ index and risk of mortality, and segmented regression was further used to identify the breakpoint value of the MAP/NEQ index for high mortality risk. Results: Multivariate Cox analysis showed that a high MAP/NEQ index was independently associated with decreased mortality risks. The areas under the receiving operating characteristic curve of the MAP/NEQ index for different mortality outcomes were nearly 0.7. The MAP/NEQ index showed an L-shaped association with mortality outcomes or mortality risks. Exploration of the breakpoint value of the MAP/NEQ index suggested that a MAP/NEQ index less than 183 might be associated with a significantly increased mortality risk. Conclusions: An early low MAP/NEQ index was indicative of poor prognosis in patients with shock on vasopressors.
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Affiliation(s)
- Jie Yang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xia Zou
- Clinical Research Management Department, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Ruoran Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xiaofeng Ou
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Bo Wang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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17
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Gales K, Hunt M, Marler J. The Association of Elevated Lactate With Multiple Vasopressor Administration in Patients With Septic Shock: A Retrospective Cohort Study. J Pharm Pract 2024; 37:110-117. [PMID: 36124978 DOI: 10.1177/08971900221128640] [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] [Indexed: 11/15/2022]
Abstract
Purpose: In patients with septic shock and elevated lactate, there is limited evidence evaluating supplementary vasopressor use beyond vasopressin (AVP) and norepinephrine (NE). The purpose of this study is to describe vasopressor utilization and clinical outcomes based on lactate level. Methods: We conducted a retrospective study of patients with septic shock requiring NE. Patients were divided into 2 groups: baseline lactate level of ≥4 mmol/L (lactate group) or <4 mmol/L (control group). The primary outcome was supplementary utilization of AVP, phenylephrine (PE), epinephrine, and dopamine, in addition to background NE therapy between the 2 patient groups. Results: A total of 100 patients in each group were included. Mean baseline lactate was 7.6 mmol/L and 2.3 mmol/L in the study and control groups, respectively (P < .01). Combination therapy with NE plus AVP (55% vs 26%; P < .01), NE plus PE (26% vs 3%; P < .01), and NE, AVP, plus PE (17% vs 0%; P < .01) was more common in the lactate group. On regression analysis, lactate group was a predictor of using AVP (OR 3.0; 95% CI 1.6-5.9), PE (OR 7.5; 95% CI 2.1-26.7), and AVP plus PE (OR 11.1; 95% CI 2.5-49.7). Conclusions: In this small retrospective study, multiple vasopressor use was high in patients with severely elevated lactate. The optimal vasopressor regimen in this patient population needs further investigation.
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Affiliation(s)
- Kee Gales
- Department of Pharmacy, Veterans Affairs Hospital, Memphis, TN, USA
| | - Molly Hunt
- Department of Pharmacy, Veterans Affairs Hospital, Memphis, TN, USA
| | - Jacob Marler
- Department of Pharmacy, Veterans Affairs Hospital, Memphis, TN, USA
- Department of Clinical Pharmacy, University of Tennessee Health Sciences Center (UTHSC), Memphis, TN, USA
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18
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DeMillard L, Thuyns M. Implementation and Evaluation of Weight-Based Vasopressors in Intensive Care Units. J Pharm Technol 2024; 40:23-29. [PMID: 38318260 PMCID: PMC10838541 DOI: 10.1177/87551225231217905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Abstract
Background: Vasopressors, including norepinephrine, epinephrine, and phenylephrine are commonly used to maintain mean arterial pressure (MAP) in critically ill patients. Despite their frequent use, the optimal dosing strategy for vasopressors remains understudied. Objective: The purpose of this study is to evaluate the implementation of a weight-based (WB) dosing strategy using ideal body weight compared to a non-weight-based (NWB) dosing strategy for vasopressors in critically ill patients. Methods: This is a retrospective chart review of patients admitted to intensive care units receiving vasopressor medications for greater than or equal to 4 hours. Patients received either an NWB or a WB vasopressor dosing strategy. The primary endpoint was the time to achieve goal MAP. Results: This study included 153 patients in the NWB vasopressor dosing group and 183 in the WB dosing group. The median time to achieve goal MAP in the NWB group was 24 minutes versus 21 minutes in the WB group (P = 0.1713). There were no significant differences in secondary outcomes including number of vasoactive agents required, hospital length of stay, and duration of mechanical ventilation. Subgroup analysis of patients with extremes of body mass index did not show a difference in time to achieve goal MAP. In a subgroup analysis of patients with septic shock, a higher percentage of patients in the WB group received corticosteroids than the NWB group patients (14% vs. 54%; P ≤ 0.001). Conclusion and relevance: There was no difference in time to achieve goal MAP when using a WB or NWB vasopressor dosing approach. Institutions should employ a consistent dosing strategy for vasopressors with either an NWB or WB approach.
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Affiliation(s)
- Laurie DeMillard
- Department of Pharmacy, Renown Regional Medical Center, Reno, NV, USA
| | - Michael Thuyns
- Department of Pharmacy, Renown Regional Medical Center, Reno, NV, USA
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McCloskey MM, Gibson GA, Pope HE, Giacomino BD, Hampton N, Micek ST, Kollef MH, Betthauser KD. Comment: Does Early Vasopressin in Septic Shock Improve Outcomes? An Important Piece to This Emerging Puzzle Has Arrived. Ann Pharmacother 2024; 58:89-90. [PMID: 37056047 DOI: 10.1177/10600280221096886] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
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20
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Abu Sardaneh A, Penm J, Oliver M, Gattas D, McLachlan AJ, James C, Cella C, Aljuhani O, Acquisto NM, Patanwala AE. International pharmacy survey of peripheral vasopressor infusions in critical care (INFUSE). J Crit Care 2023; 78:154376. [PMID: 37536012 DOI: 10.1016/j.jcrc.2023.154376] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 07/08/2023] [Accepted: 07/10/2023] [Indexed: 08/05/2023]
Abstract
PURPOSE The primary objective was to determine the proportion of hospitals that administered norepinephrine peripheral vasopressor infusions (PVIs) in critically ill adult patients. Secondary objectives were to describe how norepinephrine is used such as the maximum duration, infusion rate and concentration, and to determine the most common first-line PVI used by country. MATERIALS AND METHODS An international multi-centre cross-sectional survey study was conducted in adult intensive care units in Australia, US, UK, Canada, and Saudi Arabia. RESULTS Critical care pharmacists from 132 institutions responded to the survey. Norepinephrine PVIs were utilised in 86% of institutions (n = 113/132). The median maximum duration of norepinephrine PVIs was 24 h (IQR 24-24) (n = 57/113). The most common maximum norepinephrine PVI rate was between 11 and 20 μg/min (n = 16/113). The most common maximum norepinephrine PVI concentration was 16 μg/mL (n = 60/113). Half of the institutions had a preference to administer another PVI over norepinephrine as a first-line agent (n = 66/132). The most common alternative PVI used by country was: US (phenylephrine 41%, n = 37/90), Canada (dopamine 31%, n = 5/16), UK (metaraminol 82%, n = 9/11), and Australia (metaraminol 89%, n = 8/9). CONCLUSIONS There is variability in clinical practice regarding PVI administration in critically ill adult patients dependent on drug availability and local institutional recommendations.
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Affiliation(s)
- Arwa Abu Sardaneh
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Pharmacy, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Jonathan Penm
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Pharmacy, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Matthew Oliver
- Department of Emergency Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - David Gattas
- School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Intensive Care Service, Royal Prince Alfred Hospital, Sydney, Australia
| | - Andrew J McLachlan
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Christie James
- Department of Pharmacy, Grange University Hospital, Cwmbran, Wales, United Kingdom
| | - Christina Cella
- Canadian Society of Hospital Pharmacists, Ottawa, Ontario, Canada
| | - Ohoud Aljuhani
- Pharmacy Practice Department, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Pharmacy, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Nicole M Acquisto
- Department of Pharmacy, University of Rochester Medical Center, Rochester, NY, United States; Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Asad E Patanwala
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Pharmacy, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
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Wu H, Wu Z, Ye D, Li H, Dai Y, Wang Z, Bao J, Xu Y, He X, Wang X, Dai X. Prognostic value analysis of cholesterol and cholesterol homeostasis related genes in breast cancer by Mendelian randomization and multi-omics machine learning. Front Oncol 2023; 13:1246880. [PMID: 38023262 PMCID: PMC10661325 DOI: 10.3389/fonc.2023.1246880] [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: 06/24/2023] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction The high incidence of breast cancer (BC) prompted us to explore more factors that might affect its occurrence, development, treatment, and also recurrence. Dysregulation of cholesterol metabolism has been widely observed in BC; however, the detailed role of how cholesterol metabolism affects chemo-sensitivity, and immune response, as well as the clinical outcome of BC is unknown. Methods With Mendelian randomization (MR) analysis, the potential causal relationship between genetic variants of cholesterol and BC risk was assessed first. Then we analyzed 73 cholesterol homeostasis-related genes (CHGs) in BC samples and their expression patterns in the TCGA cohort with consensus clustering analysis, aiming to figure out the relationship between cholesterol homeostasis and BC prognosis. Based on the CHG analysis, we established a CAG_score used for predicting therapeutic response and overall survival (OS) of BC patients. Furthermore, a machine learning method was adopted to accurately predict the prognosis of BC patients by comparing multi-omics differences of different risk groups. Results We observed that the alterations in plasma cholesterol appear to be correlative with the venture of BC (MR Egger, OR: 0.54, 95% CI: 0.35-0.84, p<0.006). The expression patterns of CHGs were classified into two distinct groups(C1 and C2). Notably, the C1 group exhibited a favorable prognosis characterized by a suppressed immune response and enhanced cholesterol metabolism in comparison to the C2 group. In addition, high CHG score were accompanied by high performance of tumor angiogenesis genes. Interestingly, the expression of vascular genes (CDH5, CLDN5, TIE1, JAM2, TEK) is lower in patients with high expression of CHGs, which means that these patients have poorer vascular stability. The CAG_score exhibits robust predictive capability for the immune microenvironment characteristics and prognosis of patients(AUC=0.79). It can also optimize the administration of various first-line drugs, including AKT inhibitors VIII Imatinib, Crizotinib, Saracatinib, Erlotinib, Dasatinib, Rapamycin, Roscovitine and Shikonin in BC patients. Finally, we employed machine learning techniques to construct a multi-omics prediction model(Risklight),with an area under the feature curve (AUC) of up to 0.89. Conclusion With the help of CAG_score and Risklight, we reveal the signature of cholesterol homeostasis-related genes for angiogenesis, immune responses, and the therapeutic response in breast cancer, which contributes to precision medicine and improved prognosis of BC.
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Affiliation(s)
- Haodong Wu
- Department of Breast Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Department of Burns and Skin Repair Surgery, The Third Affiliated Hospital of Wenzhou Medical University, Ruian, Zhejiang, China
- Key Laboratory of Clinical Laboratory Diagnostics (Ministry of Education), The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhixuan Wu
- Department of Breast Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Department of Burns and Skin Repair Surgery, The Third Affiliated Hospital of Wenzhou Medical University, Ruian, Zhejiang, China
| | - Daijiao Ye
- Medical Research Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hongfeng Li
- Department of Breast Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yinwei Dai
- Department of Breast Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ziqiong Wang
- Department of Breast Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jingxia Bao
- Department of Breast Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yiying Xu
- Department of Breast Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaofei He
- Medical Research Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaowu Wang
- Department of Burns and Skin Repair Surgery, The Third Affiliated Hospital of Wenzhou Medical University, Ruian, Zhejiang, China
| | - Xuanxuan Dai
- Department of Breast Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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22
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Bauer SR, Gellatly RM, Erstad BL. Precision fluid and vasoactive drug therapy for critically ill patients. Pharmacotherapy 2023; 43:1182-1193. [PMID: 36606689 PMCID: PMC10323046 DOI: 10.1002/phar.2763] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/03/2022] [Accepted: 10/30/2022] [Indexed: 01/07/2023]
Abstract
There are several clinical practice guidelines concerning the use of fluid and vasoactive drug therapies in critically ill adult patients, but the recommendations in these guidelines are often based on low-quality evidence. Further, some were compiled prior to the publication of landmark clinical trials, particularly in the comparison of balanced crystalloid and normal saline. An important consideration in the treatment of critically ill patients is the application of precision medicine to provide the most effective care to groups of patients most likely to benefit from the therapy. Although not currently widely integrated into these practice guidelines, the utility of precision medicine in critical illness is a recognized research priority for fluid and vasoactive therapy management. The purpose of this narrative review was to illustrate the evaluation and challenges of providing precision fluid and vasoactive therapies to adult critically ill patients. The review includes a discussion of important investigations published after the release of currently available clinical practice guidelines to provide insight into how recommendations and research priorities may change future guidelines and bedside care for critically ill patients.
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Affiliation(s)
- Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rochelle M Gellatly
- Pharmacy Department, Surrey Memorial Hospital, Surrey, British Columbia, Canada
| | - Brian L Erstad
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, Arizona, USA
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23
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Johannsen CM, Nørholt C, Baltsen C, Eggertsen MA, Magnussen A, Vormfenne L, Mortensen SØ, Hansen ESS, Vammen L, Andersen LW, Granfeldt A. The effects of methylene blue during and after cardiac arrest in a porcine model; a randomized, blinded, placebo-controlled study. Am J Emerg Med 2023; 73:145-153. [PMID: 37659143 DOI: 10.1016/j.ajem.2023.08.041] [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: 03/29/2023] [Revised: 07/04/2023] [Accepted: 08/22/2023] [Indexed: 09/04/2023] Open
Abstract
PURPOSE To evaluate the effect of methylene blue administered as a bolus on return of spontaneous circulation (ROSC), lactate levels, vasopressor requirements, and markers of neurological injury in a clinically relevant pig model of cardiac arrest. MATERIALS AND METHODS 40 anesthetized pigs were subjected to acute myocardial infarction and 7 min of untreated cardiac arrest. Animals were randomized into three groups: one group received saline only (controls), one group received 2 mg/kg methylene blue and saline (MB + saline), and one group received two doses of 2 mg/kg methylene blue (MB + MB). The first intervention was given after the 3rd rhythm analysis, while the second dose was administered one hour after achieving ROSC. Animals underwent intensive care and observation for six hours, followed by cerebral magnetic resonance imaging (MRI). The primary outcome for this study was development in lactate levels after cardiac arrest. Categorical data were compared using Fisher's exact test and pointwise data were analyzed using one-way analysis of variance (ANOVA) or equivalent non-parametric test. Continuous data collected over time were analyzed using a linear mixed effects model. A value of p < .05 was considered statistically significant. RESULTS Lactate levels increased in all groups after cardiac arrest and resuscitation, however lactate levels in the MB + MB group decreased significantly faster compared with the control group (p = .007) and the MB + saline group (p = .02). The proportion of animals achieving initial ROSC was similar across groups: 11/13 (85%) in the control group, 10/13 (77%) in the MB + saline group, and 12/14 (86%) in the MB + MB group (p = .81). Time to ROSC did not differ between groups (p = .67). There was no significant difference in accumulated norepinephrine dose between groups (p = .15). Cerebral glycerol levels were significantly lower in the MB + MB group after resuscitation compared with control group (p = .03). However, MRI data revealed no difference in apparent diffusion coefficient, cerebral blood flow, or dynamic contrast enhanced MR perfusion between groups. CONCLUSION Treatment with a bolus of methylene blue during cardiac arrest and after resuscitation did not significantly improve hemodynamic function. A bolus of methylene blue did not yield the neuroprotective effects that have previously been described in animals receiving methylene blue as an infusion.
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Affiliation(s)
- Cecilie Munch Johannsen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Casper Nørholt
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Cecilie Baltsen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Mark A Eggertsen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | | | | | | | - Esben Søvsø Szocska Hansen
- Department of Clinical Medicine, Aarhus University, Denmark; MR Research Centre, Aarhus University, Denmark
| | - Lauge Vammen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Lars W Andersen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark; Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
| | - Asger Granfeldt
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark.
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Abstract
Shock occurs when there is energy failure due to inadequate oxygen/glucose delivery to meet metabolic demands. Shock is a leading cause of death and disability in children worldwide. Types of shock include hypovolemic, cardiogenic, distributive, and obstructive. This review provides an overview of the epidemiology, pathophysiology, and clinical signs and symptoms of each of these types of shock, followed by a discussion of advancements in diagnostic tests and tools and management/treatment principles for different categories of shock.
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Affiliation(s)
- Ashley Bjorklund
- Department of Pediatrics, Hennepin Healthcare, Minneapolis, MN
- Division of Pediatric Critical Care, University of Minnesota, Minneapolis, MN
| | - Joseph Resch
- Department of Pediatrics, Hennepin Healthcare, Minneapolis, MN
- Division of Pediatric Critical Care, University of Minnesota, Minneapolis, MN
| | - Tina Slusher
- Department of Pediatrics, Hennepin Healthcare, Minneapolis, MN
- Division of Pediatric Critical Care, University of Minnesota, Minneapolis, MN
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25
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Trieu NHK, Pham HM, Mai AT. Initial management of acute circulatory failure in amniotic fluid embolism: A narrative review. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2023; 52:101288. [DOI: 10.1016/j.tacc.2023.101288] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
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26
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Ganapathy AS, Patel NT, Wiley AP, Lane MR, Jordan JE, Johnson MA, Adams JY, Neff LP, Williams TK. Precision Automated Critical Care Management: Closed-loop critical care for the treatment of distributive shock in a swine model of ischemia-reperfusion. J Trauma Acute Care Surg 2023; 95:490-496. [PMID: 37314508 PMCID: PMC10545062 DOI: 10.1097/ta.0000000000004054] [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: 08/02/2022] [Revised: 05/01/2023] [Accepted: 05/02/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Goal-directed blood pressure management in the intensive care unit can improve trauma outcomes but is labor-intensive. Automated critical care systems can deliver scaled interventions to avoid excessive fluid or vasopressor administration. We compared a first-generation automated drug and fluid delivery platform, Precision Automated Critical Care Management (PACC-MAN), to a more refined algorithm, incorporating additional physiologic inputs and therapeutics. We hypothesized that the enhanced algorithm would achieve equivalent resuscitation endpoints with less crystalloid utilization in the setting of distributive shock. METHODS Twelve swine underwent 30% hemorrhage and 30 minutes of aortic occlusion to induce an ischemia-reperfusion injury and distributive shock state. Next, animals were transfused to euvolemia and randomized into a standardized critical care (SCC) of PACC-MAN or an enhanced version (SCC+) for 4.25 hours. SCC+ incorporated lactate and urine output to assess global response to resuscitation and added vasopressin as an adjunct to norepinephrine at certain thresholds. Primary and secondary outcomes were decreased crystalloid administration and time at goal blood pressure, respectively. RESULTS Weight-based fluid bolus volume was lower in SCC+ compared with SCC (26.9 mL/kg vs. 67.5 mL/kg, p = 0.02). Cumulative norepinephrine dose required was not significantly different (SCC+: 26.9 μg/kg vs. SCC: 13.76 μg/kg, p = 0.24). Three of 6 animals (50%) in SCC+ triggered vasopressin as an adjunct. Percent time spent between 60 mm Hg and 70 mm Hg, terminal creatinine and lactate, and weight-adjusted cumulative urine output were equivalent. CONCLUSION Refinement of the PACC-MAN algorithm decreased crystalloid administration without sacrificing time in normotension, reducing urine output, increasing vasopressor support, or elevating biomarkers of organ damage. Iterative improvements in automated critical care systems to achieve target hemodynamics in a distributive-shock model are feasible.
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27
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Zhou HX, Yang CF, Wang HY, Teng Y, He HY. Should we initiate vasopressors earlier in patients with septic shock: A mini systemic review. World J Crit Care Med 2023; 12:204-216. [PMID: 37745258 PMCID: PMC10515096 DOI: 10.5492/wjccm.v12.i4.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/28/2023] [Accepted: 07/17/2023] [Indexed: 09/05/2023] Open
Abstract
Septic shock treatment remains a major challenge for intensive care units, despite the recent prominent advances in both management and outcomes. Vasopressors serve as a cornerstone of septic shock therapy, but there is still controversy over the timing of administration. Specifically, it remains unclear whether vasopressors should be used early in the course of treatment. Here, we provide a systematic review of the literature on the timing of vasopressor administration. Research was systematically identified through PubMed, Embase and Cochrane searching according to PRISMA guidelines. Fourteen studies met the eligibility criteria and were included in the review. The pathophysiological basis for early vasopressor use was classified, with the exploration on indications for the early administration of mono-vasopressors or their combination with vasopressin or angiotensinII. We found that mortality was 28.1%-47.7% in the early vasopressors group, and 33.6%-54.5% in the control group. We also investigated the issue of vasopressor responsiveness. Furthermore, we acknowledged the subsequent challenge of administration of high-dose norepinephrine via peripheral veins with early vasopressor use. Based on the literature review, we propose a possible protocol for the early initiation of vasopressors in septic shock resuscitation.
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Affiliation(s)
- Hang-Xiang Zhou
- Department of Critical Care Medicine, Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou Province, China
- Department of Critical Care Medicine, The Sixth Hospital of Guiyang, Guiyang 550002, Guizhou Province, China
| | - Chun-Fu Yang
- Department of Critical Care Medicine, The Sixth Hospital of Guiyang, Guiyang 550002, Guizhou Province, China
- Department of Respiratory Medicine, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang 550002, Guizhou Province, China
| | - He-Yan Wang
- Department of Critical Care Medicine, The Sixth Hospital of Guiyang, Guiyang 550002, Guizhou Province, China
- School of Basic Medicine, Guizhou University of Traditional Chinese Medicine, Guiyang 550002, Guizhou Province, China
| | - Yin Teng
- Department of Thoracic Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou Province, China
| | - Hang-Yong He
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Beijing 100020, China
- Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Beijing 100020, China
- Beijing Key Laboratory of Respiratory and Pulmonary Circulation, Beijing Chao-Yang Hospital, Beijing 100020, China
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28
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Suh GJ, shin TG, Kwon WY, Kim K, Jo YH, Choi SH, Chung SP, Kim WY. Hemodynamic management of septic shock: beyond the Surviving Sepsis Campaign guidelines. Clin Exp Emerg Med 2023; 10:255-264. [PMID: 37439141 PMCID: PMC10579730 DOI: 10.15441/ceem.23.065] [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: 05/30/2023] [Revised: 06/19/2023] [Accepted: 06/19/2023] [Indexed: 07/14/2023] Open
Abstract
Although the Surviving Sepsis Campaign guidelines provide standardized and generalized guidance, they are less individualized. This review focuses on recent updates in the hemodynamic management of septic shock. Monitoring and intervention for septic shock should be personalized according to the phase of shock. In the salvage phase, fluid resuscitation and vasopressors should be given to provide life-saving tissue perfusion. During the optimization phase, tissue perfusion should be optimized. In the stabilization and de-escalation phases, minimal fluid infusion and safe fluid removal should be performed, respectively, while preserving organ perfusion. There is controversy surrounding the use of restrictive versus liberal fluid strategies after initial resuscitation. Fluid administration after initial resuscitation should depend upon the patient's fluid responsiveness and requires individualized management. A number of dynamic tests have been proposed to monitor fluid responsiveness, which can help clinicians decide whether to give fluid or not. The optimal timing for the initiation of vasopressor agents is unknown. Recent data suggest that early vasopressor initiation should be considered. Inotropes can be considered in patients with decreased cardiac contractility associated with impaired tissue perfusion despite adequate volume status and arterial blood pressure. Venoarterial extracorporeal membrane oxygenation should be considered for refractory septic shock with severe cardiac systolic dysfunction.
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Affiliation(s)
- Gil Joon Suh
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Tae Gun shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woon Yong Kwon
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Kyuseok Kim
- Department of Emergency Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - You Hwan Jo
- Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Korea
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sung-Hyuk Choi
- Department of Emergency Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - for the Korean Shock Society Investigators
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Korea
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Emergency Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of Emergency Medicine, Korea University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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29
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Argenti G, Ishikawa G, Fadel CB. The Direct Effects of Norepinephrine Administration on Pressure Injuries in Intensive Care Patients: A Retrospective Cohort Study. Adv Skin Wound Care 2023; 36:1-12. [PMID: 37603319 DOI: 10.1097/asw.0000000000000027] [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: 08/22/2023]
Abstract
OBJECTIVE To estimate the direct effects of norepinephrine administration on pressure injury (PI) incidence in intensive care patients. METHODS This is a secondary and exploratory analysis of a retrospective cohort study of intensive care patients discharged in 2017 to 2018. Observational cases only included patients who received primary PI preventive care during intensive care (N = 479). As a first-choice vasopressor drug, norepinephrine administration was approximated with days of norepinephrine. Linear path models were examined from norepinephrine administration to PI development. The identification of confounding variables and instrumental variables was grounded on directed acyclic graph theory. Direct effects were estimated with instrumental variables to overcome bias from unobserved variables. As models were re-specified with data analysis, the robustness of path identification was improved by requiring graph invariance with sample split. RESULTS Norepinephrine caused PI development from one stage to another after 4.0 to 6.3 days of administration in this cohort as a total effect (90% CI). The direct effect was estimated to advance the stage of PI at a rate of 0.140 per day of norepinephrine administered (standard error, 0.029; P < .001). The direct effect accounted for about 70% of the total effect on PI development. CONCLUSIONS Estimations with instrumental variables and structural equation modeling showed that norepinephrine administration directly and substantially affected hospital-acquired PI incidence in intensive care patients in this cohort.
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Affiliation(s)
- Graziela Argenti
- Graziela Argenti, MSc, RN, is Professor, Department of Nursing, Universidade Estadual de Ponta Grossa, Brazil. Gerson Ishikawa, DEng, is Associate Professor, Department of Production Engineering, Universidade Tecnologica Federal do Parana, Ponta Grossa. Also at Universidade Estadual de Ponta Grossa, Cristina Berger Fadel, DMD, is Associate Professor, Department of Dentistry. Acknowledgment: This research project was submitted and registered as CAAE 21591719.7.0000.0105 in PlataformaBrasil of Conselho Nacional de Saude and approved by the research ethics committee of Universidade Estadual de Ponta Grossa (resolution 3.604.604). The authors have disclosed no financial relationships related to this article. Submitted May 2, 2022; accepted in revised form December 1, 2022
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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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31
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Fodor R. Fluid Therapy from Friend to Foe. J Crit Care Med (Targu Mures) 2023; 9:135-137. [PMID: 37588185 PMCID: PMC10425928 DOI: 10.2478/jccm-2023-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 07/27/2023] [Indexed: 08/18/2023] Open
Affiliation(s)
- Raluca Fodor
- Department of Anesthesiology and Intensive Care, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
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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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Abu Sardaneh A, Penm J, Oliver M, Gattas D, Mclachlan A, Patanwala A. Comparison of metaraminol versus no metaraminol on time to resolution of shock in critically ill patients. Eur J Hosp Pharm 2023; 30:214-220. [PMID: 34620686 PMCID: PMC10359804 DOI: 10.1136/ejhpharm-2021-003035] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/28/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE There is limited evidence to support metaraminol use in critically ill patients. Metaraminol is not included as a vasopressor choice in international guidelines for the management of shock. Nevertheless, metaraminol is used in rates up to 42% in this patient population. The objective of this study was to investigate the effectiveness of metaraminol for the treatment of critically ill patients with shock. METHODS A single-centre retrospective matched observational study was conducted in a 54-bed intensive care unit of a tertiary hospital. Patients aged 16 years or older who were admitted from 2017 to 2019 with shock were included. Patients treated with metaraminol and norepinephrine (MET-NOR) were compared with those treated with norepinephrine without metaraminol (NOR). The primary outcome was the time to resolution of shock defined as the time to cessation of vasopressors. The secondary outcome was vasopressor-free days until 28 days. RESULTS There were 286 patients included in this study, including 143 patients in each group. The median time to resolution of shock was 44 hours (IQR 28-66 hours) in the MET-NOR group compared with 27 hours (IQR 14-63 hours) in the NOR group (95% CI of median difference 7 to 19 hours; p<0.01). The Cox regression analysis for the time to resolution of shock showed no significant difference between groups (HR 1.24, 95% CI 0.96 to 1.60; p=0.10). However, the proportional hazards assumption was not met (p<0.01). The median number of vasopressor-free days until 28 days was 26 days (IQR 24-27 days) in the MET-NOR group compared with 27 days (IQR 25-27 days) in the NOR group (95% CI of median difference -0.8 to -0.1 day; p<0.01). CONCLUSION In critically ill patients, metaraminol may be associated with a longer time to resolution of shock compared with those who do not receive metaraminol.
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Affiliation(s)
- Arwa Abu Sardaneh
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Pharmacy, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Jonathan Penm
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Pharmacy, Prince of Wales Hospital and Community Health Services, Randwick, New South Wales, Australia
| | - Matthew Oliver
- Department of Emergency Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - David Gattas
- School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Intensive Care Services, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Andrew Mclachlan
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Asad Patanwala
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Pharmacy, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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Manson DK, Dzierba AL, Seitz KM, Brodie D. Running from a Bear: How We Teach Vasopressors, Adrenoreceptors, and Shock. ATS Sch 2023; 4:216-229. [PMID: 37533537 PMCID: PMC10391691 DOI: 10.34197/ats-scholar.2021-0132ht] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023] Open
Abstract
Vasopressors are widely used in the management of shock among critically ill patients. The physiology of vasopressors and adrenoreceptors and their effects on end organs therefore represent important, high-yield topics for learners in the critical care environment. In this report, we describe our approach to teaching this core concept using the stereotypical human physiologic response when running from a bear, in the context of the relevant supporting literature. We use escaping from a threatening predator as a lens to describe the end-organ effects of activating adrenoreceptors together with the effects of endogenous and exogenous catecholamines and vasopressors. After reviewing this foundational physiology, we transition to the clinical environment, reviewing the pathophysiology of various shock states. We then consolidate our teaching by integrating the physiology of adrenoreceptors with the pathophysiology of shock to understand the appropriateness of each therapy to various shock phenotypes. We emphasize to learners the importance of generating a hypothesis about a patient's physiology, testing that hypothesis with an intervention, and then revising the hypothesis as needed, a critical component in the management of critically ill patients.
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Affiliation(s)
| | - Amy L. Dzierba
- Department of Pharmacy, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, New York; and
| | - Kaitlin M. Seitz
- Division of Pulmonary and Critical Care Medicine, NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine and
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Sef AV, Yin Ling CN, Aw TC, Romano R, Crescenzi O, Manikavasagar V, Simon A, de Waal EEC, Thakuria L, Reed AK, Marczin N. Postoperative vasoplegia in lung transplantation: incidence and relation to outcome. Br J Anaesth 2023; 130:666-676. [PMID: 37127440 DOI: 10.1016/j.bja.2023.01.027] [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: 03/15/2022] [Revised: 01/07/2023] [Accepted: 01/31/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND The incidence and clinical importance of vasoplegia after lung transplantation remains poorly studied. We describe the incidence of vasoplegia and its association with complications after lung transplantation. METHODS Perioperative data of 279 lung transplant recipients operated on from 2015 to 2020 were retrospectively analysed. RESULTS Vasoplegia occurred in 41.6% of patients after lung transplantation (mild, 31.0%; moderate, 55.2%; severe, 13.8%). Compared with non-vasoplegic patients, vasoplegic patients had a higher incidence of any acute kidney injury, defined by Kidney Disease Improving Global Outcomes (KDIGO) criteria (78.5% vs 65%, P=0.015), renal replacement therapy (47.4% vs 24.5%, P<0.001), and delayed chest closure (18.4% vs 9.2%, P=0.025); were ventilated longer (70 [32-368] vs 34 [19-105] h, P<0.001); and stayed longer in the ICU (12.9 [5-30] vs 6.8 [3-20] days, P<0.001). Mortality at 30 days and 1 yr was higher in patients with vasoplegia (11.2% vs 5.5% and 20.7% vs 11.7%, P=0.039, respectively). Severe vasoplegia represented a predictor of longer-term mortality (hazard ratio=1.65, P=0.008). Underlying infectious disease, increased BMI, higher preoperative pulmonary artery systolic pressure and bilirubin levels, lower glomerular filtration rate, and increased fresh frozen plasma transfusion were predictors of vasoplegia severity. Neutrophilia, leucocytosis, and increased C-reactive protein were associated with vasoplegia, but release of the neutrophil activation markers myeloperoxidase and heparin-binding protein was similar between groups. CONCLUSIONS Influenced by preoperative status as well as procedural factors and inflammatory response, vasoplegia is a common and critical condition after lung transplantation with worse short-term outcomes and long-term survival.
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Affiliation(s)
- Alessandra V Sef
- Department of Anesthesia and Critical Care, Harefield Hospital, Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Clarissa N Yin Ling
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Tuan C Aw
- Department of Anaesthesia, Harefield Hospital, Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rosalba Romano
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK; Department of Anaesthesia and Intensive Care, Cardarelli Hospital, Naples, Italy
| | - Oliviero Crescenzi
- Department of Anesthesia and Critical Care, Harefield Hospital, Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Venughanan Manikavasagar
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Andre Simon
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Eric E C de Waal
- Department of Anesthesiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Louit Thakuria
- Department of Cardiothoracic Transplantation and Mechanical Support, Harefield Hospital, Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Anna K Reed
- Department of Cardiothoracic Transplantation and Mechanical Support, Harefield Hospital, Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nandor Marczin
- Department of Anesthesia and Critical Care, Harefield Hospital, Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK; Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK; Department of Anaesthesia and Intensive Care, Semmelweis University Budapest, Hungary.
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36
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Mehta Y, Paul R, Ansari AS, Banerjee T, Gunaydin S, Nassiri AA, Pappalardo F, Premužić V, Sathe P, Singh V, Vela ER. Extracorporeal blood purification strategies in sepsis and septic shock: An insight into recent advancements. World J Crit Care Med 2023; 12:71-88. [PMID: 37034019 PMCID: PMC10075046 DOI: 10.5492/wjccm.v12.i2.71] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/05/2023] [Accepted: 02/17/2023] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND Despite various therapies to treat sepsis, it is one of the leading causes of mortality in the intensive care unit patients globally. Knowledge about the pathophysiology of sepsis has sparked interest in extracorporeal therapies (ECT) which are intended to balance the dysregulation of the immune system by removing excessive levels of inflammatory mediators.
AIM To review recent data on the use of ECT in sepsis and to assess their effects on various inflammatory and clinical outcomes.
METHODS In this review, an extensive English literature search was conducted from the last two decades to identify the use of ECT in sepsis. A total of 68 articles from peer-reviewed and indexed journals were selected excluding publications with only abstracts.
RESULTS Results showed that ECT techniques such as high-volume hemofiltration, coupled plasma adsorption/filtration, resin or polymer adsorbers, and CytoSorb® are emerging as adjunct therapies to improve hemodynamic stability in sepsis. CytoSorb® has the most published data in regard to the use in the field of septic shock with reports on improved survival rates and lowered sequential organ failure assessment scores, lactate levels, total leucocyte count, platelet count, interleukin- IL-6, IL-10, and TNF levels.
CONCLUSION Clinical acceptance of ECT in sepsis and septic shock is currently still limited due to a lack of large random clinical trials. In addition to patient-tailored therapies, future research developments with therapies targeting the cellular level of the immune response are expected.
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Affiliation(s)
- Yatin Mehta
- Institute of Critical Care and Anesthesiology, Medanta the Medicity, Gurugram 12201, India
| | - Rajib Paul
- Department of Internal Medicine, Apollo Hospitals, Jubilee Hills, Hyderabad 500033, India
| | - Abdul Samad Ansari
- Department of Critical Care, Nanavati Max Super Specialty Hospital, Mumbai 400065, India
| | - Tanmay Banerjee
- Department of Internal Medicine & Critical Care, Medica Institute of Critical Care Medicine, Medica Superspecialty Hospital, Kolkata 700099, India
| | - Serdar Gunaydin
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara City Hospital Campus, Ankara 06933, Turkey
| | - Amir Ahmad Nassiri
- Department of Nephrology, Shahid Beheshti University of Medical Sciences, Tehran 19839-63113, Iran
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria 15121, Italy
| | - Vedran Premužić
- Department of Nephrology, Clinical Hospital Zagreb, Clinic for internal diseases, Zagreb 10000, Croatia
| | - Prachee Sathe
- Department of Critical Care Medicine, D.Y. Patil Medical College, Sant Tukaram Nagar, Pimpri Colony, Pimpri-Chinchwad, Pune 411018, India
| | - Vinod Singh
- Department of Critical Care Medicine, Institute of critical care Medicine, Hospital Name - Sir Ganga Ram Hospital, New Delhi 110001, India
| | - Emilio Rey Vela
- Cardiac Surgery Intensive Care Unit, Samaritan University Hospital, Bogotá 11, Colombia
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Shou BL, Aravind P, Ong CS, Alejo D, Canner JK, Etchill EW, DiNatale J, Prokupets R, Esfandiary T, Lawton JS, Schena S. Early Reexploration for Bleeding Is Associated With Improved Outcome in Cardiac Surgery. Ann Thorac Surg 2023; 115:232-239. [PMID: 35952856 DOI: 10.1016/j.athoracsur.2022.07.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 07/12/2022] [Accepted: 07/19/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Reexploration after cardiac surgery, most frequently for bleeding, is a quality metric used to assess surgical performance. This may cause surgeons to delay return to the operating room in favor of attempting nonoperative management. This study investigated the impact of the timing of reexploration on morbidity and mortality. METHODS This study was a single-institution retrospective review of all adult cardiac surgery patients from July 2010 to June 2020. Time to reexploration was assessed, and outcomes were compared across increasing time intervals. Reported bleeding sites were classified into 5 groups, and bleeding rate (chest tube output) was compared across bleeding sites. Univariable analysis was performed using the Fisher exact and Kruskal-Wallis tests. Multivariable logistic regression models were used for risk-adjusted analyses. RESULTS Of 10 070 eligible patients, 251 (2.5%) required reexploration for postoperative bleeding. The most common site of bleeding was "any suture line" (n = 70; 28%). Interestingly, in 30% of cases (n = 75) "no active bleeding" site was reported. The highest rate of bleeding (mL/h) was observed in the "any mediastinal structure" group (median, 450; interquartile range [IQR], 185, 8878), and the lowest rate was noted in the "no active bleeding" group (median, 151.2; IQR, 102, 270). Both morbidity rates (0-4 hours, 12.3% vs 25-48 hours, 37.5%; P = .001) and mortality rates (0-4 hours, 3.1% vs 25-48 hours, 43.8%; P = .001) escalated significantly with increasing time to reexploration. CONCLUSIONS Delayed reexploration for bleeding after cardiac surgery is associated with increased risk for morbidity and mortality. Early surgical intervention, particularly within 4 hours, may improve outcomes. Implications from using reoperation as a performance metric may lead to unnecessary delay and patient harm.
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Affiliation(s)
- Benjamin L Shou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Pathik Aravind
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Chin Siang Ong
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Diane Alejo
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Joseph K Canner
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Eric W Etchill
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Joseph DiNatale
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Rochelle Prokupets
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Tina Esfandiary
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Jennifer S Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Stefano Schena
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
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Wood AJ, Rauniyar R, Jacques A, Palmer RN, Wibrow B, Anstey MH. Oral midodrine does not expedite liberation from protracted vasopressor infusions: A case-control study. Anaesth Intensive Care 2023; 51:20-28. [PMID: 36168754 DOI: 10.1177/0310057x221105297] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Vasopressor dependence is a common problem affecting patients in the recovery phase of critical illness, often necessitating intensive care unit (ICU) admission and other interventions which carry associated risks. Midodrine is an orally administered vasopressor which is commonly used off-label to expedite weaning from vasopressor infusions and facilitate discharge from ICU. We performed a single-centre, case-control study to assess whether midodrine accelerated liberation from vasopressor infusions in patients who were vasopressor dependent. Cases were identified at the discretion of treating intensivists and received 20 mg oral midodrine every eight h from enrolment. Controls received placebo. Data on duration and dose of vasopressor infusion, haemodynamics and adverse events were collected. Between 2012 and 2019, 42 controls and 19 cases were recruited. Cases had received vasopressor infusions for a median of 94 h versus 29.3 h for controls, indicating prolonged vasopressor dependence amongst cases. Midodrine use in cases was not associated with faster weaning of intravenous (IV) vasopressors (26 h versus 24 h for controls, P = 0.51), ICU or hospital length of stay after adjustment for confounders. Midodrine did not affect mean heart rate but was associated with bradycardia. This case-control study demonstrates that midodrine has limited efficacy in expediting weaning from vasopressor infusions in patients who have already received relatively prolonged courses of these infusions.
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Affiliation(s)
- Alexander Jt Wood
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia.,University of Western Australia, School of Medicine, Perth, Australia
| | - Rashmi Rauniyar
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia
| | - Angela Jacques
- Institute for Health Research, 3431The University of Notre Dame Australia, Fremantle, Australia.,Department of Research, Sir Charles Gairdner Hospital, Perth, Australia
| | - Robert N Palmer
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia
| | - Bradley Wibrow
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia.,University of Western Australia, School of Medicine, Perth, Australia
| | - Matthew H Anstey
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia.,University of Western Australia, School of Medicine, Perth, Australia.,Curtin University, School of Public Health, Perth, Australia
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Lindholz M, Schellenberg CM, Grunow JJ, Kagerbauer S, Milnik A, Zickler D, Angermair S, Reißhauer A, Witzenrath M, Menk M, Boie S, Balzer F, Schaller SJ. Mobilisation of critically ill patients receiving norepinephrine: a retrospective cohort study. Crit Care 2022; 26:362. [PMID: 36434724 PMCID: PMC9700948 DOI: 10.1186/s13054-022-04245-0] [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: 09/20/2022] [Accepted: 11/15/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Mobilisation and exercise intervention in general are safe and feasible in critically ill patients. For patients requiring catecholamines, however, doses of norepinephrine safe for mobilisation in the intensive care unit (ICU) are not defined. This study aimed to describe mobilisation practice in our hospital and identify doses of norepinephrine that allowed a safe mobilisation. METHODS We conducted a retrospective single-centre cohort study of 16 ICUs at a university hospital in Germany with patients admitted between March 2018 and November 2021. Data were collected from our patient data management system. We analysed the effect of norepinephrine on level (ICU Mobility Scale) and frequency (units per day) of mobilisation, early mobilisation (within 72 h of ICU admission), mortality, and rate of adverse events. Data were extracted from free-text mobilisation entries using supervised machine learning (support vector machine). Statistical analyses were done using (generalised) linear (mixed-effect) models, as well as chi-square tests and ANOVAs. RESULTS A total of 12,462 patients were analysed in this study. They received a total of 59,415 mobilisation units. Of these patients, 842 (6.8%) received mobilisation under continuous norepinephrine administration. Norepinephrine administration was negatively associated with the frequency of mobilisation (adjusted difference -0.07 mobilisations per day; 95% CI - 0.09, - 0.05; p ≤ 0.001) and early mobilisation (adjusted OR 0.83; 95% CI 0.76, 0.90; p ≤ 0.001), while a higher norepinephrine dose corresponded to a lower chance to be mobilised out-of-bed (adjusted OR 0.01; 95% CI 0.00, 0.04; p ≤ 0.001). Mobilisation with norepinephrine did not significantly affect mortality (p > 0.1). Higher compared to lower doses of norepinephrine did not lead to a significant increase in adverse events in our practice (p > 0.1). We identified that mobilisation was safe with up to 0.20 µg/kg/min norepinephrine for out-of-bed (IMS ≥ 2) and 0.33 µg/kg/min for in-bed (IMS 0-1) mobilisation. CONCLUSIONS Mobilisation with norepinephrine can be done safely when considering the status of the patient and safety guidelines. We demonstrated that safe mobilisation was possible with norepinephrine doses up to 0.20 µg/kg/min for out-of-bed (IMS ≥ 2) and 0.33 µg/kg/min for in-bed (IMS 0-1) mobilisation.
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Affiliation(s)
- Maximilian Lindholz
- grid.6363.00000 0001 2218 4662Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Clara M. Schellenberg
- grid.6363.00000 0001 2218 4662Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Julius J. Grunow
- grid.6363.00000 0001 2218 4662Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Simone Kagerbauer
- grid.6936.a0000000123222966Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany ,grid.6582.90000 0004 1936 9748Department of Anesthesiology and Intensive Care Medicine, Ulm University, Ulm, Germany
| | - Annette Milnik
- grid.6612.30000 0004 1937 0642Division of Molecular Neuroscience, University of Basel, Basel, Switzerland
| | - Daniel Zickler
- grid.6363.00000 0001 2218 4662Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Stefan Angermair
- grid.6363.00000 0001 2218 4662Department of Anesthesiology and Operative Intensive Care Medicine (CBF), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Anett Reißhauer
- grid.6363.00000 0001 2218 4662Department of Physical Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Martin Witzenrath
- grid.6363.00000 0001 2218 4662Department of Infectious Diseases and Pulmonary Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Mario Menk
- grid.6363.00000 0001 2218 4662Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany ,grid.6363.00000 0001 2218 4662Institute of Medical Informatics, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Sebastian Boie
- grid.6363.00000 0001 2218 4662Institute of Medical Informatics, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Felix Balzer
- grid.6363.00000 0001 2218 4662Institute of Medical Informatics, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Stefan J. Schaller
- grid.6363.00000 0001 2218 4662Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany ,grid.6936.a0000000123222966Department of Anesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Munich, Germany
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Kamaleldin M, Kilcommons S, Opgenorth D, Fiest K, Karvellas CJ, Kutsogiannis J, Lau V, MacIntyre E, Rochwerg B, Senaratne J, Slemko J, Sligl W, Wang X, Bagshaw SM, Rewa OG. Midodrine therapy for vasopressor dependent shock in the intensive care unit: a protocol for a systematic review and meta-analysis. BMJ Open 2022; 12:e064060. [PMID: 36418124 PMCID: PMC9684992 DOI: 10.1136/bmjopen-2022-064060] [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: 11/24/2022] Open
Abstract
INTRODUCTION Intensive care unit (ICU) lengths of stay are modified by ongoing need for haemodynamic support in critically ill patients. This is most commonly provided by intravenous vasopressor therapy. Midodrine has been used as an oral agent for haemodynamic support in patients with orthostatic hypotension or cirrhosis. However, its efficacy in treating shock in the ICU, particularly for patients weaning from intravenous vasopressors, remains uncertain. The objective of this systematic review is to determine the efficacy of midodrine in vasopressor dependent shock. METHODS AND ANALYSIS We will search Ovid MEDLINE, Ovid Embase, CINAHL and Cochrane Library for observational trials and randomised controlled trials evaluating midodrine in critically ill patients from inception to 21 April 2022. We will also review unpublished data and relevant conference abstracts. Outcomes will include ICU length of stay, duration of intravenous vasopressor support, ICU mortality, hospital mortality, hospital length of stay and rates of ICU readmission. Data will be analysed in aggregate, where appropriate. We will evaluate risk of bias using the modified Cochrane tool and certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluations methodology. We will perform trial sequential analysis for the outcome of ICU length of stay. ETHICS AND DISSEMINATION Ethics approval is not required as primary data will not be collected. Findings of this review will be disseminated through peer-related publication and will inform future clinical trials. PROSPERO REGISTRATION NUMBER CRD42021260375.
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Affiliation(s)
| | | | - Dawn Opgenorth
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Kirsten Fiest
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Constantine Jason Karvellas
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Jim Kutsogiannis
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Vincent Lau
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Erika MacIntyre
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Bram Rochwerg
- Department of Medicine and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Janek Senaratne
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Jocelyn Slemko
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Wendy Sligl
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Xiaoming Wang
- Statistical and Analytical Methods, Alberta Health Services, Edmonton, Alberta, Canada
| | - Sean M Bagshaw
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Oleksa G Rewa
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
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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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Almuntashiri S, Chase A, Sikora A, Zhang D. The Potential Synergistic Risk of Albuterol and Vasoactives in Acute Lung Injury Trials. Ann Pharmacother 2022:10600280221128014. [PMID: 36189647 PMCID: PMC10066837 DOI: 10.1177/10600280221128014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Critically ill patients are often prescribed both inhaled beta-agonists and intravenous vasoactive; however, the interaction of the additive beta-agonist effects of these 2 agents remains largely uncharacterized. Objective: The purpose of this study was to evaluate how concomitant use of albuterol and vasoactive or inotropes affected ventilator-free days (VFDs) by re-analyzing the data from the Albuterol to Treat Acute Lung Injury (ALTA) trial. Methods: In this study, subjects were grouped to albuterol-vasoactive (n = 84) versus (vs) placebo-vasoactive (n = 62). Ventilator-free days, intensive care unit (ICU)-free days, organ failure-free days, cardiovascular adverse events, and 90-day mortality were compared. The primary outcome was VFDs. Results: Patients in the albuterol-vasoactive group had significantly fewer VFDs than patients in the placebo-vasoactive group (11 vs 19, P = 0.05). Patients in the albuterol-vasoactive group also had significantly fewer ICU-free days (9.5 vs 18.5, P = .006). The 90-day mortality was similar between groups (36.9% vs 27.4%, P = .20). Similarly, no significant difference in cardiac adverse events between the groups (14.3% vs 11.3%, P = 0.59). Conclusion and Relevance: This study has shown fewer VFDs for patients who received both vasoactive and albuterol. There were also fewer ICU-free days when compared to those on vasoactive only. Given the common use of both agents, a prospective evaluation of the additive adverse effects of beta-agonism is warranted.
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Affiliation(s)
- Sultan Almuntashiri
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia, Augusta, GA, USA
- Charlie Norwood VA Medical Center, Augusta, GA, USA
- Department of Clinical Pharmacy, College of Pharmacy, University of Hail, Hail, Saudi Arabia
| | - Aaron Chase
- Department of Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, Augusta, GA, USA
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| | - Andrea Sikora
- Department of Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, Augusta, GA, USA
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| | - Duo Zhang
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia, Augusta, GA, USA
- Charlie Norwood VA Medical Center, Augusta, GA, USA
- Vascular Biology Center, Augusta University, Augusta, GA, USA
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Buchtele N, Schwameis M, Roth D, Schwameis F, Kraft F, Ullrich R, Mühlbacher J, Laggner R, Gamper G, Semmler G, Schoergenhofer C, Staudinger T, Herkner H. Applicability of Vasopressor Trials in Adult Critical Care: A Prospective Multicentre Meta-Epidemiologic Cohort Study. Clin Epidemiol 2022; 14:1087-1098. [PMID: 36204153 PMCID: PMC9531614 DOI: 10.2147/clep.s372340] [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: 04/27/2022] [Accepted: 07/30/2022] [Indexed: 12/15/2022] Open
Abstract
Objective To assess the applicability of evidence from landmark randomized controlled trials (RCTs) of vasopressor treatment in critically ill adults. Study Design and Setting This prospective, multi-center cohort study was conducted at five medical and surgical intensive care units at three tertiary care centers. Consecutive cases of newly initiated vasopressor treatment were included. The primary end point was the proportion of patients (≥18 years) who met the eligibility criteria of 25 RCTs of vasopressor therapy in critically ill adults included in the most recent Cochrane review. Multilevel Poisson regression was used to estimate the eligibility proportions with 95% confidence intervals for each trial. Secondary end points included the eligibility criteria that contributed most to trial ineligibility, and the relationship between eligibility proportions and (i) the Pragmatic-Explanatory Continuum Indicator Summary-2 (PRECIS-2) score, and (ii) the recruitment-to-screening ratio of each RCT. The PRECIS-2 score was used to assess the degree of pragmatism of each trial. Results Between January 1, 2017, and January 1, 2019, a total of 1189 cases of newly initiated vasopressor therapy were included. The median proportion of cases meeting eligibility criteria for all 25 RCTs ranged from 1.3% to 6.0%. The eligibility criteria contributing most to trial ineligibility were the exceedance of a specific norepinephrine dose, the presence of a particular shock type, and the drop below a particular blood pressure value. Eligibility proportions increased with the PRECIS-2 score but not with the recruitment-to-screening ratio of the trials. Conclusion The applicability of evidence from available trials on vasopressor treatment in critically ill adults to patients receiving vasopressors in daily practice is limited. Applicability increases with the degree of study pragmatism but is not reflected in a high recruitment-to-screening ratio. Our findings may help researchers design vasopressor trials and promote standardized assessment and reporting of the degree of pragmatism achieved.
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Affiliation(s)
- Nina Buchtele
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
- Correspondence: Michael Schwameis, Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria, Tel +43 1 40400 39560, Fax +43 1 40400 19650, Email
| | - Dominik Roth
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Franz Schwameis
- Department of Anaesthesiology and Intensive Care Medicine, Landesklinikum Baden, Vienna, Austria
| | - Felix Kraft
- Department of Anaesthesia, Critical Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Roman Ullrich
- Department of Anaesthesia, Critical Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Jakob Mühlbacher
- Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Roberta Laggner
- Department of Orthopaedics and Trauma-Surgery, Medical University of Vienna, Vienna, Austria
| | - Gunnar Gamper
- Department of Cardiology, Universitätsklinikum Sankt Pölten, Vienna, Austria
| | - Georg Semmler
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | | | - Thomas Staudinger
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
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Lozada Martinez ID, Bayona-Gamboa AJ, Meza-Fandiño DF, Paz-Echeverry OA, Ávila-Bonilla ÁM, Paz-Echeverry MJ, Pineda-Trujillo FJ, Rodríguez-García GP, Covaleda-Vargas JE, Narvaez-Rojas AR. Inotropic support in cardiogenic shock: who leads the battle, milrinone or dobutamine? Ann Med Surg (Lond) 2022; 82:104763. [PMID: 36268289 PMCID: PMC9577832 DOI: 10.1016/j.amsu.2022.104763] [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: 07/16/2022] [Revised: 09/16/2022] [Accepted: 09/19/2022] [Indexed: 11/16/2022] Open
Abstract
Cardiovascular diseases remain the leading cause of death globally, with acute myocardial infarction being one of the most frequent. One of the complications that can occur after a myocardial infarction is cardiogenic shock. At present, the evidence on the use of inotropic agents for the management of this complication is scarce, and only a few trials have evaluated the efficacy-adverse effects relationship of some agents. Milrinone and Dobutamine are some of the most frequently mentioned drugs that have been studied recently. However, there are still no data that affirm with certainty the supremacy of one over the other. The aim of this review is to synthesize evidence on basic and practical aspects of these agents, allowing us to conclude which might be more useful in current clinical practice, based on the emerging literature. Studies suggest that Milrinone has a higher safety and efficacy profile over Dobutamine. The evidence on the advantages of using Milrinone vs. Dobutamine is heterogeneous. Additional factors need to be considered to reduce the risk of adverse events.
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Affiliation(s)
- Ivan David Lozada Martinez
- Medical and Surgical Research Center, Future Surgeons Chapter, Colombian Surgery Association, Bogotá, Colombia
- Grupo Prometheus y Biomedicina Aplicada a las Ciencias Clínicas, School of Medicine, Universidad de Cartagena, Cartagena, Colombia
| | | | | | | | | | | | | | | | | | - Alexis Rafael Narvaez-Rojas
- International Coalition on Surgical Research, Universidad Nacional Autónoma de Nicaragua, Managua, Nicaragua
- Corresponding author.
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Albertson TE, Chenoweth JA, Lewis JC, Pugashetti JV, Sandrock CE, Morrissey BM. The pharmacotherapeutic options in patients with catecholamine-resistant vasodilatory shock. Expert Rev Clin Pharmacol 2022; 15:959-976. [PMID: 35920615 DOI: 10.1080/17512433.2022.2110067] [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] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Septic and vasoplegic shock are common types of vasodilatory shock (VS) with high mortality. After fluid resuscitation and the use of catecholamine-mediated vasopressors (CMV), vasopressin, angiotensin II, methylene blue (MB) and hydroxocobalamin can be added to maintain blood pressure. AREAS COVERED VS treatment utilizes a phased approach with secondary vasopressors added to vasopressor agents to maintain an acceptable mean arterial pressure (MAP). This review covers additional vasopressors and adjunctive therapies used when fluid and catecholamine-mediated vasopressors fail to maintain target MAP. EXPERT OPINION Evidence supporting additional vasopressor agents in catecholamine resistant VS is limited to case reports, series, and a few randomized control trials (RCTs) to guide recommendations. Vasopressin is the most common agent added next when MAPs are not adequately supported with CMV. VS patients failing fluids and vasopressors with cardiomyopathy may have cardiotonic agents such as dobutamine or milrinone added before or after vasopressin. Angiotensin II, another class of vasopressor is used in VS to maintain adequate MAP. MB and/or hydoxocobalamin, vitamin C, thiamine and corticosteroids are adjunctive therapies used in refractory VS. More RCTs are needed to confirm the utility of these drugs, at what doses, which combinations and in what order they should be given.
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Affiliation(s)
- Timothy E Albertson
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA.,Department of Clinical Pharmacy, University of California, San Francisco, CA, USA
| | - James A Chenoweth
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA
| | - Justin C Lewis
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Clinical Pharmacy, University of California, San Francisco, CA, USA
| | - Janelle V Pugashetti
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA
| | - Christian E Sandrock
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA
| | - Brian M Morrissey
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA
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Obray JD, Small CA, Baldwin EK, Jang EY, Lee JG, Yang CH, Yorgason JT, Steffensen SC. Dopamine D2-Subtype Receptors Outside the Blood-Brain Barrier Mediate Enhancement of Mesolimbic Dopamine Release and Conditioned Place Preference by Intravenous Dopamine. Front Cell Neurosci 2022; 16:944243. [PMID: 35903367 PMCID: PMC9314669 DOI: 10.3389/fncel.2022.944243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 06/17/2022] [Indexed: 11/26/2022] Open
Abstract
Dopamine (DA) is a cell-signaling molecule that does not readily cross the blood-brain barrier. Despite this, peripherally administered DA enhances DA levels in the nucleus accumbens and alters DA-related behaviors. This study was designed to investigate whether DA subtype-2 receptors are involved in the enhancement of nucleus accumbens (NAc) DA levels elicited by intravenous DA administration. This was accomplished by using microdialysis in the NAc and extracellular single unit recordings of putative DA neurons in the ventral tegmental area (VTA). Additionally, the reinforcing properties of intravenous DA were investigated using a place conditioning paradigm and the effects of intravenous DA on ultrasonic vocalizations were assessed. Following administration of intravenous dopamine, the firing rate of putative DA neurons in the VTA displayed a biphasic response and DA levels in the nucleus accumbens were enhanced. Pretreatment with domperidone, a peripheral-only DA D2 receptor (D2R) antagonist, reduced intravenous DA mediated increases in VTA DA neuron activity and NAc DA levels. Pretreatment with phentolamine, a peripheral α-adrenergic receptor antagonist, did not alter the effects of IV DA on mesolimbic DA neurotransmission. These results provide evidence for peripheral D2R mediation of the effects of intravenous DA on mesolimbic DA signaling.
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Affiliation(s)
- J. Daniel Obray
- Department of Psychology and Neuroscience, Brigham Young University, Provo, UT, United States
| | - Christina A. Small
- Department of Psychology and Neuroscience, Brigham Young University, Provo, UT, United States
| | - Emily K. Baldwin
- Department of Psychology and Neuroscience, Brigham Young University, Provo, UT, United States
| | - Eun Young Jang
- Department of Psychology and Neuroscience, Brigham Young University, Provo, UT, United States
- Research Center for Convergence Toxicology, Korea Institute of Toxicology, Daejeon, South Korea
| | - Jin Gyeom Lee
- College of Korean Medicine, Daegu Haany University, Daegu, South Korea
| | - Chae Ha Yang
- College of Korean Medicine, Daegu Haany University, Daegu, South Korea
| | - Jordan T. Yorgason
- Department of Psychology and Neuroscience, Brigham Young University, Provo, UT, United States
| | - Scott C. Steffensen
- Department of Psychology and Neuroscience, Brigham Young University, Provo, UT, United States
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48
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Pérsico RS, Viana MV, Viana LV. Diabetes Insipidus after Vasopressin Withdrawal: A Scoping Review. Indian J Crit Care Med 2022; 26:846-852. [PMID: 36864877 PMCID: PMC9973175 DOI: 10.5005/jp-journals-10071-24244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Objectives The objective of this study is to synthesize the current literature about the relationship between the occurrence of diabetes insipidus (DI), its diagnosis criteria, and management after withdrawal of vasopressin (VP) in critically ill. Data sources This scoping review followed the recommendations of Preferred Reporting Items for Systematic Review and Meta-Analyses for Scoping Review (PRISMA-ScR). The search literature was conducted in MEDLINE and EMBASE databases, until March 2022. A manual search was also conducted in order to include articles that were not identified in the initial search performed in the databases. Study selection and data extraction The selection of studies and extraction of data were carried out in a paired and independent manner. There was no restriction regarding the language of publication of the included manuscripts. Data synthesis The analysis included 17 studies (16 case reports and one retrospective cohort). All studies used VP, with a median time of drug infusion of 48 hours (IQR: 16-72) and DI incidence of 1.53%. The diagnosis of DI was based on diuresis output and concomitant hypernatremia or changes in serum sodium concentration, with median time to symptoms onset after discontinuation of VP of 5 hours (IQR: 3-10). The treatment of DI consisted mainly of fluid management and the use of desmopressin. Conclusions DI after VP withdrawal was present in 51 patients described in 17 studies, but diagnosis and management varied among each report. Using the available data, we propose a diagnosis suggestion and a flowchart for managing patients with DI after withdrawal of VP in the Intensive Care Unit. Multicentric collaborative research is urgently needed to obtain more quality data on this topic. How to cite this article Pérsico RS, Viana MV, Viana LV. Diabetes Insipidus after Vasopressin Withdrawal: A Scoping Review. Indian J Crit Care Med 2022;26(7):846-852.
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Affiliation(s)
- Raquel S Pérsico
- Programa de Pos-Graduaçao em Ciencias Medicas: Endocrinologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Marina V Viana
- Department of Critical Care Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Luciana V Viana
- Department of Nutrology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
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Jozwiak M. Alternatives to norepinephrine in septic shock: Which agents and when? JOURNAL OF INTENSIVE MEDICINE 2022; 2:223-232. [PMID: 36788938 PMCID: PMC9924015 DOI: 10.1016/j.jointm.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/28/2022] [Accepted: 05/07/2022] [Indexed: 10/18/2022]
Abstract
Vasopressors are the cornerstone of hemodynamic management in patients with septic shock. Norepinephrine is currently recommended as the first-line vasopressor in these patients. In addition to norepinephrine, there are many other potent vasopressors with specific properties and/or advantages that act on vessels through different pathways after activation of specific receptors; these could be of interest in patients with septic shock. Dopamine is no longer recommended in patients with septic shock because its use is associated with a higher rate of cardiac arrhythmias without any benefit in terms of mortality or organ dysfunction. Epinephrine is currently considered as a second-line vasopressor therapy, because of the higher rate of associated metabolic and cardiac adverse effects compared with norepinephrine; however, it may be considered in settings where norepinephrine is unavailable or in patients with refractory septic shock and myocardial dysfunction. Owing to its potential effects on mortality and renal function and its norepinephrine-sparing effect, vasopressin is recommended as second-line vasopressor therapy instead of norepinephrine dose escalation in patients with septic shock and persistent arterial hypotension. However, two synthetic analogs of vasopressin, namely, terlipressin and selepressin, have not yet been employed in the management of patients with septic shock, as their use is associated with a higher rate of digital ischemia. Finally, angiotensin Ⅱ also appears to be a promising vasopressor in patients with septic shock, especially in the most severe cases and/or in patients with acute kidney injury requiring renal replacement therapy. Nevertheless, due to limited evidence and concerns regarding safety (which remains unclear because of potential adverse effects related to its marked vasopressor activity), angiotensin Ⅱ is currently not recommended in patients with septic shock. Further studies are needed to better define the role of these vasopressors in the management of these patients.
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Affiliation(s)
- Mathieu Jozwiak
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire l'Archet 1, 151 route Saint Antoine de Ginestière, 06200 Nice, France,Equipe 2 CARRES UR2CA – Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur UCA, 06103 Nice, France
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Legrand M, Zarbock A. Ten tips to optimize vasopressors use in the critically ill patient with hypotension. Intensive Care Med 2022; 48:736-739. [PMID: 35504977 DOI: 10.1007/s00134-022-06708-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/16/2022] [Indexed: 01/04/2023]
Affiliation(s)
- Matthieu Legrand
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), 505 Parnassus Avenue, San Francisco, CA, 94143, USA. .,INI-CRCT Network, Nancy, France.
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
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