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Lim HS, González-Costello J, Belohlavek J, Zweck E, Blumer V, Schrage B, Hanff TC. Hemodynamic management of cardiogenic shock in the intensive care unit. J Heart Lung Transplant 2024; 43:1059-1073. [PMID: 38518863 PMCID: PMC11148863 DOI: 10.1016/j.healun.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 03/01/2024] [Accepted: 03/11/2024] [Indexed: 03/24/2024] Open
Abstract
Hemodynamic derangements are defining features of cardiogenic shock. Randomized clinical trials have examined the efficacy of various therapeutic interventions, from percutaneous coronary intervention to inotropes and mechanical circulatory support (MCS). However, hemodynamic management in cardiogenic shock has not been well-studied. This State-of-the-Art review will provide a framework for hemodynamic management in cardiogenic shock, including a description of the 4 therapeutic phases from initial 'Rescue' to 'Optimization', 'Stabilization' and 'de-Escalation or Exit therapy' (R-O-S-E), phenotyping and phenotype-guided tailoring of pharmacological and MCS support, to achieve hemodynamic and therapeutic goals. Finally, the premises that form the basis for clinical management and the hypotheses for randomized controlled trials will be discussed, with a view to the future direction of cardiogenic shock.
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Affiliation(s)
- Hoong Sern Lim
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - José González-Costello
- Advanced Heart Failure and Heart Transplant Unit, Department of Cardiology, Hospital Universitari de Bellvitge, BIOHEART-Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, Barcelona, Spain; Ciber Cardiovascular (CIBERCV), Instituto Salud Carlos III, Madrid, Spain
| | - Jan Belohlavek
- 2nd Department of Medicine-Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic; Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Elric Zweck
- Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Vanessa Blumer
- Inova Schar Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Benedikt Schrage
- University Heart and Vascular Centre Hamburg, German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Thomas C Hanff
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
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Mirsajadi A, Erickson D, Alias S, Froese L, Singh Sainbhi A, Gomez A, Majumdar R, Herath I, Wilson M, Zarychanski R, Zeiler FA, Mendelson AA. Microvascular Autoregulation in Skeletal Muscle Using Near-Infrared Spectroscopy and Derivation of Optimal Mean Arterial Pressure in the ICU: Pilot Study and Comparison With Cerebral Near-Infrared Spectroscopy. Crit Care Explor 2024; 6:e1111. [PMID: 38904977 PMCID: PMC11196085 DOI: 10.1097/cce.0000000000001111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2024] Open
Abstract
IMPORTANCE Microvascular autoregulation (MA) maintains adequate tissue perfusion over a range of arterial blood pressure (ABP) and is frequently impaired in critical illness. MA has been studied in the brain to derive personalized hemodynamic targets after brain injury. The ability to measure MA in other organs is not known, which may inform individualized management during shock. OBJECTIVES This study determines the feasibility of measuring MA in skeletal muscle using near-infrared spectroscopy (NIRS) as a marker of tissue perfusion, the derivation of optimal mean arterial pressure (MAPopt), and comparison with indices from the brain. DESIGN Prospective observational study. SETTING Medical and surgical ICU in a tertiary academic hospital. PARTICIPANTS Adult critically ill patients requiring vasoactive support on the first day of ICU admission. MAIN OUTCOMES AND MEASURES Fifteen critically ill patients were enrolled. NIRS was applied simultaneously to skeletal muscle (brachioradialis) and brain (frontal cortex) while ABP was measured continuously via invasive catheter. MA correlation indices were calculated between ABP and NIRS from skeletal muscle total hemoglobin (MVx), muscle tissue saturation index (MOx), brain total hemoglobin (THx), and brain tissue saturation index (COx). Curve fitting algorithms derive the MAP with the lowest correlation index value, which is the MAPopt. RESULTS MAPopt values were successfully calculated for each correlation index for all patients and were frequently (77%) above 65 mm Hg. For all correlation indices, median time was substantially above impaired MA threshold (24.5-34.9%) and below target MAPopt (9.0-78.6%). Muscle and brain MAPopt show moderate correlation (MVx-THx r = 0.76, p < 0.001; MOx-COx r = 0.69, p = 0.005), with a median difference of -1.27 mm Hg (-9.85 to -0.18 mm Hg) and 0.05 mm Hg (-7.05 to 2.68 mm Hg). CONCLUSIONS AND RELEVANCE This study demonstrates, for the first time, the feasibility of calculating MA indices and MAPopt in skeletal muscle using NIRS. Future studies should explore the association between impaired skeletal muscle MA, ICU outcomes, and organ-specific differences in MA and MAPopt thresholds.
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Affiliation(s)
- Amirali Mirsajadi
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Dustin Erickson
- Section of Critical Care Medicine, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Soumya Alias
- Section of Critical Care Medicine, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Logan Froese
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Amanjyot Singh Sainbhi
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Alwyn Gomez
- Division of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, MB, Canada
| | - Raju Majumdar
- Section of Critical Care Medicine, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Isuru Herath
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Maggie Wilson
- Section of Critical Care Medicine, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Ryan Zarychanski
- Section of Critical Care Medicine, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Department of Medical Oncology and Hematology, University of Manitoba/CancerCare Manitoba, Winnipeg, MB, Canada
| | - Frederick A. Zeiler
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, MB, Canada
- Pan Am Clinic Foundation, Winnipeg, MB, Canada
| | - Asher A. Mendelson
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Section of Critical Care Medicine, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Department of Physiology, University of Manitoba, Winnipeg, MB, Canada
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Zeymer U, Freund A, Hochadel M, Schneider S, Thiele H. VA-ECMO for infarct-related cardiogenic shock - Authors' reply. Lancet 2024; 403:2487-2488. [PMID: 38851286 DOI: 10.1016/s0140-6736(24)00964-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 05/03/2024] [Indexed: 06/10/2024]
Affiliation(s)
- Uwe Zeymer
- Klinikum Ludwigshafen, Ludwigshafen 67063, Germany; Institut für Herzinfarktforschung, Ludwigshafen, Germany.
| | - Anne Freund
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | | | | | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
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4
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Yu Z, Li G. VA-ECMO for infarct-related cardiogenic shock. Lancet 2024; 403:2487. [PMID: 38851287 DOI: 10.1016/s0140-6736(24)00958-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 05/03/2024] [Indexed: 06/10/2024]
Affiliation(s)
- Zhexuan Yu
- The First School of Clinial Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Guanhua Li
- Department of Cardiothoracic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China.
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González R, Urbano J, López-Herce J. Resuscitating the macro- vs. microcirculation in septic shock. Curr Opin Pediatr 2024; 36:274-281. [PMID: 38446225 DOI: 10.1097/mop.0000000000001345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
PURPOSE OF REVIEW This review summarizes current literature about the relationships between macro and microcirculation and their practical clinical implications in children with septic shock. RECENT FINDINGS Current evidence from experimental and clinical observational studies in children and adults with septic shock reveals that the response to treatment and resuscitation is widely variable. Furthermore, there is a loss of hemodynamic coherence, as resuscitation-induced improvement in macrocirculation (systemic hemodynamic parameters) does not necessarily result in a parallel improvement in the microcirculation. Therefore, patient-tailored monitoring is essential in order to adjust treatment requirements during resuscitation in septic shock. Optimal monitoring must integrate macrocirculation (heart rate, blood pressure, cardiac output, and ultrasound images), microcirculation (videomicroscopy parameters and capillary refill time) and cellular metabolism (lactic acid, central venous blood oxygen saturation, and difference of central venous to arterial carbon dioxide partial pressure). SUMMARY There is a dire need for high-quality studies to assess the relationships between macrocirculation, microcirculation and tissue metabolism in children with septic shock. The development of reliable and readily available microcirculation and tissue perfusion biomarkers (other than lactic acid) is also necessary to improve monitoring and treatment adjustment in such patients.
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Affiliation(s)
- Rafael González
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón
- Health Research Institute of the Gregorio Marañón Hospital
- Maternal and Child Public Health Department. School of Medicine, Complutense University of Madrid
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - Javier Urbano
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón
- Health Research Institute of the Gregorio Marañón Hospital
- Maternal and Child Public Health Department. School of Medicine, Complutense University of Madrid
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - Jesús López-Herce
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón
- Health Research Institute of the Gregorio Marañón Hospital
- Maternal and Child Public Health Department. School of Medicine, Complutense University of Madrid
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
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Kotani Y, D'Andria Ursoleo J, Murru CP, Landoni G. Blood Pressure Management for Hypotensive Patients in Intensive Care and Perioperative Cardiovascular Settings. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00266-0. [PMID: 38918089 DOI: 10.1053/j.jvca.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 03/23/2024] [Accepted: 04/08/2024] [Indexed: 06/27/2024]
Abstract
Blood pressure is a critical physiological parameter, particularly in the context of cardiac intensive care and perioperative settings. As a primary indicator of organ perfusion, the maintenance of adequate blood pressure is imperative for the assurance of sufficient tissue oxygen delivery. Among critically ill and major surgery patients, the continuous monitoring of blood pressure is performed as a standard practice for patients. Nonetheless, uncertainties remain regarding blood pressure goals, and there is no consensus regarding blood pressure targets. This review describes the determinants of blood pressure, examine the influence of blood pressure on organ perfusion, and synthesize the current clinical evidence from various intensive care and perioperative settings to provide a concise guidance for daily clinical practice.
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Affiliation(s)
- Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Jacopo D'Andria Ursoleo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlotta Pia Murru
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
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Heymer J, Raepple D. The ongoing journey in targeting hemodynamic interventions: missing miles for missing the last micron? Intensive Care Med Exp 2024; 12:35. [PMID: 38594581 PMCID: PMC11004093 DOI: 10.1186/s40635-024-00621-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 04/04/2024] [Indexed: 04/11/2024] Open
Affiliation(s)
- Johannes Heymer
- Internistische Intensivmedizin, Zentrum Für Innere Medizin, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Daniel Raepple
- Internistische Intensivmedizin, Zentrum Für Innere Medizin, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany.
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Kattan E, Ibarra-Estrada M, Jung C. Knowing the ropes of vasopressor dosing: a focus on norepinephrine. Intensive Care Med 2024; 50:587-589. [PMID: 38498164 PMCID: PMC11018687 DOI: 10.1007/s00134-024-07374-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 02/25/2024] [Indexed: 03/20/2024]
Affiliation(s)
- Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Miguel Ibarra-Estrada
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Universidad de Guadalajara. Guadalajara, Jalisco, México
| | - Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225, Duesseldorf, Germany.
- CARID (Cardiovascular Research Institute Düsseldorf), Düsseldorf, Germany.
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Matsushita H, Saku K, Nishikawa T, Yokota S, Sato K, Morita H, Yoshida Y, Fukumitsu M, Uemura K, Kawada T, Yamaura K. The impact of ECPELLA on haemodynamics and global oxygen delivery: a comprehensive simulation of biventricular failure. Intensive Care Med Exp 2024; 12:13. [PMID: 38361021 PMCID: PMC10869331 DOI: 10.1186/s40635-024-00599-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/18/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND ECPELLA, a combination of veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) and Impella, a percutaneous left ventricular (LV) assist device, has emerged as a novel therapeutic option in patients with severe cardiogenic shock (CS). Since multiple cardiovascular and pump factors influence the haemodynamic effects of ECPELLA, optimising ECPELLA management remains challenging. In this study, we conducted a comprehensive simulation study of ECPELLA haemodynamics. We also simulated global oxygen delivery (DO2) under ECPELLA in severe CS and acute respiratory failure as a first step to incorporate global DO2 into our developed cardiovascular simulation. METHODS AND RESULTS Both the systemic and pulmonary circulations were modelled using a 5-element resistance‒capacitance network. The four ventricles were represented by time-varying elastances with unidirectional valves. In the scenarios of severe LV dysfunction, biventricular dysfunction with normal pulmonary vascular resistance (PVR, 0.8 Wood units), and biventricular dysfunction with high PVR (6.0 Wood units), we compared the changes in haemodynamics, pressure-volume relationship (PV loop), and global DO2 under different VA-ECMO flows and Impella support levels. RESULTS In the simulation, ECPELLA improved total systemic flow with a minimising biventricular pressure-volume loop, indicating biventricular unloading in normal PVR conditions. Meanwhile, increased Impella support level in high PVR conditions rendered the LV-PV loop smaller and induced LV suction in ECPELLA support conditions. The general trend of global DO2 was followed by the changes in total systemic flow. The addition of veno-venous ECMO (VV-ECMO) augmented the global DO2 increment under ECPELLA total support conditions. CONCLUSIONS The optimal ECPELLA support increased total systemic flow and achieved both biventricular unloading. The VV-ECMO effectively improves global DO2 in total ECPELLA support conditions.
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Affiliation(s)
- Hiroki Matsushita
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Keita Saku
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.
| | - Takuya Nishikawa
- Department of Research Promotion and Management, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Shohei Yokota
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Kei Sato
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Hidetaka Morita
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Yuki Yoshida
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Masafumi Fukumitsu
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Kazunori Uemura
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
- NTTR-NCVC Bio Digital Twin Centre, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Toru Kawada
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Ken Yamaura
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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De Backer D, Deutschman CS, Hellman J, Myatra SN, Ostermann M, Prescott HC, Talmor D, Antonelli M, Pontes Azevedo LC, Bauer SR, Kissoon N, Loeches IM, Nunnally M, Tissieres P, Vieillard-Baron A, Coopersmith CM. Surviving Sepsis Campaign Research Priorities 2023. Crit Care Med 2024; 52:268-296. [PMID: 38240508 DOI: 10.1097/ccm.0000000000006135] [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: 01/23/2024]
Abstract
OBJECTIVES To identify research priorities in the management, epidemiology, outcome, and pathophysiology of sepsis and septic shock. DESIGN Shortly after publication of the most recent Surviving Sepsis Campaign Guidelines, the Surviving Sepsis Research Committee, a multiprofessional group of 16 international experts representing the European Society of Intensive Care Medicine and the Society of Critical Care Medicine, convened virtually and iteratively developed the article and recommendations, which represents an update from the 2018 Surviving Sepsis Campaign Research Priorities. METHODS Each task force member submitted five research questions on any sepsis-related subject. Committee members then independently ranked their top three priorities from the list generated. The highest rated clinical and basic science questions were developed into the current article. RESULTS A total of 81 questions were submitted. After merging similar questions, there were 34 clinical and ten basic science research questions submitted for voting. The five top clinical priorities were as follows: 1) what is the best strategy for screening and identification of patients with sepsis, and can predictive modeling assist in real-time recognition of sepsis? 2) what causes organ injury and dysfunction in sepsis, how should it be defined, and how can it be detected? 3) how should fluid resuscitation be individualized initially and beyond? 4) what is the best vasopressor approach for treating the different phases of septic shock? and 5) can a personalized/precision medicine approach identify optimal therapies to improve patient outcomes? The five top basic science priorities were as follows: 1) How can we improve animal models so that they more closely resemble sepsis in humans? 2) What outcome variables maximize correlations between human sepsis and animal models and are therefore most appropriate to use in both? 3) How does sepsis affect the brain, and how do sepsis-induced brain alterations contribute to organ dysfunction? How does sepsis affect interactions between neural, endocrine, and immune systems? 4) How does the microbiome affect sepsis pathobiology? 5) How do genetics and epigenetics influence the development of sepsis, the course of sepsis and the response to treatments for sepsis? CONCLUSIONS Knowledge advances in multiple clinical domains have been incorporated in progressive iterations of the Surviving Sepsis Campaign guidelines, allowing for evidence-based recommendations for short- and long-term management of sepsis. However, the strength of existing evidence is modest with significant knowledge gaps and mortality from sepsis remains high. The priorities identified represent a roadmap for research in sepsis and septic shock.
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Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Clifford S Deutschman
- Department of Pediatrics, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY
- Sepsis Research Lab, the Feinstein Institutes for Medical Research, Manhasset, NY
| | - Judith Hellman
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Hallie C Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Massimo Antonelli
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Ignacio-Martin Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital, Leinster, Dublin, Ireland
| | | | - Pierre Tissieres
- Pediatric Intensive Care, Neonatal Medicine and Pediatric Emergency, AP-HP Paris Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Antoine Vieillard-Baron
- Service de Medecine Intensive Reanimation, Hopital Ambroise Pare, Universite Paris-Saclay, Le Kremlin-Bicêtre, France
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11
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Jung C. [ECLS shock study-no advantage for venoarterial ECMO in cardiogenic shock]. Med Klin Intensivmed Notfmed 2024; 119:46-48. [PMID: 37747480 DOI: 10.1007/s00063-023-01070-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2023] [Indexed: 09/26/2023]
Affiliation(s)
- Christian Jung
- Klinik für Kardiologie, Pneumologie und Angiologie des Universitätsklinikums Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland.
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12
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Saravi B, Goebel U, Hassenzahl LO, Jung C, David S, Feldheiser A, Stopfkuchen-Evans M, Wollborn J. Capillary leak and endothelial permeability in critically ill patients: a current overview. Intensive Care Med Exp 2023; 11:96. [PMID: 38117435 PMCID: PMC10733291 DOI: 10.1186/s40635-023-00582-8] [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: 09/18/2023] [Accepted: 12/12/2023] [Indexed: 12/21/2023] Open
Abstract
Capillary leak syndrome (CLS) represents a phenotype of increased fluid extravasation, resulting in intravascular hypovolemia, extravascular edema formation and ultimately hypoperfusion. While endothelial permeability is an evolutionary preserved physiological process needed to sustain life, excessive fluid leak-often caused by systemic inflammation-can have detrimental effects on patients' outcomes. This article delves into the current understanding of CLS pathophysiology, diagnosis and potential treatments. Systemic inflammation leading to a compromise of endothelial cell interactions through various signaling cues (e.g., the angiopoietin-Tie2 pathway), and shedding of the glycocalyx collectively contribute to the manifestation of CLS. Capillary permeability subsequently leads to the seepage of protein-rich fluid into the interstitial space. Recent insights into the importance of the sub-glycocalyx space and preserving lymphatic flow are highlighted for an in-depth understanding. While no established diagnostic criteria exist and CLS is frequently diagnosed by clinical characteristics only, we highlight more objective serological and (non)-invasive measurements that hint towards a CLS phenotype. While currently available treatment options are limited, we further review understanding of fluid resuscitation and experimental approaches to target endothelial permeability. Despite the improved understanding of CLS pathophysiology, efforts are needed to develop uniform diagnostic criteria, associate clinical consequences to these criteria, and delineate treatment options.
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Affiliation(s)
- Babak Saravi
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center, University of Freiburg, University of Freiburg, Freiburg, Germany.
| | - Ulrich Goebel
- Department of Anesthesiology and Critical Care, St. Franziskus-Hospital, Muenster, Germany
| | - Lars O Hassenzahl
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Duesseldorf, Germany
| | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Aarne Feldheiser
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Evang. Kliniken Essen-Mitte, Huyssens-Stiftung/Knappschaft, University of Essen, Essen, Germany
| | - Matthias Stopfkuchen-Evans
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Jakob Wollborn
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
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13
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Hilty MP, Duranteau J, Montomoli J, Yeh TYC, Ince C. A microcirculation-guided trial doomed to fail. Intensive Care Med 2023; 49:1557-1558. [PMID: 37707580 DOI: 10.1007/s00134-023-07223-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 09/15/2023]
Affiliation(s)
- Matthias P Hilty
- Institute of Intensive Care Medicine, University Hospital of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, UMR-S 999, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), INSERM, Paris Saclay University, Le Kremlin-Bicêtre, France
| | - Jonathan Montomoli
- Department of Anesthesia and Intensive Care, Infermi Hospital, AUSL Romagna, Rimini, Italy
| | - Tony Yu-Chang Yeh
- Department of Anaesthesiology, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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14
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Bruno RR, Hernandez G, Thiele H, Kattan E, Jung C. A microcirculation-guided trial: never trying is worse than failing. Intensive Care Med 2023; 49:1555-1556. [PMID: 37812227 PMCID: PMC10709223 DOI: 10.1007/s00134-023-07245-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 10/10/2023]
Affiliation(s)
- Raphael Romano Bruno
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Holger Thiele
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225, Duesseldorf, Germany.
- CARID (Cardiovascular Research Institute Düsseldorf), Duesseldorf, Germany.
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15
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Damiani E, Scorcella C, Carsetti A, Donati A, Adrario E. Microcirculation as a guide for therapy: do not condemn an innocent without a fair trial. Intensive Care Med 2023; 49:1270-1271. [PMID: 37603098 DOI: 10.1007/s00134-023-07192-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/02/2023] [Indexed: 08/22/2023]
Affiliation(s)
- Elisa Damiani
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, via Tronto 10/a, 60126, Ancona, Italy.
- Clinica di Anestesia e Rianimazione Generale, Respiratoria e del Trauma Maggiore, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy.
| | - Claudia Scorcella
- Clinica di Anestesia e Rianimazione Generale, Respiratoria e del Trauma Maggiore, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Andrea Carsetti
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, via Tronto 10/a, 60126, Ancona, Italy
- Clinica di Anestesia e Rianimazione Generale, Respiratoria e del Trauma Maggiore, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Abele Donati
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, via Tronto 10/a, 60126, Ancona, Italy
- Clinica di Anestesia e Rianimazione Generale, Respiratoria e del Trauma Maggiore, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Erica Adrario
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, via Tronto 10/a, 60126, Ancona, Italy
- Clinica di Anestesia e Rianimazione Generale, Respiratoria e del Trauma Maggiore, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
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16
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Bruno RR, Hernandez G, Wollborn J, Saugel B, Jung C. Microcirculation information in clinical decision making: Rome wasn't built in a day. Intensive Care Med 2023; 49:1272-1273. [PMID: 37695331 PMCID: PMC10556112 DOI: 10.1007/s00134-023-07216-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2023] [Indexed: 09/12/2023]
Affiliation(s)
- Raphael Romano Bruno
- Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jakob Wollborn
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Jung
- Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany.
- CARID (Cardiovascular Research Institute Düsseldorf), Duesseldorf, Germany.
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17
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Kanoore Edul VS, Dubin A. Pitfalls in the use of microcirculation as a resuscitation goal. Intensive Care Med 2023; 49:1268-1269. [PMID: 37603099 DOI: 10.1007/s00134-023-07191-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/01/2023] [Indexed: 08/22/2023]
Affiliation(s)
- Vanina S Kanoore Edul
- Servicio de Terapia Intensiva, Sanatorio Otamendi, Ciudad Autónoma de Buenos Aires, Azcuénaga 870, C1115AAB, Buenos Aires, Argentina
- Cátedras de Terapia Intensiva y Farmacología Aplicada, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, La Plata, Argentina
| | - Arnaldo Dubin
- Servicio de Terapia Intensiva, Sanatorio Otamendi, Ciudad Autónoma de Buenos Aires, Azcuénaga 870, C1115AAB, Buenos Aires, Argentina.
- Cátedras de Terapia Intensiva y Farmacología Aplicada, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, La Plata, Argentina.
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18
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Jacquet-Lagrèze M, Magnin M, Allaouchiche B, Abrard S. Is handheld video microscopy really the future of microcirculation monitoring? Crit Care 2023; 27:352. [PMID: 37700327 PMCID: PMC10498643 DOI: 10.1186/s13054-023-04642-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/08/2023] [Indexed: 09/14/2023] Open
Affiliation(s)
- Matthias Jacquet-Lagrèze
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677, Bron Cedex, France
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon Cedex 08, France
- Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard, Lyon 1, Lyon, France
| | - Mathieu Magnin
- Unité de Physiologie, Pharmacodynamie et Thérapeutique, VetAgro Sup, Université de Lyon, 1 Avenue Bourgelat, 69280, Marcy L'Etoile, France
- Pulmonary and Cardiovascular Aggression in Sepsis APCSe, UPSP 2021.A101, Université de Lyon, VetAgro Sup, Campus Vétérinaire de Lyon, 69280, Marcy L'Étoile, France
| | - Bernard Allaouchiche
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon Cedex 08, France
- Pulmonary and Cardiovascular Aggression in Sepsis APCSe, UPSP 2021.A101, Université de Lyon, VetAgro Sup, Campus Vétérinaire de Lyon, 69280, Marcy L'Étoile, France
- Centre Hospitalier Lyon-Sud, Service de Réanimation, Hospices Civils de Lyon, 69310, Pierre-Bénite, France
| | - Stanislas Abrard
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon Cedex 08, France.
- Service d'Anesthésie-Réanimation, Hospices Civils de Lyon, Hôpital Edouard Herriot, 5 Pl d'Arsonval, 69437, Lyon, France.
- Institut MitoVasc, INSERM 1083 ‑ CNRS 6015, Université d'Angers, 3 Rue Roger Amsler, 49100, Angers, France.
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19
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Damiani E, Carsetti A, Casarotta E, Domizi R, Scorcella C, Donati A, Adrario E. Microcirculation-guided resuscitation in sepsis: the next frontier? Front Med (Lausanne) 2023; 10:1212321. [PMID: 37476612 PMCID: PMC10354242 DOI: 10.3389/fmed.2023.1212321] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/20/2023] [Indexed: 07/22/2023] Open
Abstract
Microcirculatory dysfunction plays a key role in the pathogenesis of tissue dysoxia and organ failure in sepsis. Sublingual videomicroscopy techniques enable the real-time non-invasive assessment of microvascular blood flow. Alterations in sublingual microvascular perfusion were detected during sepsis and are associated with poor outcome. More importantly, sublingual videomicroscopy allowed to explore the effects of commonly applied resuscitative treatments in septic shock, such as fluids, vasopressors and inotropes, and showed that the optimization of macro-hemodynamic parameters may not be accompanied by an improvement in microvascular perfusion. This loss of "hemodynamic coherence," i.e., the concordance between the response of the macrocirculation and the microcirculation, advocates for the integration of microvascular monitoring in the management of septic patients. Nonetheless, important barriers remain for a widespread use of sublingual videomicroscopy in the clinical practice. In this review, we discuss the actual limitations of this technique and future developments that may allow an easier and faster evaluation of the microcirculation at the bedside, and propose a role for sublingual microvascular monitoring in guiding and titrating resuscitative therapies in sepsis.
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Affiliation(s)
- Elisa Damiani
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Andrea Carsetti
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Erika Casarotta
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Roberta Domizi
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Claudia Scorcella
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Abele Donati
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Erica Adrario
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
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