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Carrara M, Campitelli R, Guberti D, Monge Garcia MI, Ferrario M. The role of pulse wave analysis indexes for critically ill patients: a narrative review. Physiol Meas 2024; 45:08TR01. [PMID: 39094611 DOI: 10.1088/1361-6579/ad6acf] [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: 04/12/2024] [Accepted: 08/02/2024] [Indexed: 08/04/2024]
Abstract
Objective.Arterial pulse wave analysis (PWA) is now established as a powerful tool to investigate the cardiovascular system, and several clinical studies have shown how PWA can provide valuable prognostic information over and beyond traditional cardiovascular risk factors. Typically these techniques are applied to chronic conditions, such as hypertension or aging, to monitor the slow structural changes of the vascular system which lead to important alterations of the arterial PW. However, their application to acute critical illness is not currently widespread, probably because of the high hemodynamic instability and acute dynamic alterations affecting the cardiovascular system of these patients.Approach.In this work we propose a review of the physiological and methodological basis of PWA, describing how it can be used to provide insights into arterial structure and function, cardiovascular biomechanical properties, and to derive information on wave propagation and reflection.Main results.The applicability of these techniques to acute critical illness, especially septic shock, is extensively discussed, highlighting the feasibility of their use in acute critical patients and their role in optimizing therapy administration and hemodynamic monitoring.Significance.The potential for the clinical use of these techniques lies in the ease of computation and availability of arterial blood pressure signals, as invasive arterial lines are commonly used in these patients. We hope that the concepts illustrated in the present review will soon be translated into clinical practice.
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Affiliation(s)
- Marta Carrara
- Department of Electronics, Information, and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Riccardo Campitelli
- Department of Electronics, Information, and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Diletta Guberti
- Department of Electronics, Information, and Bioengineering, Politecnico di Milano, Milan, Italy
| | - M Ignacio Monge Garcia
- Intensive Care Department, Hospital Universitario SAS de Jerez, Jerez de la Frontera, Spain
| | - Manuela Ferrario
- Department of Electronics, Information, and Bioengineering, Politecnico di Milano, Milan, Italy
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Brown A, Udy A, Burrell A, Joyce CJ. Beta-blockade for the treatment of refractory hypoxaemia during venovenous extracorporeal membrane oxygenation: An in-silico study. Perfusion 2024:2676591241262261. [PMID: 38881099 DOI: 10.1177/02676591241262261] [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: 06/18/2024]
Abstract
INTRODUCTION Venovenous extracorporeal membrane oxygenation (VV ECMO) is used for refractory hypoxemia, although despite this, in high cardiac output states, hypoxaemia may persist. The administration of beta-blockers has been suggested as an approach in this scenario, however the physiological consequences of this intervention are not clear. METHODS We performed an in-silico study using a previously described mathematical model to evaluate the effect of beta-blockade on mixed venous and arterial saturations (S v ¯ O 2 , SaO2), in three different clinical scenarios and considered the potential effects of beta-blockers on, cardiac output, oxygen consumption and recirculation. Additionally we assessed the interaction of beta-blockade with haemoglobin concentration. RESULTS In scenario 1: simulating a patient with high cardiac output and partial lung shunt S v ¯ O 2 decreased from increased 53.5% to 44.7% despite SaO2 rising from 74.2% to 79.2%. In scenario 2 simulating a patient with high cardiac output and complete lung shunt S v ¯ O 2 remained unchanged at 52.2% and SaO2 rose from 71.9% to 85%. In scenario 3 a patient with normal cardiac output and high recirculation S v ¯ O 2 fell from 50.8% to 25.5% and also fell from 82.4% to to 78.3%. Across the remaining modelling examples the effect on S v ¯ O 2 varied but oxygen delivery was consistently reduced across all scenarios. CONCLUSION The administration of beta-blockers for refractory hypoxemia during VV ECMO are unpredictable and may reduce oxygen delivery, although this will vary with patient and circuit features. This study does not support the use of beta-blockers for this indication.
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Affiliation(s)
- Alastair Brown
- Australia and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Critical Care Medicine, St Vincent's Hospital Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Andrew Udy
- Australia and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Aidan Burrell
- Australia and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Christopher J Joyce
- Department of Intensive Care, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Academy of Critical Care, University of Queensland, Brisbane, QLD, Australia
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Obata Y, Matsuki Y, Okafuji K, Shigemi K. Effect of age and gender on ventricular-arterial coupling estimated using a non-invasive technique. BMC Anesthesiol 2024; 24:83. [PMID: 38413898 PMCID: PMC10898067 DOI: 10.1186/s12871-024-02452-6] [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: 06/12/2023] [Accepted: 02/09/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Left ventricular-arterial coupling is assessed as the ratio of left ventricular end-systolic elastance (Ees) to arterial elastance (Ea). Previous studies have introduced non-invasive estimations of Ees/Ea. It requires only four variables, namely pre-ejection period, ejection time, end-systolic pressure and diastolic pressure. The aims of the present study were to clarify the reference values of Ees/Ea estimated using the noninvasive technique, and to investigate the effects of age and gender on Ees/Ea in healthy subjects. METHODS This retrospective study utilized data from healthy, 30-79-year-old subjects. We recorded electrocardiogram, phonocardiogram, and brachial arterial pulse waves simultaneously using the vascular screening system, and used the observed variables to calculate Ees/Ea. We separated subjects into five groups according to their age and compared Ees/Ea among the different age groups. RESULTS The study included 2114 males and 2292 females. Ees/Ea ranged from 1.87 to 2.04 in males, and 1.98 to 2.32 in females. We observed no age-related differences in Ees/Ea in males (p = 0.10), and significant differences in females (p < 0.001). Ees/Ea in males was not different compared to those in females in 60-69-year-old group (p = 0.92). Whereas Ees/Ea was higher in females compared to those in males in the other age groups. The differences between medians of Ees/Ea in males and those in females were 0.45 (p < 0.001), 0.24 (p < 0.001), 0.13 (p = 0.01), and 0.13 (p = 0.03) in 30-39, 40-49, 50-59, and 70-79-year-old age groups, respectively. CONCLUSIONS We clarified the reference values of Ees/Ea in healthy subjects. The effect of age on Ees/Ea is different in males and females, although Ees/Ea is maintained within a relatively narrow range in all subjects.
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Affiliation(s)
- Yurie Obata
- Department of Anesthesiology, Yodogawa Christian Hospital, Osaka, Japan
| | - Yuka Matsuki
- Department of Anesthesiology and Reanimatology, Faculty of Medicine Sciences, University of Fukui, Fukui, Japan.
- Department of Anesthesiology and Reanimatology, Faculty of Medicine Sciences, University of Fukui, 23-3 Eiheijicho, Yoshidagun, 910-1193, Fukui, Japan.
| | - Kazuhiro Okafuji
- Health Examination Center, Fukui-ken Saiseikai Hospital, Fukui, Japan
| | - Kenji Shigemi
- Department of Anesthesiology and Reanimatology, Faculty of Medicine Sciences, University of Fukui, Fukui, Japan
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Sato R, Sanfilippo F, Hasegawa D, Prasitlumkum N, Duggal A, Dugar S. Prevalence and prognosis of hyperdynamic left ventricular systolic function in septic patients: a systematic review and meta-analysis. Ann Intensive Care 2024; 14:22. [PMID: 38308701 PMCID: PMC10838258 DOI: 10.1186/s13613-024-01255-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 01/21/2024] [Indexed: 02/05/2024] Open
Abstract
PURPOSE The prevalence of hyperdynamic left ventricular (LV) systolic function in septic patients and its impact on mortality remain controversial. In this systematic review and meta-analysis, we investigated the prevalence and association of hyperdynamic LV systolic function with mortality in patients with sepsis. METHODS We searched MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. Primary outcomes were the prevalence of hyperdynamic LV systolic function in adult septic patients and the associated short-term mortality as compared to normal LV systolic function. Hyperdynamic LV systolic function was defined using LV ejection fraction (LVEF) of 70% as cutoff. Secondary outcomes were heart rate, LV end-diastolic diameter (LVEDD), and E/e' ratio. RESULTS Four studies were included, and the pooled prevalence of hyperdynamic LV systolic function was 18.2% ([95% confidence interval (CI) 12.5, 25.8]; I2 = 7.0%, P < 0.0001). Hyperdynamic LV systolic function was associated with higher mortality: odds ratio of 2.37 [95%CI 1.47, 3.80]; I2 = 79%, P < 0.01. No difference was found in E/e' (P = 0.43) between normal and hyperdynamic LV systolic function, while higher values of heart rate (mean difference: 6.14 beats/min [95%CI 3.59, 8.69]; I2 = 51%, P < 0.0001) and LVEDD (mean difference: - 0.21 cm [95%CI - 0.33, - 0.09]; I2 = 73%, P < 0.001) were detected in patients with hyperdynamic LV systolic function. CONCLUSION The prevalence of hyperdynamic LV systolic function is not negligible in septic patients. Such a finding is associated with significantly higher short-term mortality as compared to normal LV systolic function.
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Affiliation(s)
- Ryota Sato
- Division of Critical Care Medicine, Department of Medicine, The Queen's Medical Center, Honolulu, HI, USA
| | - Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. Policlinico-San Marco, Site "Policlinico G. Rodolico", Via S. Sofia N 78, 95123, Catania, Italy
| | - Daisuke Hasegawa
- Department of Internal Medicine, Mount Sinai Beth Israel, New York, NY, USA
| | | | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA.
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Gonzalez FA, Santonocito C, Maybauer MO, Lopes LR, Almeida AG, Sanfilippo F. Diastology in the intensive care unit: Challenges for the assessment and future directions. Echocardiography 2024; 41:e15773. [PMID: 38380688 DOI: 10.1111/echo.15773] [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: 12/17/2023] [Revised: 01/19/2024] [Accepted: 01/20/2024] [Indexed: 02/22/2024] Open
Abstract
Myocardial dysfunction is common in patients admitted to the intensive care unit (ICU). Septic disease frequently results in cardiac dysfunction, and sepsis represents the most common cause of admission and death in the ICU. The association between left ventricular (LV) systolic dysfunction and mortality is not clear for critically ill patients. Conversely, LV diastolic dysfunction (DD) seems increasingly recognized as a factor associated with poor outcomes, not only in sepsis but also more generally in critically ill patients. Despite recent attempts to simplify the diagnosis and grading of DD, this remains relatively complex, with the need to use several echocardiographic parameters. Furthermore, the current guidelines have several intrinsic limitations when applied to the ICU setting. In this manuscript, we discuss the challenges in DD classification when applied to critically ill patients, the importance of left atrial pressure estimates for the management of patients in ICU, and whether the study of cardiac dysfunction spectrum during critical illness may benefit from the integration of left ventricular and left atrial strain data to improve diagnostic accuracy and implications for the treatment and prognosis.
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Affiliation(s)
- Filipe A Gonzalez
- Intensive Care Department of Hospital Garcia de Orta, Almada, Portugal
- Centro Cardiovascular da Universidade de Lisboa, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Cristina Santonocito
- Department of Anesthesia and Intensive Care, "Policlinico-San Marco" University Hospital, Catania, Italy
| | - Marc O Maybauer
- Department of Anesthesiology, Division of Critical Care Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Luís Rocha Lopes
- Inherited Cardiac Disease Unit, Bart's Heart Centre St Bartholomew's Hospital London, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Ana G Almeida
- Centro Cardiovascular da Universidade de Lisboa, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, "Policlinico-San Marco" University Hospital, Catania, Italy
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
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Sanfilippo F, Messina A, Scolletta S, Bignami E, Morelli A, Cecconi M, Landoni G, Romagnoli S. The "CHEOPS" bundle for the management of Left Ventricular Diastolic Dysfunction in critically ill patients: an experts' opinion. Anaesth Crit Care Pain Med 2023; 42:101283. [PMID: 37516408 DOI: 10.1016/j.accpm.2023.101283] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 07/31/2023]
Abstract
The impact of left ventricular (LV) diastolic dysfunction (DD) on the outcome of patients with heart failure was established over three decades ago. Nevertheless, the relevance of LVDD for critically ill patients admitted to the intensive care unit has seen growing interest recently, and LVDD is associated with poor prognosis. Whilst an assessment of LV diastolic function is desirable in critically ill patients, treatment options for LVDD are very limited, and pharmacological possibilities to rapidly optimize diastolic function have not been found yet. Hence, a proactive approach might have a substantial role in improving the outcomes of these patients. Recalling historical Egyptian parallelism suggesting that Doppler echocardiography has been the "Rosetta stone" to decipher the study of LV diastolic function, we developed a potentially useful acronym for physicians at the bedside to optimize the management of critically ill patients with LVDD with the application of the bundle. We summarized the bundle under the acronym of the famous ancient Egyptian pharaoh CHEOPS: Chest Ultrasound, combining information from echocardiography and lung ultrasound; HEmodynamics assessment, with careful evaluation of heart rate and rhythm, as well as afterload and vasoactive drugs; OPtimization of mechanical ventilation and pulmonary circulation, considering the effects of positive end-expiratory pressure on both right and left heart function; Stabilization, with cautious fluid administration and prompt fluid removal whenever judged safe and valuable. Notably, the CHEOPS bundle represents experts' opinion and are not targeted at the initial resuscitation phase but rather for the optimization and subsequent period of critical illness.
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Affiliation(s)
- Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. Policlinico-San Marco, Catania, Italy; Department of General Surgery and Medico-Surgical Specialties, School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy.
| | - Antonio Messina
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center IRCCS, 20089, Rozzano, Milan, Italy.
| | - Sabino Scolletta
- Anesthesia and Intensive Care Unit, University Hospital of Siena, University of Siena, Siena, Italy.
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Andrea Morelli
- Department Clinical Internal, Anesthesiological and Cardiovascular Sciences, University of Rome, "La Sapienza", Policlinico Umberto Primo, Roma, Italy.
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center IRCCS, 20089, Rozzano, Milan, Italy.
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
| | - Stefano Romagnoli
- Department of Health Science, Section of Anaesthesia and Intensive Care, University of Florence, Department of Anetshesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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Whitehouse T, Hossain A, Perkins GD, Gordon AC, Bion J, Young D, McAuley D, Singer M, Lord J, Gates S, Veenith T, MacCallum NS, Yeung J, Innes R, Welters I, Boota N, Skilton E, Ghuman B, Hill M, Regan SE, Mistry D, Lall R. Landiolol and Organ Failure in Patients With Septic Shock: The STRESS-L Randomized Clinical Trial. JAMA 2023; 330:1641-1652. [PMID: 37877587 PMCID: PMC10600724 DOI: 10.1001/jama.2023.20134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 09/18/2023] [Indexed: 10/26/2023]
Abstract
Importance Patients with septic shock undergo adrenergic stress, which affects cardiac, immune, inflammatory, and metabolic pathways. β-Blockade may attenuate the adverse effects of catecholamine exposure and has been associated with reduced mortality. Objectives To assess the efficacy and safety of landiolol in patients with tachycardia and established septic shock requiring prolonged (>24 hours) vasopressor support. Design, Setting, and Participants An open-label, multicenter, randomized trial involving 126 adults (≥18 years) with tachycardia (heart rate ≥95/min) and established septic shock treated for at least 24 hours with continuous norepinephrine (≥0.1 μg/kg/min) in 40 UK National Health Service intensive care units. The trial ran from April 2018 to December 2021, with early termination in December 2021 due to a signal of possible harm. Intervention Sixty-three patients were randomized to receive standard care and 63 to receive landiolol infusion. Main Outcomes and Measures The primary outcome was the mean Sequential Organ Failure Assessment (SOFA) score from randomization through 14 days. Secondary outcomes included mortality at days 28 and 90 and the number of adverse events in each group. Results The trial was stopped prematurely on the advice of the independent data monitoring committee because it was unlikely to demonstrate benefit and because of possible harm. Of a planned 340 participants, 126 (37%) were enrolled (mean age, 55.6 years [95% CI, 52.7 to 58.5 years]; 58.7% male). The mean (SD) SOFA score in the landiolol group was 8.8 (3.9) compared with 8.1 (3.2) in the standard care group (mean difference [MD], 0.75 [95% CI, -0.49 to 2.0]; P = .24). Mortality at day 28 after randomization in the landiolol group was 37.1% (23 of 62) and 25.4% (16 of 63) in the standard care group (absolute difference, 11.7% [95% CI, -4.4% to 27.8%]; P = .16). Mortality at day 90 after randomization was 43.5% (27 of 62) in the landiolol group and 28.6% (18 of 63) in the standard care group (absolute difference, 15% [95% CI, -1.7% to 31.6%]; P = .08). There were no differences in the number of patients having at least one adverse event. Conclusion and Relevance Among patients with septic shock with tachycardia and treated with norepinephrine for more than 24 hours, an infusion of landiolol did not reduce organ failure measured by the SOFA score over 14 days from randomization. These results do not support the use of landiolol for managing tachycardia among patients treated with norepinephrine for established septic shock. Trial Registration EU Clinical Trials Register Eudra CT: 2017-001785-14; isrctn.org Identifier: ISRCTN12600919.
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Affiliation(s)
- Tony Whitehouse
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, United Kingdom
| | - Anower Hossain
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Gavin D. Perkins
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Anthony C. Gordon
- Division of Anaesthetics, Pain Medicine & Intensive Care, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Julian Bion
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Clinical Sciences, University of Birmingham, United Kingdom
| | - Duncan Young
- Kadoorie Centre for Critical Care Research, Nuffield Division of Anaesthesia, University of Oxford, Oxford, United Kingdom
| | - Danny McAuley
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, United Kingdom
- The Wellcome Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, United Kingdom
| | - Mervyn Singer
- Centre for Intensive Care Medicine, Department of Medicine and Wolfson Institute for Biomedical Research, University College, London, United Kingdom
| | - Janet Lord
- Institute of Inflammation and Ageing, University of Birmingham, United Kingdom
| | - Simon Gates
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Tonny Veenith
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, United Kingdom
| | - Niall S. MacCallum
- University College London Hospitals NHS Foundation Trust, Gower Street, London, United Kingdom
| | - Joyce Yeung
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Richard Innes
- Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, United Kingdom
| | | | - Nafisa Boota
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Emma Skilton
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Belinder Ghuman
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Maddy Hill
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Scott E. Regan
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Dipesh Mistry
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Ranjit Lall
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
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Guarracino F, Cortegiani A, Antonelli M, Behr A, Biancofiore G, Del Gaudio A, Forfori F, Galdieri N, Grasselli G, Paternoster G, Rocco M, Romagnoli S, Sardo S, Treskatsch S, Tripodi VF, Tritapepe L. The role of beta-blocker drugs in critically ill patients: a SIAARTI expert consensus statement. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2023; 3:41. [PMID: 37872608 PMCID: PMC10591347 DOI: 10.1186/s44158-023-00126-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/10/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND The role of β-blockers in the critically ill has been studied, and data on the protective effects of these drugs on critically ill patients have been repeatedly reported in the literature over the last two decades. However, consensus and guidelines by scientific societies on the use of β-blockers in critically ill patients are still lacking. The purpose of this document is to support the clinical decision-making process regarding the use of β-blockers in critically ill patients. The recipients of this document are physicians, nurses, healthcare personnel, and other professionals involved in the patient's care process. METHODS The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) selected a panel of experts and asked them to define key aspects underlying the use of β-blockers in critically ill adult patients. The methodology followed by the experts during this process was in line with principles of modified Delphi and RAND-UCLA methods. The experts developed statements and supportive rationales in the form of informative text. The overall list of statements was subjected to blind votes for consensus. RESULTS The literature search suggests that adrenergic stress and increased heart rate in critically ill patients are associated with organ dysfunction and increased mortality. Heart rate control thus seems to be critical in the management of the critically ill patient, requiring careful clinical evaluation aimed at both the differential diagnosis to treat secondary tachycardia and the treatment of rhythm disturbance. In addition, the use of β-blockers for the treatment of persistent tachycardia may be considered in patients with septic shock once hypovolemia has been ruled out. Intravenous application should be the preferred route of administration. CONCLUSION β-blockers protective effects in critically ill patients have been repeatedly reported in the literature. Their use in the acute treatment of increased heart rate requires understanding of the pathophysiology and careful differential diagnosis, as all causes of tachycardia should be ruled out and addressed first.
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Affiliation(s)
- Fabio Guarracino
- Cardiothoracic and Vascular Anesthesia and Intensive Care, Anesthesia and Resuscitation Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy.
- Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, 90127, Palermo, Italy.
| | - Massimo Antonelli
- Department of Emergency, Anesthesiological and Resuscitation Sciences, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Astrid Behr
- Operative Unit of Anesthesia and Resuscitation, Hospital of Camposampiero, Padua, Italy
| | - Giandomenico Biancofiore
- Anesthesia and Resuscitation Transplants, Department of Medical Pathology Surgical, Molecular and Critical Area, University of Pisa, Pisa, Italy
| | - Alfredo Del Gaudio
- Emergency Department, Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Italy
| | - Francesco Forfori
- Anesthesia and Intensive Care, Anesthesia and Resuscitation Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Nicola Galdieri
- General Cardiac Surgery Unit, Critical Area Department, Ospedale Dei Colli, Naples, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Resuscitation and Emergency, IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Medical-Surgical and Transplant Pathophysiology, University of Milan, Milan, Italy
| | | | - Monica Rocco
- Department of Surgical and Medical Science and Translational Medicine, Sapienza University of Rome, Rome, Italy
| | - Stefano Romagnoli
- Anesthesia and Intensive Care Section, Department of Health Sciences, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, Careggi University Hospital, Florence, Italy
| | - Salvatore Sardo
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Freie Universität and Humboldt-Universität Zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Vincenzo Francesco Tripodi
- Anesthesia and Intensive Care Unit, Department of Surgery, University Hospital "Gaetano Martino", Messina, Italy
| | - Luigi Tritapepe
- Anesthesia and Resuscitation Unit, San Camillo-Forlanini Hospital, Sapienza University, Rome, Italy
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Demailly Z, Besnier E, Tamion F, Lesur O. Ventriculo-arterial (un)coupling in septic shock: Impact of current and upcoming hemodynamic drugs. Front Cardiovasc Med 2023; 10:1172703. [PMID: 37324631 PMCID: PMC10266274 DOI: 10.3389/fcvm.2023.1172703] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/08/2023] [Indexed: 06/17/2023] Open
Abstract
Sepsis is an archetype of distributive shock and combines different levels of alterations in preload, afterload, and often cardiac contractility. The use of hemodynamic drugs has evolved over the past few years, along with the invasive and non-invasive tools used to measure these components in real time. However, none of them is impeccable, which is why the mortality of septic shock remains too high. The concept of ventriculo-arterial coupling (VAC) allows for the integration of these three fundamental macroscopic hemodynamic components. In this mini review, we discuss the knowledge, tools, and limitations of VAC measurement, along with the evidence supporting ventriculo-arterial uncoupling in septic shock. Finally, the impact of recommended hemodynamic drugs and molecules on VAC is detailed.
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Affiliation(s)
- Zoé Demailly
- Medical Intensive Care Unit, UNIROUEN, INSERM U1096, CHU Rouen, Normandie Université, Rouen, France
- Department of Anesthesiology and Critical Care, UNIROUEN, INSERM U1096, CHU Rouen, Normandie Université, Rouen, France
| | - Emmanuel Besnier
- Department of Anesthesiology and Critical Care, UNIROUEN, INSERM U1096, CHU Rouen, Normandie Université, Rouen, France
| | - Fabienne Tamion
- Medical Intensive Care Unit, UNIROUEN, INSERM U1096, CHU Rouen, Normandie Université, Rouen, France
| | - Olivier Lesur
- Centre de Recherche Clinique du CHU Sherbrooke, Sherbrooke, QC, Canada
- Départements de Soins Intensifs et de Médecine et Service de Pneumologie, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
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10
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Mulder MP, Broomé M, Donker DW, Westerhof BE. Distinct morphologies of arterial waveforms reveal preload-, contractility-, and afterload-deficient hemodynamic instability: An in silico simulation study. Physiol Rep 2022; 10:e15242. [PMID: 35412023 PMCID: PMC9004248 DOI: 10.14814/phy2.15242] [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: 11/08/2021] [Revised: 02/18/2022] [Accepted: 03/05/2022] [Indexed: 11/24/2022] Open
Abstract
Hemodynamic instability is frequently present in critically ill patients, primarily caused by a decreased preload, contractility, and/or afterload. We hypothesized that peripheral arterial blood pressure waveforms allow to differentiate between these underlying causes. In this in-silico experimental study, a computational cardiovascular model was used to simulate hemodynamic instability by decreasing blood volume, left ventricular contractility or systemic vascular resistance, and additionally adaptive and compensatory mechanisms. From the arterial pressure waveforms, 45 features describing the morphology were discerned and a sensitivity analysis and principal component analysis were performed, to quantitatively investigate their discriminative power. During hemodynamic instability, the arterial waveform morphology changed distinctively, for example, the slope of the systolic upstroke having a sensitivity of 2.02 for reduced preload, 0.80 for reduced contractility, and -0.02 for reduced afterload. It was possible to differentiate between the three underlying causes based on the derived features, as demonstrated by the first two principal components explaining 99% of the variance in waveforms. The features with a high correlation coefficient (>0.25) to these principal components are describing the systolic up- and downstroke, and the anacrotic and dicrotic notches of the waveforms. In this study, characteristic peripheral arterial waveform morphologies were identified that allow differentiation between deficits in preload, contractility, and afterload causing hemodynamic instability. These findings are confined to an in silico simulation and warrant further experimental and clinical research in order to prove clinical usability in daily practice.
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Affiliation(s)
- Marijn P Mulder
- Cardiovascular and Respiratory Physiology, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Michael Broomé
- Anesthesia and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden.,ECMO Department, Karolinska University Hospital, Stockholm, Sweden
| | - Dirk W Donker
- Cardiovascular and Respiratory Physiology, TechMed Centre, University of Twente, Enschede, The Netherlands.,Intensive Care Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Berend E Westerhof
- Cardiovascular and Respiratory Physiology, TechMed Centre, University of Twente, Enschede, The Netherlands.,Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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11
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Lescroart M, Pequignot B, Kimmoun A, Klein T, Levy B. Beta-blockers in septic shock: What is new? JOURNAL OF INTENSIVE MEDICINE 2022; 2:150-155. [PMID: 36789018 PMCID: PMC9923987 DOI: 10.1016/j.jointm.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 12/27/2021] [Accepted: 01/06/2022] [Indexed: 11/29/2022]
Abstract
The use of beta(β)-blockers during septic shock aimed at countering peripheral adrenergic stress may be justified by the early reduction in deleterious effects resulting from sympathetic overactivation, and could improve the prognosis of patients in septic shock. Animal studies have demonstrated either a maintenance or increase in cardiac output (CO) despite the decrease in heart rate (HR) associated with improved myocardial performance. The mechanism by which β-blockers alter hemodynamics in septic shock is debated; however, preclinical and clinical data show that β-blockers are safe when started at a low dose. Recent publications (2019-2021) on adrenergic β1 receptor antagonists used in septic shock indicate that esmolol and landiolol should not be used in the early phase. While there is no optimal timing for their administration, a minimum of 12 h after the initiation of vasopressor therapy in stabilized euvolemic patients is a reasonable option. Patients should have a normal cardiac function, although a slight depression is compatible with landiolol use under hemodynamic monitoring. Slow titration in patients who remain tachycardic is preferable to rapid titration. When used to decrease HR, landiolol is also effective in reducing the incidence of new arrhythmias. Results of a well-performed and well-powered randomized controlled trial (RCT) demonstrating a positive effect on survival - or at least on hard surrogates such as the incidence/duration of organ failure - are pending.
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Affiliation(s)
- Mickael Lescroart
- Service de Médecine Intensive et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, University Hospital of Nancy-Brabois, Rue du Morvan, Vandœuvre-les-Nancy 54511, France,INSERM U1116, Faculté de Médecine, Vandœuvre-les-Nancy 54511, France,Université de Lorraine, Nancy 54000, France
| | - Benjamin Pequignot
- Service de Médecine Intensive et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, University Hospital of Nancy-Brabois, Rue du Morvan, Vandœuvre-les-Nancy 54511, France,INSERM U1116, Faculté de Médecine, Vandœuvre-les-Nancy 54511, France,Université de Lorraine, Nancy 54000, France
| | - Antoine Kimmoun
- Service de Médecine Intensive et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, University Hospital of Nancy-Brabois, Rue du Morvan, Vandœuvre-les-Nancy 54511, France,INSERM U1116, Faculté de Médecine, Vandœuvre-les-Nancy 54511, France,Université de Lorraine, Nancy 54000, France
| | - Thomas Klein
- Service de Médecine Intensive et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, University Hospital of Nancy-Brabois, Rue du Morvan, Vandœuvre-les-Nancy 54511, France,INSERM U1116, Faculté de Médecine, Vandœuvre-les-Nancy 54511, France,Université de Lorraine, Nancy 54000, France
| | - Bruno Levy
- Service de Médecine Intensive et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, University Hospital of Nancy-Brabois, Rue du Morvan, Vandœuvre-les-Nancy 54511, France,INSERM U1116, Faculté de Médecine, Vandœuvre-les-Nancy 54511, France,Université de Lorraine, Nancy 54000, France,Corresponding author: Bruno Levy, Service de Médecine Intensive et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, University Hospital of Nancy-Brabois, Rue du Morvan, Vandœuvre-les-Nancy 54511, France.
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12
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Boissier F, Aissaoui N. Septic cardiomyopathy: Diagnosis and management. JOURNAL OF INTENSIVE MEDICINE 2021; 2:8-16. [PMID: 36789232 PMCID: PMC9923980 DOI: 10.1016/j.jointm.2021.11.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/14/2021] [Accepted: 11/25/2021] [Indexed: 12/12/2022]
Abstract
There is an extensive body of literature focused on sepsis-induced myocardial dysfunction, but results are conflicting and no objective definition of septic cardiomyopathy (SCM) has been established. SCM may be defined as a sepsis-associated acute syndrome of non-ischemic cardiac dysfunction with systolic and/or diastolic left ventricular (LV) dysfunction and/or right ventricular dysfunction. Physicians should consider this diagnosis in patients with sepsis-associated organ dysfunction, and particularly in cases of septic shock that require vasopressors. Echocardiography is currently the gold standard for diagnosis of SCM. Left ventricular ejection fraction is the most common parameter used to describe LV function in the literature, but its dependence on loading conditions, particularly afterload, limits its use as a measure of intrinsic myocardial contractility. Therefore, repeated echocardiography evaluation is mandatory. Evaluation of global longitudinal strain (GLS) may be more sensitive and specific for SCM than LV ejection fraction (LVEF). Standard management includes etiological treatment, adapted fluid resuscitation, use of vasopressors, and monitoring. Use of inotropes remains uncertain, and heart rate control could be an option in some patients.
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Affiliation(s)
- Florence Boissier
- Service de Médecine Intensive Réanimation, CHU de Poitiers, Poitiers 86021, France,Université de Poitiers, Poitiers INSERM CIC 1402 (ALIVE group), France
| | - Nadia Aissaoui
- Service de Médecine Intensive Réanimation, Hôpital Cochin, APHP, Paris 75014, France,Université de Paris, Paris Cardiovascular Research Center, INSERM U970, Paris 75015, France,Corresponding author: Nadia Aissaoui, Service de Médecine Intensive–Réanimation, Hôpital Cochin Assistance Publique–Hôpitaux de Paris, 27 Rue du Faubourg Saint-Jacques, 75014 Paris, France.
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13
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Current practice and evolving concepts in septic shock resuscitation. Intensive Care Med 2021; 48:148-163. [PMID: 34910228 DOI: 10.1007/s00134-021-06595-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/27/2021] [Indexed: 12/12/2022]
Abstract
Clinical and pathophysiological understanding of septic shock has progressed exponentially in the previous decades, translating into a steady decrease in septic shock-related morbidity and mortality. Even though large randomized, controlled trials have addressed fundamental aspects of septic shock resuscitation, many questions still exist. In this review, we will describe the current standards of septic shock resuscitation, but the emphasis will be placed on evolving concepts in different domains such as clinical resuscitation targets, adequate use of fluids and vasoactive drugs, refractory shock, and the use of extracorporeal therapies. Multiple research opportunities remain open, and collaborative endeavors should be performed to fill in these gaps.
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14
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Abdallah HM, El-Bassossy HM, El-Halawany AM, Ahmed TA, Mohamed GA, Malebari AM, Hassan NA. Self-Nanoemulsifying Drug Delivery System Loaded with Psiadia punctulata Major Metabolites for Hypertensive Emergencies: Effect on Hemodynamics and Cardiac Conductance. Front Pharmacol 2021; 12:681070. [PMID: 34177590 PMCID: PMC8222910 DOI: 10.3389/fphar.2021.681070] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 05/20/2021] [Indexed: 12/12/2022] Open
Abstract
Vasodilators are an important class of antihypertensive agents. However, they have limited clinical use due to the reflex tachycardia associated with their use which masks most of its antihypertensive effect and raises cardiac risk. Chemical investigation of Psiadia punctulata afforded five major methoxylated flavonoids (1–5) three of which (1, 4, and 5) showed vasodilator activity. Linoleic acid-based self-nanoemulsifying drug delivery system (SNEDDS) was utilized to develop intravenous (IV) formulations that contain compounds 1, 4, or 5. The antihypertensive effect of the prepared SNEDDS formulations, loaded with each of the vasodilator compounds, was tested in the angiotensin-induced rat model of hypertension. Rats were subjected to real-time recording of blood hemodynamics and surface Electrocardiogram (ECG) while the pharmaceutical formulations were individually slowly injected in cumulative doses. Among the tested formulations, only that contains umuhengerin (1) and 5,3′-dihydroxy-6,7,4′,5′-tetramethoxyflavone (5) showed potent antihypertensive effects. Low IV doses, from the prepared SNEDDS, containing either compound 1 or 5 showed a marked reduction in the elevated systolic blood pressure by 10 mmHg at 12 μg/kg and by more than 20 mmHg at 36 μg/kg. The developed SNEDDS formulation containing either compound 1 or 5 significantly reduced the elevated diastolic, pulse pressure, dicrotic notch pressure, and the systolic–dicrotic notch pressure difference. Moreover, both formulations decreased the ejection duration and increased the non-ejection duration while they did not affect the time to peak. Both formulations did not affect the AV conduction as appear from the lack of effect on p duration and PR intervals. Similarly, they did not affect the ventricular repolarization as no effect on QTc or JT interval. Both formulations decreased the R wave amplitude but increased the T wave amplitude. In conclusion, the careful selection of linoleic acid for the development of SNEDDS formulation rescues the vasodilating effect of P. punctulata compounds from being masked by the reflex tachycardia that is commonly associated with the decrease in peripheral resistance by most vasodilators. The prepared SNEDDS formulation could be suggested as an effective medication in the treatment of hypertensive emergencies, after clinical evaluation.
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Affiliation(s)
- Hossam M Abdallah
- Department of Natural Products and Alternative Medicine, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia.,Department of Pharmacognosy, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Hany M El-Bassossy
- Department of Pharmacology, Faculty of Pharmacy, Zagazig University, Zagazig, Egypt
| | - Ali M El-Halawany
- Department of Pharmacognosy, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Tarek A Ahmed
- Department of Pharmaceutics, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia.,Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Al-Azhar University, Cairo, Egypt
| | - Gamal A Mohamed
- Department of Natural Products and Alternative Medicine, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia.,Department of Pharmacognosy, Faculty of Pharmacy, Al-Azhar University, Assiut Branch, Assiut, Egypt
| | - Azizah M Malebari
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Noura A Hassan
- Department of Pharmacology, Faculty of Pharmacy, Zagazig University, Zagazig, Egypt
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15
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Ultrashort-Acting β-Blockers: Are We on the Right Path? Chest 2021; 159:2139-2140. [PMID: 34099120 DOI: 10.1016/j.chest.2021.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/05/2021] [Indexed: 11/23/2022] Open
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16
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Morelli A, Sanfilippo F, Romano SM, Vieillard-Baron A. Assessment of ventriculo-arterial coupling from peripheral waveform analysis in septic shock. Reply to Br J Anaesth 2021; 126: e101-2. Br J Anaesth 2021; 127:e17-e19. [PMID: 33931172 DOI: 10.1016/j.bja.2021.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 02/25/2021] [Accepted: 03/02/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
- Andrea Morelli
- Department of Internal Clinical, Anesthesiological and Cardiovascular Sciences, University of Rome, "La Sapienza", Rome, Italy.
| | - Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, Policlinico-Vittorio Emanuele University Hospital, Catania, Italy
| | - Salvatore M Romano
- Department of Experimental and Clinical Medicine, Unit of Internal Medicine and Cardiology, University of Florence, Florence, Italy
| | - Antoine Vieillard-Baron
- Intensive Care Medicine Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise, Boulogne-Billancourt, France; INSERM UMR-1018, CESP, Team Kidney and Heart, University of Versailles Saint-Quentin en Yvelines, Villejuif, France
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17
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Donovan K, Shah A, Day J, McKechnie SR. Adjunctive treatments for the management of septic shock - a narrative review of the current evidence. Anaesthesia 2021; 76:1245-1258. [PMID: 33421029 DOI: 10.1111/anae.15369] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2020] [Indexed: 12/13/2022]
Abstract
Septic shock is a leading cause of death and morbidity worldwide. The cornerstones of management include prompt identification of sepsis, early initiation of antibiotic therapy, adequate fluid resuscitation and organ support. Over the past two decades, there have been considerable improvements in our understanding of the pathophysiology of sepsis and the host response, including regulation of inflammation, endothelial disruption and impaired immunity. This has offered opportunities for innovative adjunctive treatments such as vitamin C, corticosteroids and beta-blockers. Some of these approaches have shown promising results in early phase trials in humans, while others, such as corticosteroids, have been tested in large, international, multicentre randomised controlled trials. Contemporary guidelines make a weak recommendation for the use of corticosteroids to reduce mortality in sepsis and septic shock. Vitamin C, despite showing initial promise in observational studies, has so far not been shown to be clinically effective in randomised trials. Beta-blocker therapy may have beneficial cardiac and non-cardiac effects in septic shock, but there is currently insufficient evidence to recommend their use for this condition. The results of ongoing randomised trials are awaited. Crucial to reducing heterogeneity in the trials of new sepsis treatments will be the concept of enrichment, which refers to the purposive selection of patients with clinical and biological characteristics that are likely to be responsive to the intervention being tested.
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Affiliation(s)
- K Donovan
- Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A Shah
- Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - J Day
- Adult Intensive Care Unit and Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S R McKechnie
- Adult Intensive Care Unit and Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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18
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Hasegawa D, Sato R, Prasitlumkum N, Nishida K, Takahashi K, Yatabe T, Nishida O. Effect of Ultrashort-Acting β-Blockers on Mortality in Patients With Sepsis With Persistent Tachycardia Despite Initial Resuscitation: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Chest 2021; 159:2289-2300. [PMID: 33434497 DOI: 10.1016/j.chest.2021.01.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 12/10/2020] [Accepted: 01/03/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Historically, β-blockers have been considered to be relatively contraindicated for septic shock because they may cause cardiac suppression. On the other hand, there is an increasing interest in the use of β-blockers for treating patients with sepsis with persistent tachycardia despite initial resuscitation. RESEARCH QUESTION Do ultrashort-acting β-blockers such as esmolol and landiolol improve mortality in patients with sepsis with persistent tachycardia despite initial resuscitation? STUDY DESIGN AND METHODS This was a systematic review and meta-analysis. We searched MEDLINE, Cochrane Central Register of Controlled Trials, and Embase for randomized controlled trials (RCTs) that compared the mortality of patients with sepsis and septic shock treated with esmolol or landiolol. We updated our search on April 20, 2020. Two independent reviewers assessed whether titles and abstracts met the following eligibility criteria: (1) RCT, (2) patients with sepsis and septic shock ≥ 18 years of age, and (3) treatment with either esmolol/landiolol or placebo/no interventions. Two authors independently extracted selected patient and study characteristics and outcomes. The results of all analyses are presented using random effect models. RESULTS Seven RCTs with a pooled sample size of 613 patients were included. Of these, six RCTs with 572 patients reported 28-day mortality. Esmolol or landiolol use in patients with sepsis and septic shock was significantly associated with lower 28-day mortality (risk ratio, 0.68; 95% CI, 0.54-0.85; P < .001). Unimportant heterogeneity was observed (I2 = 31%). The absolute risk reduction and number of patients to be treated to prevent one death were 18.2% and 5.5, respectively. INTERPRETATION The use of ultrashort-acting β-blockers such as esmolol and landiolol in patients with sepsis with persistent tachycardia despite initial resuscitation was associated with significantly lower 28-day mortality. TRIAL REGISTRY UMIN Clinical Trials Registry; No.: UMIN000040174; URL: https://www.umin.ac.jp/ctr/index.htm.
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Affiliation(s)
- Daisuke Hasegawa
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Aichi, Japan
| | - Ryota Sato
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Narut Prasitlumkum
- Department of Cardiology, University of California Riverside School of Medicine, CA
| | - Kazuki Nishida
- Department of Biostatistics Section, Center for Advanced Medicine and Clinical Research, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kunihiko Takahashi
- Department of Biostatistics, M&D Data Science Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomoaki Yatabe
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Aichi, Japan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Aichi, Japan.
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19
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Levy B, Fritz C, Piona C, Duarte K, Morelli A, Guerci P, Kimmoun A, Girerd N. Hemodynamic and anti-inflammatory effects of early esmolol use in hyperkinetic septic shock: a pilot study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:21. [PMID: 33413583 PMCID: PMC7791811 DOI: 10.1186/s13054-020-03445-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/17/2020] [Indexed: 12/31/2022]
Abstract
Background Several studies have shown that heart rate control with selective beta-1 blockers in septic shock is safe. In these trials, esmolol was administered 24 h after onset of septic shock in patients who remained tachycardic. While an earlier use of beta-blockers might be beneficial, such use remains challenging due to the difficulty in distinguishing between compensatory and non-compensatory tachycardia. Therefore, the Esmosepsis study was designed to study the effects of esmolol aimed at reducing the heart rate by 20% after the initial resuscitation process in hyperkinetic septic shock patients on (1) cardiac index and (2) systemic and regional hemodynamics as well as inflammatory patterns. Methods Nine consecutive stabilized tachycardic hyperkinetic septic shock patients treated with norepinephrine for a minimum of 6 h were included. Esmolol was infused during 6 h in order to decrease the heart rate by 20%. The following data were recorded at hours H0 (before esmolol administration), H1–H6 (esmolol administration) and 1 h after esmolol cessation (H7): systolic arterial pressure, diastolic arterial pressure, mean arterial pressure, central venous pressure, heart rate, PICCO transpulmonary thermodilution, sublingual and musculo-cutaneous microcirculation, indocyanine green clearance and echocardiographic parameters, diuresis, lactate, and arterial and venous blood gases. Results Esmolol was infused 9 (6.4–11.6) hours after norepinephrine introduction. Esmolol was ceased early in 3 out of 9 patients due to a marked increase in norepinephrine requirement associated with a picture of persistent cardiac failure at the lowest esmolol dose. For the global group, during esmolol infusion, norepinephrine infusion increased from 0.49 (0.34–0.83) to 0.78 (0.3–1.11) µg/min/kg. The use of esmolol was associated with a significant decrease in heart rate from 115 (110–125) to 100 (92–103) beats/min and a decrease in cardiac index from 4.2 (3.1–4.4) to 2.9 (2.5–3.7) l/min/m−2. Indexed stroke volume remained unchanged. Cardiac function index and global ejection fraction also markedly decreased. Using echocardiography, systolic, diastolic as well as left and right ventricular function parameters worsened. After esmolol cessation, all parameters returned to baseline values. Lactate and microcirculatory parameters did not change while the majority of pro-inflammatory proteins decreased in all patients. Conclusion In the very early phase of septic shock, heart rate reduction using fast esmolol titration is associated with an increased risk of hypotension and decreased cardiac index despite maintained adequate tissue perfusion (NCT02068287).
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Affiliation(s)
- Bruno Levy
- Service de Médecine Intensive Et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, 54511, Vandœuvre-lès-Nancy, France. .,INSERM U1116, Faculté de Médecine, 54511, Vandœuvre-lès-Nancy, France. .,Université de Lorraine, 54000, Nancy, France. .,Medical Intensive Care Unit, University Hospital of Nancy, Brabois, Rue du Morvan, 54500, Vandœuvre-lès-Nancy, France.
| | - Caroline Fritz
- Service de Médecine Intensive Et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, 54511, Vandœuvre-lès-Nancy, France.,INSERM U1116, Faculté de Médecine, 54511, Vandœuvre-lès-Nancy, France.,Université de Lorraine, 54000, Nancy, France
| | - Caroline Piona
- Service de Médecine Intensive Et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, 54511, Vandœuvre-lès-Nancy, France.,INSERM U1116, Faculté de Médecine, 54511, Vandœuvre-lès-Nancy, France.,Université de Lorraine, 54000, Nancy, France
| | - Kevin Duarte
- INSERM CIC1433, Nancy University Hospital, 54000, Nancy, France
| | - Andrea Morelli
- INSERM CIC1433, Nancy University Hospital, 54000, Nancy, France.,Department of Internal Clinical, Anesthesiological and Cardiovascular Sciences, University of Rome, La Sapienza, Rome, Italy
| | - Philippe Guerci
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Nancy, 54511, Vandœuvre-lès-Nancy, France
| | - Antoine Kimmoun
- Service de Médecine Intensive Et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, 54511, Vandœuvre-lès-Nancy, France.,INSERM U1116, Faculté de Médecine, 54511, Vandœuvre-lès-Nancy, France.,Université de Lorraine, 54000, Nancy, France
| | - Nicolas Girerd
- INSERM CIC1433, Nancy University Hospital, 54000, Nancy, France
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20
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Giosa L, Busana M, Payen D. Pitfalls in the assessment of ventriculo-arterial coupling from peripheral waveform analysis in septic shock. Comment on Br J Anaesth 2020; 125: 1018-1024. Br J Anaesth 2021; 126:e101-e102. [PMID: 33422286 DOI: 10.1016/j.bja.2020.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 11/27/2020] [Accepted: 12/08/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Lorenzo Giosa
- Department of Surgical Sciences, University of Turin, Turin, Italy.
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center of Göttingen, Göttingen, Germany
| | - Didier Payen
- University of Paris 7, Denis Diderot, Paris, France
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