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Mergoum AM, Rhone AR, Larson NJ, Dries DJ, Blondeau B, Rogers FB. A Guide to the Use of Vasopressors and Inotropes for Patients in Shock. J Intensive Care Med 2024:8850666241246230. [PMID: 38613381 DOI: 10.1177/08850666241246230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
Shock is a life-threatening circulatory failure that results in inadequate tissue perfusion and oxygenation. Vasopressors and inotropes are vasoactive medications that are vital in increasing systemic vascular resistance and cardiac contractility, respectively, in patients presenting with shock. To be well versed in using these agents is an important skill to have in the critical care setting where patients can frequently exhibit symptoms of shock. In this review, we will discuss the pathophysiological mechanisms of shock and evaluate the current evidence behind the management of shock with an emphasis on vasopressors and inotropes.
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Affiliation(s)
| | | | | | - David J Dries
- Department of Surgery, Regions Hospital, Saint Paul, MN, USA
| | - Benoit Blondeau
- Department of Surgery, Regions Hospital, Saint Paul, MN, USA
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2
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Conflicting interactions in multiple closed-loop controlled critical care Treatments: A hemorrhage resuscitation-intravenous propofol sedation case study. Biomed Signal Process Control 2022. [DOI: 10.1016/j.bspc.2021.103268] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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3
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Differential Prognostic Implications of Vasoactive Inotropic Score for Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock According to Use of Mechanical Circulatory Support. Crit Care Med 2021; 49:770-780. [PMID: 33590998 DOI: 10.1097/ccm.0000000000004815] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVES To identify whether the prognostic implications of Vasoactive Inotropic Score according to use of mechanical circulatory support differ in the treatment of acute myocardial infarction complicated by cardiogenic shock. DESIGN A multicenter retrospective and prospective observational cohort study. SETTING/PATIENT The REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy registry includes 1,247 patients with cardiogenic shock from 12 centers in Korea. A total of 836 patients with acute myocardial infarction complicated by cardiogenic shock were finally selected, and the study population was stratified by quartiles of Vasoactive Inotropic Score (< 10, 10-30, 30-90, and > 90) for the present study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Primary endpoint was in-hospital mortality and secondary endpoint was follow-up mortality. Among the study population, 326 patients (39.0%) received medical treatment alone, 218 (26.1%) received intra-aortic balloon pump, and 292 (34.9%) received extracorporeal membrane oxygenation. In-hospital mortality occurred in 305 patients (36.5%) and was significantly higher in patients with higher Vasoactive Inotropic Score (15.6%, 20.8%, 40.2%, and 67.3%, for < 10, 10-30, 30-90, and > 90; p < 0.001). Vasoactive Inotropic Score showed better ability to predict in-hospital mortality in acute myocardial infarction patients with cardiogenic shock who received medical treatment alone (area under the curve: 0.797; 95% CI, 0.728-0.865) than in those who received intra-aortic balloon pump (area under the curve, 0.704; 95% CI, 0.625-0.783) or extracorporeal membrane oxygenation (area under the curve, 0.644; 95% CI, 0.580-0.709). The best cutoff value of Vasoactive Inotropic Score for the prediction of in-hospital mortality also differed according to the use of mechanical circulatory support (16.5, 40.1, and 84.0 for medical treatment alone, intra-aortic balloon pump, and extracorporeal membrane oxygenation, respectively). There was a significant interaction between Vasoactive Inotropic Score as a continuous value and the use of mechanical circulatory support including intra-aortic balloon pump (interaction-p = 0.006) and extracorporeal membrane oxygenation (interaction-p < 0.001) for all-cause mortality during follow-up. CONCLUSIONS High Vasoactive Inotropic Score was associated with significantly higher in-hospital and follow-up mortality in patients with acute myocardial infarction complicated by cardiogenic shock. The predictive value of Vasoactive Inotropic Score for mortality was significantly higher in acute myocardial infarction patients with cardiogenic shock treated by medical treatment alone than in those treated by mechanical circulatory support such as intra-aortic balloon pump or extracorporeal membrane oxygenation.
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Jung JH, Cho YH, Park MS, Joo SP. Clinical warning signs of life-threatening hematochezia in neurosurgical patients with long-term bed rest: Three cases report. Medicine (Baltimore) 2020; 99:e22471. [PMID: 32991485 PMCID: PMC7523836 DOI: 10.1097/md.0000000000022471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
RATIONALE Patients with long term bed rest in intensive care unit after neurosurgery could experience splanchnic hypoperfusion. These patients have several other medical conditions that exacerbate splanchnic hypoperfusion during treatment and the splanchnic hypoperfusion could result in "stress-induced intestinal necrosis", which could cause massive hematochezia. We report here the experience of life-threatening hematochezia in 3 patients who underwent brain surgery in our institution. PATIENTS CONCERNS One female patient (72-year-old) and 2 male patients (58- and 35-year-old) were admitted to our institution because of traumatic intracerebral hemorrhage, subarachnoid hemorrhage due to a ruptured anterior communicating artery, and subarachnoid hemorrhage with unknown cause respectively. All patients underwent emergency brain surgery for diagnosis and treatment. After surgery, they all experienced long-term bed rest in intensive care unit. Hematochezia occurred on postoperative day 15, 17, and 49, respectively. DIAGNOSES All of the patients were assessed by abdomen/pelvis computed tomography and underwent a colonoscopy. INTERVENTIONS The female patient underwent embolization through pelvic arteriography and epinephrine injection through colonoscopy, but a total colectomy and ileostomy was performed due to refractory hematochezia. 58-year-old male patient had a laparoscopic ileostomy for the bowel rest. The other patient underwent nil per os and conservative treatment for 2 weeks. OUTCOMES The female patient was discharged without further treatment plan, 58-year-old male patient survived after laparoscopic ileostomy, while the other patient survived after 2 weeks of nil per os. LESSON Abdominal symptoms, such as hematochezia, should be actively managed in neurosurgical patients who are undergoing long-term bed rest in an intensive care unit under physiologically stressful medical conditions.
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Affiliation(s)
| | | | - Man-Seok Park
- Department of Neurology, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
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5
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Guilherme E, Jacquet-Lagrèze M, Pozzi M, Achana F, Armoiry X, Fellahi JL. Can levosimendan reduce ECMO weaning failure in cardiogenic shock?: a cohort study with propensity score analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:442. [PMID: 32677985 PMCID: PMC7367381 DOI: 10.1186/s13054-020-03122-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 06/29/2020] [Indexed: 12/13/2022]
Abstract
Background Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been increasingly used over the last decade in patients with refractory cardiogenic shock. ECMO weaning can, however, be challenging and lead to circulatory failure and death. Recent data suggest a potential benefit of levosimendan for ECMO weaning. We sought to further investigate whether the use of levosimendan could decrease the rate of ECMO weaning failure in adult patients with refractory cardiogenic shock. Methods We performed an observational single-center cohort study. All patients undergoing VA-ECMO from January 2012 to December 2018 were eligible and divided into two groups: group levosimendan and group control (without levosimendan). The primary endpoint was VA-ECMO weaning failure defined as death during VA-ECMO treatment or within 24 h after VA-ECMO removal. Secondary outcomes were mortality at day 28 and at 6 months. The two groups were compared after propensity score matching. P < 0.05 was considered statistically significant. Results Two hundred patients were analyzed (levosimendan group: n = 53 and control group: n = 147). No significant difference was found between groups on baseline characteristics except for ECMO duration, which was longer in the levosimendan group (10.6 ± 4.8 vs. 6.5 ± 4.7 days, p < 0.001). Levosimendan administration started 6.6 ± 5.4 days on average following ECMO implantation. After matching of 48 levosimendan patients to 78 control patients, the duration of ECMO was similar in both groups. The rate of weaning failure was 29.1% and 35.4% in levosimendan and control groups, respectively (OR: 0.69, 95%CI: 0.25–1.88). No significant difference was found between groups for all secondary outcomes. Conclusion Levosimendan did not improve the rate of successful VA-ECMO weaning in patients with refractory cardiogenic shock. Trial registration ClinicalTrials.gov, NCT04323709.
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Affiliation(s)
- Enrique Guilherme
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service d'Anesthésie-Réanimation, Lyon, France
| | - Matthias Jacquet-Lagrèze
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service d'Anesthésie-Réanimation, Lyon, France. .,INSERM U1060, Laboratoire CarMeN, IHU OPeRa, Lyon, France.
| | - Matteo Pozzi
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service de Chirurgie Cardiaque, Lyon, France
| | - Felix Achana
- Nuffield Department of Primary care, Oxford University, Oxford, UK
| | - Xavier Armoiry
- Lyon School of Pharmacy (ISPB), Public Health department/UMR CNRS 5510 MATEIS, I2B Team, Lyon, France.,Division of Health Sciences, Warwick Medical School, Warwick university, Coventry, UK
| | - Jean-Luc Fellahi
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service d'Anesthésie-Réanimation, Lyon, France.,INSERM U1060, Laboratoire CarMeN, IHU OPeRa, Lyon, France
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6
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Balmer J, Smith R, Pretty CG, Desaive T, Shaw GM, Chase JG. Accurate end systole detection in dicrotic notch-less arterial pressure waveforms. J Clin Monit Comput 2020; 35:79-88. [PMID: 32048103 DOI: 10.1007/s10877-020-00473-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 01/24/2020] [Indexed: 11/26/2022]
Abstract
Identification of end systole is often necessary when studying events specific to systole or diastole, for example, models that estimate cardiac function and systolic time intervals like left ventricular ejection duration. In proximal arterial pressure waveforms, such as from the aorta, the dicrotic notch marks this transition from systole to diastole. However, distal arterial pressure measures are more common in a clinical setting, typically containing no dicrotic notch. This study defines a new end systole detection algorithm, for dicrotic notch-less arterial waveforms. The new algorithm utilises the beta distribution probability density function as a weighting function, which is adaptive based on previous heartbeats end systole locations. Its accuracy is compared with an existing end systole estimation method, on dicrotic notch-less distal pressure waveforms. Because there are no dicrotic notches defining end systole, validating which method performed better is more difficult. Thus, a validation method is developed using dicrotic notch locations from simultaneously measured aortic pressure, forward projected by pulse transit time (PTT) to the more distal pressure signal. Systolic durations, estimated by each of the end systole estimates, are then compared to the validation systolic duration provided by the PTT based end systole point. Data comes from ten pigs, across two protocols testing the algorithms under different hemodynamic states. The resulting mean difference ± limits of agreement between measured and estimated systolic duration, of [Formula: see text] versus [Formula: see text], for the new and existing algorithms respectively, indicate the new algorithms superiority.
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Affiliation(s)
- Joel Balmer
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand.
| | - Rachel Smith
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Christopher G Pretty
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Thomas Desaive
- GIGA Cardiovascular Science, University of Liège, Liège, Belgium
| | - Geoff M Shaw
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - J Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
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Simonetto DA, Piccolo Serafim L, Gallo de Moraes A, Gajic O, Kamath PS. Management of Sepsis in Patients With Cirrhosis: Current Evidence and Practical Approach. Hepatology 2019; 70:418-428. [PMID: 30516866 DOI: 10.1002/hep.30412] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/30/2018] [Indexed: 12/13/2022]
Abstract
Sepsis in patients with cirrhosis is associated with high mortality. An impaired immune response accounts for the increased infection risk observed in these patients. Hemodynamic and systemic changes suggestive of sepsis may be observed in patients with cirrhosis in the absence of infection; therefore, diagnosis and treatment of sepsis may be delayed. The optimal management of the critically ill patient with sepsis and cirrhosis has not been well established and is generally extrapolated from consensus guidelines and expert recommendations made for management of patients without cirrhosis with sepsis. Despite the lack of strong evidence, we propose a contemporary pragmatic approach to sepsis management in patients with cirrhosis, including the choice of fluids, vasopressors, and antibiotics.
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Affiliation(s)
- Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Laura Piccolo Serafim
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Alice Gallo de Moraes
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN
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Balmer J, Pretty C, Davidson S, Desaive T, Kamoi S, Pironet A, Morimont P, Janssen N, Lambermont B, Shaw GM, Chase JG. Pre-ejection period, the reason why the electrocardiogram Q-wave is an unreliable indicator of pulse wave initialization. Physiol Meas 2018; 39:095005. [DOI: 10.1088/1361-6579/aada72] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Kamoi S, Pretty CG, Chiew YS, Pironet A, Davidson S, Desaive T, Shaw GM, Chase JG. Stroke Volume estimation using aortic pressure measurements and aortic cross sectional area: Proof of concept. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2018; 2015:1005-8. [PMID: 26736434 DOI: 10.1109/embc.2015.7318534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Accurate Stroke Volume (SV) monitoring is essential for patient with cardiovascular dysfunction patients. However, direct SV measurements are not clinically feasible due to the highly invasive nature of measurement devices. Current devices for indirect monitoring of SV are shown to be inaccurate during sudden hemodynamic changes. This paper presents a novel SV estimation using readily available aortic pressure measurements and aortic cross sectional area, using data from a porcine experiment where medical interventions such as fluid replacement, dobutamine infusions, and recruitment maneuvers induced SV changes in a pig with circulatory shock. Measurement of left ventricular volume, proximal aortic pressure, and descending aortic pressure waveforms were made simultaneously during the experiment. From measured data, proximal aortic pressure was separated into reservoir and excess pressures. Beat-to-beat aortic characteristic impedance values were calculated using both aortic pressure measurements and an estimate of the aortic cross sectional area. SV was estimated using the calculated aortic characteristic impedance and excess component of the proximal aorta. The median difference between directly measured SV and estimated SV was -1.4ml with 95% limit of agreement +/- 6.6ml. This method demonstrates that SV can be accurately captured beat-to-beat during sudden changes in hemodynamic state. This novel SV estimation could enable improved cardiac and circulatory treatment in the critical care environment by titrating treatment to the effect on SV.
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Saadeh YS, Smith BW, Joseph JR, Jaffer SY, Buckingham MJ, Oppenlander ME, Szerlip NJ, Park P. The impact of blood pressure management after spinal cord injury: a systematic review of the literature. Neurosurg Focus 2017; 43:E20. [DOI: 10.3171/2017.8.focus17428] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVESpinal cord injury (SCI) results in significant morbidity and mortality. Improving neurological recovery by reducing secondary injury is a major principle in the management of SCI. To minimize secondary injury, blood pressure (BP) augmentation has been advocated. The objective of this study was to review the evidence behind BP management after SCI.METHODSThis systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Using the PubMed database, the authors identified studies that investigated BP management after acute SCI. Information on BP goals, duration of BP management, vasopressor selection, and neurological outcomes were analyzed.RESULTSEleven studies that met inclusion criteria were identified. Nine studies were retrospective, and 2 were single-cohort prospective investigations. Of the 9 retrospective studies, 7 reported a goal mean arterial pressure (MAP) of higher than 85 mm Hg. For the 2 prospective studies, the MAP goals were higher than 85 mm Hg and higher than 90 mm Hg. The duration of BP management varied from more than 24 hours to 7 days in 6 of the retrospective studies that reported the duration of treatment. In both prospective studies, the duration of treatment was 7 days. In the 2 prospective studies, neurological outcomes were stable to improved with BP management. The retrospective studies, however, were contradictory with regard to the correlation of BP management and outcomes. Dopamine, norepinephrine, and phenylephrine were the agents that were frequently used to augment BP. However, more complications have been associated with dopamine use than with the other vasopressors.CONCLUSIONSThere are no high-quality data regarding optimal BP goals and duration in the management of acute SCI. Based on the highest level of evidence available from the 2 prospective studies, MAP goals of 85–90 mm Hg for a duration of 5–7 days should be considered. Norepinephrine for cervical and upper thoracic injuries and phenylephrine or norepinephrine for mid- to lower thoracic injuries should be considered.
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Balmer J, Pretty C, Kamoi S, Davidson S, Pironet A, Desaive T, Shaw GM, Chase JG. Electrocardiogram R-wave is an Unreliable Indicator of Pulse Wave Initialization. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.ifacol.2017.08.254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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12
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Kamoi S, Pretty C, Balmer J, Davidson S, Pironet A, Desaive T, Shaw GM, Chase JG. Improved pressure contour analysis for estimating cardiac stroke volume using pulse wave velocity measurement. Biomed Eng Online 2017; 16:51. [PMID: 28438216 PMCID: PMC5404318 DOI: 10.1186/s12938-017-0341-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 04/19/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Pressure contour analysis is commonly used to estimate cardiac performance for patients suffering from cardiovascular dysfunction in the intensive care unit. However, the existing techniques for continuous estimation of stroke volume (SV) from pressure measurement can be unreliable during hemodynamic instability, which is inevitable for patients requiring significant treatment. For this reason, pressure contour methods must be improved to capture changes in vascular properties and thus provide accurate conversion from pressure to flow. METHODS This paper presents a novel pressure contour method utilizing pulse wave velocity (PWV) measurement to capture vascular properties. A three-element Windkessel model combined with the reservoir-wave concept are used to decompose the pressure contour into components related to storage and flow. The model parameters are identified beat-to-beat from the water-hammer equation using measured PWV, wave component of the pressure, and an estimate of subject-specific aortic dimension. SV is then calculated by converting pressure to flow using identified model parameters. The accuracy of this novel method is investigated using data from porcine experiments (N = 4 Pietrain pigs, 20-24.5 kg), where hemodynamic properties were significantly altered using dobutamine, fluid administration, and mechanical ventilation. In the experiment, left ventricular volume was measured using admittance catheter, and aortic pressure waveforms were measured at two locations, the aortic arch and abdominal aorta. RESULTS Bland-Altman analysis comparing gold-standard SV measured by the admittance catheter and estimated SV from the novel method showed average limits of agreement of ±26% across significant hemodynamic alterations. This result shows the method is capable of estimating clinically acceptable absolute SV values according to Critchely and Critchely. CONCLUSION The novel pressure contour method presented can accurately estimate and track SV even when hemodynamic properties are significantly altered. Integrating PWV measurements into pressure contour analysis improves identification of beat-to-beat changes in Windkessel model parameters, and thus, provides accurate estimate of blood flow from measured pressure contour. The method has great potential for overcoming weaknesses associated with current pressure contour methods for estimating SV.
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Affiliation(s)
- Shun Kamoi
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Christopher Pretty
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Joel Balmer
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Shaun Davidson
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Antoine Pironet
- GIGA Cardiovascular Science, University of Liege, Liege, Belgium
| | - Thomas Desaive
- GIGA Cardiovascular Science, University of Liege, Liege, Belgium
| | - Geoffrey M. Shaw
- Intensive Care Unit, Christchurch Hospital, Christchurch, New Zealand
| | - J. Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
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García-Canales A, Peña-Juárez RA, Sandoval-Franco LDM. [Vasopressors and inotropes: use in paediatrics]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2017; 88:39-50. [PMID: 28336302 DOI: 10.1016/j.acmx.2017.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 02/14/2017] [Accepted: 02/15/2017] [Indexed: 11/16/2022] Open
Abstract
The cardiovascular system is a dynamic system, which is required to ensure adequate delivery of oxygen, nutrients, and hormones to the tissues that are necessary for cell metabolism. It also synthesises and modifies the vasoactive components that regulate vascular tone and myocardial function. These vasoactive components have demonstrated their beneficial effects in the management of paediatric patients in a critical condition with heart failure and shock. However, their use and abuse brings harmful effects, increases mortality, and is associated with arrhythmias. An increase in myocardial oxygen consumption favours the presence of ischaemia, therefore it is necessary to know the mechanism of action and indications of these drugs to minimise their harmful effects. The purpose of this review is to describe the pharmacology and clinical applications of inotropic and vasopressor agents in the paediatric patient in acritical condition.
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Affiliation(s)
- Adrián García-Canales
- Departamento de Terapia Intensiva Pediátrica, Hospital Regional Valentín Gómez Farías, ISSSTE, Zapopan, Jalisco, México.
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14
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Bernardelli AK, Da Silva RDCVDAF, Corrêa T, Da Silva-Santos JE. Vasoplegia in sepsis depends on the vascular system, vasopressor, and time-point: a comparative evaluation in vessels from rats subjected to the cecal ligation puncture model. Can J Physiol Pharmacol 2016; 94:1227-1236. [PMID: 27526256 DOI: 10.1139/cjpp-2015-0514] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
We evaluated the effects of phenylephrine, norepinephrine, angiotensin II, and vasopressin in mesenteric, renal, carotid, and tail arteries, and in perfused mesenteric vascular bed from rats subjected to the cecal ligation and puncture (CLP) model of sepsis. Phenylephrine and angiotensin II were less efficacious in mesenteric arteries from the CLP 6 h and CLP 18 h groups than in preparations from non-septic animals, but no differences were found for norepinephrine and vasopressin between the preparations. In renal arteries, none of the vasoconstrictors had impaired activity in the CLP groups. Nonetheless, carotid arteries from the CLP 18 h group presented reduced reactivity to all vasoconstrictors tested, but only phenylephrine and norepinephrine had their effects reduced in carotid arteries from the CLP 6 h group. Despite the reduced responsiveness to phenylephrine, tail arteries from septic rats were hyperreactive to vasopressin and norepinephrine at 6 h and 18 h after the CLP surgery, respectively. The mesenteric vascular bed from CLP groups was hyporeactive to phenylephrine, norepinephrine, and angiotensin II, but not to vasopressin. The vascular contractility in sepsis varies from the well-described refractoriness, to unaltered or even hyperresponsiveness to vasoconstrictors, depending on the vessel, the vasoactive agent, and the time period evaluated.
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Affiliation(s)
- Angélica K Bernardelli
- a Department of Pharmacology, Universidade Federal do Paraná, Curitiba, PR, Brazil.,b Laboratory of Cardiovascular Biology, Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Rita de C V de A F Da Silva
- a Department of Pharmacology, Universidade Federal do Paraná, Curitiba, PR, Brazil.,b Laboratory of Cardiovascular Biology, Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Thiago Corrêa
- b Laboratory of Cardiovascular Biology, Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - José Eduardo Da Silva-Santos
- b Laboratory of Cardiovascular Biology, Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
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Kamoi S, Pretty C, Chiew YS, Davidson S, Pironet A, Desaive T, Shaw GM, Chase JG. Relationship between Stroke Volume and Pulse Wave Velocity. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.ifacol.2015.10.153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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16
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Bighamian R, Soleymani S, Reisner AT, Seri I, Hahn JO. Prediction of Hemodynamic Response to Epinephrine via Model-Based System Identification. IEEE J Biomed Health Inform 2014; 20:416-23. [PMID: 25420273 DOI: 10.1109/jbhi.2014.2371533] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In this study, we present a system identification approach to the mathematical modeling of hemodynamic responses to vasopressor-inotrope agents. We developed a hybrid model called the latency-dose-response-cardiovascular (LDC) model that incorporated 1) a low-order lumped latency model to reproduce the delay associated with the transport of vasopressor-inotrope agent and the onset of physiological effect, 2) phenomenological dose-response models to dictate the steady-state inotropic, chronotropic, and vasoactive responses as a function of vasopressor-inotrope dose, and 3) a physiological cardiovascular model to translate the agent's actions into the ultimate response of blood pressure. We assessed the validity of the LDC model to fit vasopressor-inotrope dose-response data using data collected from five piglet subjects during variable epinephrine infusion rates. The results suggested that the LDC model was viable in modeling the subjects' dynamic responses: After tuning the model to each subject, the r (2) values for measured versus model-predicted mean arterial pressure were consistently higher than 0.73. The results also suggested that intersubject variability in the dose-response models, rather than the latency models, had significantly more impact on the model's predictive capability: Fixing the latency model to population-averaged parameter values resulted in r(2) values higher than 0.57 between measured versus model-predicted mean arterial pressure, while fixing the dose-response model to population-averaged parameter values yielded nonphysiological predictions of mean arterial pressure. We conclude that the dose-response relationship must be individualized, whereas a population-averaged latency-model may be acceptable with minimal loss of model fidelity.
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Kitchen CC, Nissen P, Secher NH, Nielsen HB. Preserved frontal lobe oxygenation following calcium chloride for treatment of anesthesia-induced hypotension. Front Physiol 2014; 5:407. [PMID: 25374543 PMCID: PMC4205832 DOI: 10.3389/fphys.2014.00407] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 10/01/2014] [Indexed: 01/05/2023] Open
Abstract
Vasopressor agents may affect cerebral oxygenation (rScO2) as determined by near-infrared spectroscopy on the forehead. This case series evaluated the effect of calcium chloride vs. α and β-adrenergic receptor agonists on rScO2 in patients (n = 47) undergoing surgery during i.v. anesthesia. Mean arterial pressure (MAP) and cardiac output (CO) were assessed by Model-flow® and ephedrine (55 ± 3 vs. 74 ± 9 mmHg; 10 mg, n = 9), phenylephrine (51 ± 5 vs. 78 ± 9 mmHg, 0.1 mg, n = 11), adrenaline (53 ± 3 vs. 72 ± 11 mmHg; 1–2 μg, n = 6), noradrenaline (53 ± 5 vs. 72 ± 12 mmHg; 2–4 μg, n = 11), and calcium chloride (49 ± 7 vs. 57 ± 16 mmHg; 5 mmol, n = 10) increased MAP (all P < 0.05). CO increased with ephedrine (4.3 ± 0.9 vs. 5.3 ± 1.2, P < 0.05) and adrenaline (4.7 ± 1.2 vs. 5.9 ± 1.1 l/min; P = 0.07) but was not significantly affected by phenylephrine (3.9 ± 0.7 vs. 3.6 ± 1.0 l/min), noradrenaline (3.8 ± 1.2 vs. 3.7 ± 0.7 l/min), or calcium chloride (4.0 ± 1.4 vs. 4.1 ± 1.5 l/min). Following administration of β-adrenergic agents and calcium chloride rScO2 was preserved while after administration of α-adrenergic drugs rScO2 was reduced by app. 2% (P < 0.05). Following α-adrenergic drugs to treat anesthesia-induced hypotension tissue oxygenation is reduced while the use of β-adrenergic agonists and calcium chloride preserve tissue oxygenation.
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Affiliation(s)
| | - Peter Nissen
- Department of Anesthesia, Rigshospitalet, University of Copenhagen Copenhagen, Denmark
| | - Niels H Secher
- Department of Anesthesia, Rigshospitalet, University of Copenhagen Copenhagen, Denmark
| | - Henning B Nielsen
- Department of Anesthesia, Rigshospitalet, University of Copenhagen Copenhagen, Denmark
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Kamoi S, Pretty C, Docherty P, Squire D, Revie J, Chiew YS, Desaive T, Shaw GM, Chase JG. Continuous stroke volume estimation from aortic pressure using zero dimensional cardiovascular model: proof of concept study from porcine experiments. PLoS One 2014; 9:e102476. [PMID: 25033442 PMCID: PMC4102500 DOI: 10.1371/journal.pone.0102476] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 06/18/2014] [Indexed: 11/18/2022] Open
Abstract
Introduction Accurate, continuous, left ventricular stroke volume (SV) measurements can convey large amounts of information about patient hemodynamic status and response to therapy. However, direct measurements are highly invasive in clinical practice, and current procedures for estimating SV require specialized devices and significant approximation. Method This study investigates the accuracy of a three element Windkessel model combined with an aortic pressure waveform to estimate SV. Aortic pressure is separated into two components capturing; 1) resistance and compliance, 2) characteristic impedance. This separation provides model-element relationships enabling SV to be estimated while requiring only one of the three element values to be known or estimated. Beat-to-beat SV estimation was performed using population-representative optimal values for each model element. This method was validated using measured SV data from porcine experiments (N = 3 female Pietrain pigs, 29–37 kg) in which both ventricular volume and aortic pressure waveforms were measured simultaneously. Results The median difference between measured SV from left ventricle (LV) output and estimated SV was 0.6 ml with a 90% range (5th–95th percentile) −12.4 ml–14.3 ml. During periods when changes in SV were induced, cross correlations in between estimated and measured SV were above R = 0.65 for all cases. Conclusion The method presented demonstrates that the magnitude and trends of SV can be accurately estimated from pressure waveforms alone, without the need for identification of complex physiological metrics where strength of correlations may vary significantly from patient to patient.
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Affiliation(s)
- Shun Kamoi
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
- * E-mail:
| | - Christopher Pretty
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Paul Docherty
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Dougie Squire
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - James Revie
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Yeong Shiong Chiew
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Thomas Desaive
- GIGA Cardiovascular Science, University of Liege, Liege, Belgium
| | - Geoffrey M. Shaw
- Intensive Care Unit, Christchurch Hospital, Christchurch, New Zealand
| | - J. Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
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Fang Y, Li S, Zhou H, Tian X, Lv S, Chen Q. Opiorphin increases blood pressure of conscious rats through renin-angiotensin system (RAS). Peptides 2014; 55:47-51. [PMID: 24486428 DOI: 10.1016/j.peptides.2014.01.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 01/22/2014] [Accepted: 01/22/2014] [Indexed: 11/23/2022]
Abstract
Human opiorphin is a recently identified endogenous pentapeptide, encoded by ProL1 multigenes family that contributes to cardiovascular modulation. The aim of this study was to evaluate the effect of opiorphin through intravenous injection (i.v.) on mean arterial pressure (MAP) regulation. To investigate the bioactivity of opiorphin, a rat cannulation model was developed for MAP measurement and blood sampling. In our present study, opiorphin (200-700 nmol/kg) increased MAP in dose-related and time-dependent manner in conscious rats, which associated highly with the elevation of angiotensin II (AngII) levels in serum. Furthermore, the MAP elevation induced by opiorphin was completely blocked by AngII receptor antagonist valsartan and partially attenuated by angiotensin-converting enzyme inhibitor captopril. Finally, we tested the effect of opiorphin in hypoxia condition, which exhibited that opiorphin reversed hypoxia induced hypotension in conscious rats. Taken together, these results indicated that opiorphin may play an important role in the modulation of blood pressure through AngII dependent pathway, which may help future development of potent clinical therapeutics for emergency treatment.
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Affiliation(s)
- Yuan Fang
- Department of Biochemistry and Molecular Biology, School of Life Sciences, Lanzhou University, 222 Tian Shui South Road, Lanzhou 730000, P.R. China
| | - Shuo Li
- Department of Biochemistry and Molecular Biology, School of Life Sciences, Lanzhou University, 222 Tian Shui South Road, Lanzhou 730000, P.R. China
| | - Huabin Zhou
- Department of Biochemistry and Molecular Biology, School of Life Sciences, Lanzhou University, 222 Tian Shui South Road, Lanzhou 730000, P.R. China
| | - Xiaozhu Tian
- Department of Biochemistry and Molecular Biology, School of Life Sciences, Lanzhou University, 222 Tian Shui South Road, Lanzhou 730000, P.R. China
| | - Shuangyu Lv
- Department of Biochemistry and Molecular Biology, School of Life Sciences, Lanzhou University, 222 Tian Shui South Road, Lanzhou 730000, P.R. China
| | - Qiang Chen
- Department of Biochemistry and Molecular Biology, School of Life Sciences, Lanzhou University, 222 Tian Shui South Road, Lanzhou 730000, P.R. China.
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Kamoi S, Squire D, Revie J, Pretty C, Docherty P, Chiew YS, Desaive T, Shaw GM, Chase JG. Accuracy of Stroke Volume Estimation via Reservoir Pressure Concept and Three Element Windkessel Model. ACTA ACUST UNITED AC 2014. [DOI: 10.3182/20140824-6-za-1003.01104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Bighamian R, Reisner AT. An analytic tool for prediction of hemodynamic responses to vasopressors. IEEE Trans Biomed Eng 2013; 61:109-18. [PMID: 23955691 DOI: 10.1109/tbme.2013.2277867] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
This paper presents a new analytic tool for automated control of vasopressor infusion, which uses measured changes in blood pressure to infer changes in the underlying cardiovascular system and then estimate dose-response relationships for the underlying cardinal cardiovascular parameters, i.e., those related to cardiac output (CO) and total peripheral resistance (TPR). Ultimately, blood pressure as a function of vasopressor dose is predicted based on the estimated underlying cardiovascular state by extrapolating the dose-response relationship. As well, this tool adapts to individual subjects with a minimum of individualized training data. In this report, proof-of-principle is provided using experimental epinephrine dose-response data from four different sets of subjects. Given two observations from different infusion rates, the analytic tool was able to accurately predict the groups' blood pressure, heart rate, TPR, stroke volume, and CO as a function of vasopressor dose levels: the root-mean-squared prediction error for the mean arterial pressure (MAP) was consistently smaller than 5% of the underlying MAP; the r(2) values for the TPR, stroke volume, and CO were consistently higher than 0.96; and the limits of agreement between actual versus predicted blood pressure (BP), TPR, stroke volume, and CO were consistently smaller than 8% of the respective underlying values. The proposed analytic tool may provide a meaningful step towards automated control of vasopressor therapy.
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Jia X, Kowalski RG, Sciubba DM, Geocadin RG. Critical care of traumatic spinal cord injury. J Intensive Care Med 2011; 28:12-23. [PMID: 21482574 DOI: 10.1177/0885066611403270] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Approximately 11 000 people suffer traumatic spinal cord injury (TSCI) in the United States, each year. TSCI incidences vary from 13.1 to 52.2 per million people and the mortality rates ranged from 3.1 to 17.5 per million people. This review examines the critical care of TSCI. The discussion will focus on primary and secondary mechanisms of injury, spine stabilization and immobilization, surgery, intensive care management, airway and respiratory management, cardiovascular complication management, venous thromboembolism, nutrition and glucose control, infection management, pressure ulcers and early rehabilitation, pharmacologic cord protection, and evolving treatment options including the use of pluripotent stem cells and hypothermia.
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Affiliation(s)
- Xiaofeng Jia
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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World allergy organization guidelines for the assessment and management of anaphylaxis. World Allergy Organ J 2011; 4:13-37. [PMID: 23268454 PMCID: PMC3500036 DOI: 10.1097/wox.0b013e318211496c] [Citation(s) in RCA: 494] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The illustrated World Allergy Organization (WAO) Anaphylaxis Guidelines were created in response to absence of global guidelines for anaphylaxis. Uniquely, before they were developed, lack of worldwide availability of essentials for the diagnosis and treatment of anaphylaxis was documented. They incorporate contributions from more than 100 allergy/immunology specialists on 6 continents. Recommendations are based on the best evidence available, supported by references published to the end of December 2010. The Guidelines review patient risk factors for severe or fatal anaphylaxis, co-factors that amplify anaphylaxis, and anaphylaxis in vulnerable patients, including pregnant women, infants, the elderly, and those with cardiovascular disease. They focus on the supreme importance of making a prompt clinical diagnosis and on the basic initial treatment that is urgently needed and should be possible even in a low resource environment. This involves having a written emergency protocol and rehearsing it regularly; then, as soon as anaphylaxis is diagnosed, promptly and simultaneously calling for help, injecting epinephrine (adrenaline) intramuscularly, and placing the patient on the back or in a position of comfort with the lower extremities elevated. When indicated, additional critically important steps include administering supplemental oxygen and maintaining the airway, establishing intravenous access and giving fluid resuscitation, and initiating cardiopulmonary resuscitation with continuous chest compressions. Vital signs and cardiorespiratory status should be monitored frequently and regularly (preferably, continuously). The Guidelines briefly review management of anaphylaxis refractory to basic initial treatment. They also emphasize preparation of the patient for self-treatment of anaphylaxis recurrences in the community, confirmation of anaphylaxis triggers, and prevention of recurrences through trigger avoidance and immunomodulation. Novel strategies for dissemination and implementation are summarized. A global agenda for anaphylaxis research is proposed.
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