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Tai-Passmann S, Slegers CAD, Hemelaar P, Waalders N, Koopmans M, van den Bogaard B, van Lookeren Campagne M, Goedegebuur J, Kuindersma M, Schroten N, van der Elsen F, Grady BPX, van den Beuken WMF, Kiers D, Pickkers P, van den Oever HLA. Phosphodiesterase 3 inhibitors do not influence lactate kinetics and clinical outcomes in patients with septic shock: A multicentre cohort study. J Crit Care 2024; 83:154827. [PMID: 38718462 DOI: 10.1016/j.jcrc.2024.154827] [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: 12/11/2023] [Revised: 04/16/2024] [Accepted: 04/27/2024] [Indexed: 08/04/2024]
Abstract
PURPOSE We investigated the association between the administration of phosphodiesterase 3 inhibitors (PDE3i) and lactate kinetics, resolution of organ failure, ICU and hospital length of stay (LOS) and hospital mortality in a retrospective cohort of patients with septic shock and persistently elevated lactate concentrations. MATERIAL AND METHODS Patients with septic shock and two arterial lactate concentrations ≥4 mmol/L with at least 4 h between measurements were eligible. Clinical data of the first four days of admission were collected in an online database. For each patient, the area between the actual lactate concentrations and 2.2 mmol/L (AUClact2.2), was calculated for three days. RESULTS Data on 229 patients from 10 hospitals were collected, of whom 123 received PDE3i (54%). First, a linear multivariate model was developed to predict AUClact2.2 (R2 = 0.57). Adding PDE3i as a cofactor did not affect R2. Second, 60 patients receiving PDE3i at any time between days 0 and 2 were compared to 60 propensity matched no-PDE3i patients. Third, 30 patients who received PDE3i from ICU admission to day 3 were compared to 30 propensity-matched no-PDE3i patients. These analyses showed no differences in AUClact2.2, SOFA scores, ICU or hospital LOS or hospital mortality between treatment groups. CONCLUSIONS No association was found between the administration of PDE3i and lactate kinetics, resolution of organ failure, ICU or hospital LOS or hospital mortality.
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Affiliation(s)
- Sharon Tai-Passmann
- Intensive Care Department, Deventer Hospital, Nico Bolkesteinlaan 75, 7416, SE, Deventer, Netherlands
| | - Claire A D Slegers
- Intensive Care Department, Deventer Hospital, Nico Bolkesteinlaan 75, 7416, SE, Deventer, Netherlands
| | - Pleun Hemelaar
- Intensive Care Department, Radboud university medical center, geert Grooteplein Zuid 10, 6525, GA, Nijmegen, Netherlands
| | - Nicole Waalders
- Intensive Care Department, Radboud university medical center, geert Grooteplein Zuid 10, 6525, GA, Nijmegen, Netherlands
| | - Matty Koopmans
- Intensive Care Department, OLVG, Oosterpark 9, 1091, AC, Amsterdam, Netherlands
| | - Bas van den Bogaard
- Intensive Care Department, OLVG, Oosterpark 9, 1091, AC, Amsterdam, Netherlands
| | | | - Jamilla Goedegebuur
- Intensive Care, Department, Haga Hospital, Leyweg 275, 2545, CH, Den Haag, Netherlands
| | - Marnix Kuindersma
- Intensive Care Department, Gelre Hospitals, Albert Schweitzerlaan 31, 7334, DZ, Apeldoorn, Netherlands
| | - Nicolas Schroten
- Intensive Care Department, Gelre Hospitals, Albert Schweitzerlaan 31, 7334, DZ, Apeldoorn, Netherlands
| | - Fieke van der Elsen
- Intensive Care Department, Dijklander Hospital, Maelsonstraat 3, 1624, NP, Hoorn, Netherlands
| | - Bart P X Grady
- Intensive Care Department, Hospital Group Twente, Zilvermeeuw 1, 7609, PP, Almelo, Netherlands
| | | | - Dorien Kiers
- Intensive Care Department, Franciscus Gasthuis & Vlietland, Kleiweg 500, 3045, PM, Rotterdam, Netherlands
| | - Peter Pickkers
- Intensive Care Department, Radboud university medical center, geert Grooteplein Zuid 10, 6525, GA, Nijmegen, Netherlands
| | - Huub L A van den Oever
- Intensive Care Department, Deventer Hospital, Nico Bolkesteinlaan 75, 7416, SE, Deventer, Netherlands; Intensive Care Department, Radboud university medical center, geert Grooteplein Zuid 10, 6525, GA, Nijmegen, Netherlands.
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2
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Bækgaard ES, Madsen BK, Crone V, El-Hallak H, Møller MH, Vester-Andersen M, Krag M. Perioperative hypotension and use of vasoactive agents in non-cardiac surgery: A scoping review. Acta Anaesthesiol Scand 2024. [PMID: 38965670 DOI: 10.1111/aas.14485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/03/2024] [Accepted: 06/13/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Perioperative hypotension is common and associated with adverse patient outcomes. Vasoactive agents are often used to manage hypotension, but the ideal drug, dose and duration of treatment has not been established. With this scoping review, we aim to provide an overview of the current body of evidence regarding the vasoactive agents used to treat perioperative hypotension in non-cardiac surgery. METHODS We included all studies describing the use of vasoactive agents for the treatment of perioperative hypotension in non-cardiac surgery. We excluded literature reviews, case studies, and studies on animals and healthy subjects. We posed the following research questions: (1) in which surgical populations have vasoactive agents been studied? (2) which agents have been studied? (3) what doses have been assessed? (4) what is the duration of treatment? and (5) which desirable and undesirable outcomes have been assessed? RESULTS We included 124 studies representing 10 surgical specialties. Eighteen different agents were evaluated, predominantly phenylephrine, ephedrine, and noradrenaline. The agents were administered through six different routes, and numerous comparisons between agents, dosages and routes were included. Then, 88 distinct outcome measures were assessed, of which 54 were judged to be non-patient-centred. CONCLUSIONS We found that studies concerning vasoactive agents for the treatment of perioperative hypotension varied considerably in all aspects. Populations were heterogeneous, interventions and exposures included multiple agents compared against themselves, each other, fluids or placebo, and studies reported primarily non-patient-centred outcomes.
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Affiliation(s)
| | - Bennedikte Kollerup Madsen
- Department of Anaesthesiology and Intensive Care, Holbæk Hospital, Holbæk, Denmark
- Department of Anaesthesiology and Intensive Care, Zealand University Hospital, Køge, Denmark
| | - Vera Crone
- Department of Anaesthesiology and Intensive Care, Holbæk Hospital, Holbæk, Denmark
| | - Hayan El-Hallak
- Department of Anaesthesiology and Intensive Care, Holbæk Hospital, Holbæk, Denmark
- Department of Anaesthesiology, Copenhagen University Hospital-Gentofte, Hellerup, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Morten Vester-Andersen
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital-Herlev-Gentofte, Herlev, Denmark
| | - Mette Krag
- Department of Anaesthesiology and Intensive Care, Holbæk Hospital, Holbæk, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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3
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Stampfl M, DeBlieux P. A Clinical Review of Vasopressors in Emergency Medicine. J Emerg Med 2024; 67:e31-e41. [PMID: 38789351 DOI: 10.1016/j.jemermed.2024.03.004] [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: 06/18/2023] [Revised: 01/22/2024] [Accepted: 03/06/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Vasopressor medications raise blood pressure through vasoconstriction and are essential in reversing the hypotension seen in many critically ill patients. Previously, vasopressor administration was largely limited to continuous infusions through central venous access. OBJECTIVES OF THE REVIEW This review addresses the clinical use of vasopressors in various shock states, including practical considerations and innovations in vasopressor administration. The focus is on the clinical administration of vasopressors across a range of shock states, including hypovolemic, distributive, cardiogenic, and obstructive shock. DISCUSSION Criteria for starting vasopressors are not clearly defined, though early use may be beneficial. A number of physiologic factors affect the body's response to vasopressors, such as acidosis and adrenal insufficiency. Peripheral and push-dose administration of vasopressors are becoming more common. Distributive shock is characterized by inappropriate vasodilation and vasopressors play a crucial role in maintaining adequate blood pressure. The use of vasopressors is more controversial in hypovolemic shock, as the preferred treatment is correction of the volume deficit. Evidence for vasopressors is limited in cardiogenic shock. For obstructive shock, vasopressors can temporize a patient's blood pressure until definitive therapy can reverse the underlying cause. CONCLUSION Across the categories of shock states, norepinephrine has wide applicability and is a reasonable first-line agent for shock of uncertain etiology. Keeping a broad differential when hypotension is refractory to vasopressors may help to identify adjunctive treatments in physiologic states that impair vasopressor effectiveness. Peripheral administration of vasopressors is safe and facilitates early administration, which may help to improve outcomes in some shock states.
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Affiliation(s)
- Matthew Stampfl
- UW Health Med Flight, Madison, Wisconsin; BerbeeWalsh Department of Emergency Medicine, Madison, Wisconsin.
| | - Peter DeBlieux
- Louisiana State University Medical Center, New Orleans, Louisiana; Tulane University School of Medicine Department of Surgery, New Orleans, Louisiana
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4
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Tan R, Guo H, Yang Z, Yang H, Li Q, Zhu Q, Du Q. Efficacy and safety of levosimendan in patients with sepsis: a systematic review and network meta-analysis. Front Pharmacol 2024; 15:1358735. [PMID: 38523635 PMCID: PMC10957638 DOI: 10.3389/fphar.2024.1358735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/21/2024] [Indexed: 03/26/2024] Open
Abstract
Objective: We conducted a systematic review to assess the advantages and disadvantages of levosimendan in patients with sepsis compared with placebo, milrinone, and dobutamine and to explore the clinical efficacy of different concentrations of levosimendan. Methods: PubMed, Web of Science, Cochrane Library, Embase, CNKI, Wanfang data, VIP, and CBM databases were searched using such keywords as simendan, levosimendan, and sepsis. The search time was from the establishment of the database to July 2023. Two researchers were responsible for literature screening and data collection respectively. After the risk of bias in the included studies was evaluated, network meta-analysis was performed using R software gemtc and rjags package. Results: Thirty-two randomized controlled trials (RCTs) were included in the network meta-analysis. Meta-analysis results showed that while levosimendan significantly improved CI levels at either 0.1 µg/kg/min (mean difference [MD] [95%CrI] = 0.41 [-0.43, 1.4]) or 0.2 µg/kg/min (MD [95%CrI] =0.54 [0.12, 0.99]). Levosimendan, at either 0.075 µg/kg/min (MD [95% CrI] =0.033 [-0.75, 0.82]) or 0.2 µg/kg/min (MD [95% CrI] = -0.014 [-0.26, 0.23]), had no significant advantage in improving Lac levels. Levosimendan, at either 0.1 µg/kg/min (RR [95% CrI] = 0.99 [0.73, 1.3]) or 0.2 µg/kg/min (RR [95% CrI] = 1.0 [0.88, 1.2]), did not have a significant advantage in reducing mortality. Conclusion: The existing evidence suggests that levosimendan can significantly improve CI and lactate levels in patients with sepsis, and levosimendan at 0.1 µg/kg/min might be the optimal dose. Unfortunately, all interventions in this study failed to reduce the 28-day mortality. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023441220.
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Affiliation(s)
- Ruimin Tan
- School of Clinical Medical, North China University of Science and Technology, Tangshan, Hebei, China
- Critical Care Department, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - He Guo
- Critical Care Department, Hebei General Hospital, Shijiazhuang, Hebei, China
- School of Graduate, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Zinan Yang
- Critical Care Department, Hebei General Hospital, Shijiazhuang, Hebei, China
- School of Graduate, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Huihui Yang
- School of Clinical Medical, North China University of Science and Technology, Tangshan, Hebei, China
- Critical Care Department, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Qinghao Li
- Critical Care Department, Hebei General Hospital, Shijiazhuang, Hebei, China
- School of Graduate, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Qiong Zhu
- Department of Orthopaedics, The People’s Hospital of Shizhu, Chongqing, China
| | - Quansheng Du
- Critical Care Department, Hebei General Hospital, Shijiazhuang, Hebei, China
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5
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Ho L, Chen X, Kwok YL, Wu IXY, Mao C, Chung VCH. Methodological quality of systematic reviews on sepsis treatments: A cross-sectional study. Am J Emerg Med 2024; 77:21-28. [PMID: 38096636 DOI: 10.1016/j.ajem.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/22/2023] [Accepted: 12/04/2023] [Indexed: 02/16/2024] Open
Abstract
OBJECTIVE Systematic reviews (SRs) offer updated evidence to support decision-making on sepsis treatments. However, the rigour of SRs may vary, and methodological flaws may limit their validity in guiding clinical practice. This cross-sectional study appraised the methodological quality of SRs on sepsis treatments. METHODS We searched MEDLINE, EMBASE, and Cochrane Database for eligible SRs on randomised controlled trials on sepsis treatments with at least one meta-analysis published between 2018 and 2023. We extracted SRs' bibliographical characteristics with a pre-designed form and appraised their methodological quality using AMSTAR (A MeaSurement Tool to Assess systematic Reviews) 2. We applied logistic regressions to explore associations between bibliographical characteristics and methodological quality ratings. RESULTS Among the 102 SRs, two (2.0%) had high overall quality, while respectively four (3.9%), seven (6.9%) and 89 (87.3%) were of moderate, low, and critically low quality. Performance in several critical methodological domains was poor, with only 32 (31.4%) considering the risk of bias in primary studies in result interpretation, 22 (21.6%) explaining excluded primary studies, and 16 (15.7%) applying comprehensive searching strategies. SRs published in higher impact factor journals (adjusted odds ratio: 1.19; 95% confidence interval: 1.05 to 1.36) was associated with higher methodological quality. CONCLUSIONS The methodological quality of recent SRs on sepsis treatments is unsatisfactory. Future reviewers should address the above critical methodological aspects. More resources should also be allocated to support continuous training in critical appraisal among healthcare professionals and other evidence users.
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Affiliation(s)
- Leonard Ho
- Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Xi Chen
- Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong; Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Yan Ling Kwok
- Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Irene X Y Wu
- Xiangya School of Public Health, Central South University, Changsha, Hunan, China; Hunan Provincial Key Laboratory of Clinical Epidemiology, Changsha, Hunan, China
| | - Chen Mao
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, Guangdong, China
| | - Vincent Chi Ho Chung
- Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong; School of Chinese Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.
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6
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Srivastava V, Singh S. Organ support in sepsis: A panoramic view from infection to death. Med J Armed Forces India 2024; 80:4-9. [PMID: 38239603 PMCID: PMC10793238 DOI: 10.1016/j.mjafi.2023.10.010] [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: 09/28/2023] [Accepted: 11/10/2023] [Indexed: 01/22/2024] Open
Abstract
Despite significant advancements in medical research, sepsis persists as a leading cause of mortality in intensive care units (ICUs). Sepsis intricately contributes to organ failure, amplifying both morbidity and mortality. In these instances, a comprehensive comprehension of the physiology of each organ is imperative for accurate diagnosis and effective management. Within the context of an ICU clinical scenario, a meticulous evaluation and monitoring of six pivotal organ systems cardiovascular, renal, respiratory, neurological, hematological, and hepatic are essential. The primary objective in managing sepsis-induced organ failure is the early detection and intervention, encompassing timely administration of antibiotics, identification and control of the infection source, and implementation of supportive therapy. Despite the extensive body of medical literature, there is a conspicuous absence of evidence-based multi-organ management strategies for such patients. The intricate interplay between organs, commonly referred to as organ crosstalk, presents a formidable challenge in navigating the complexities of sepsis management.
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Affiliation(s)
| | - Shalendra Singh
- Senior Advisor (Anaesthesia) & Neuroanaesthesiologist, Command Hospital (Northern Commmand), Udhampur, India
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7
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Bansal M, Mehta A, Machanahalli Balakrishna A, Kalyan Sundaram A, Kanwar A, Singh M, Vallabhajosyula S. RIGHT VENTRICULAR DYSFUNCTION IN SEPSIS: AN UPDATED NARRATIVE REVIEW. Shock 2023; 59:829-837. [PMID: 36943772 DOI: 10.1097/shk.0000000000002120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
ABSTRACT Sepsis is a multisystem disease process, which constitutes a significant public health challenge and is associated with high morbidity and mortality. Among other systems, sepsis is known to affect the cardiovascular system, which may manifest as myocardial injury, arrhythmias, refractory shock, and/or septic cardiomyopathy. Septic cardiomyopathy is defined as the reversible systolic and/or diastolic dysfunction of one or both ventricles. Left ventricle dysfunction has been extensively studied in the past, and its prognostic role in patients with sepsis is well documented. However, there is relatively scarce literature on right ventricle (RV) dysfunction and its role. Given the importance of timely detection of septic cardiomyopathy and its bearing on prognosis of patients, the role of RV dysfunction has come into renewed focus. Hence, through this review, we sought to describe the pathophysiology of RV dysfunction in sepsis and what have we learnt so far about its multifactorial nature. We also elucidate the roles of different biomarkers for its detection and prognosis, along with appropriate management of such patient population.
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Affiliation(s)
- Mridul Bansal
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Aryan Mehta
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | - Arvind Kalyan Sundaram
- Section of Cardiovascular Medicine, Department of Medicine, UMass Chan-Baystate Medical Center, Springfield, Massachusetts
| | | | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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8
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Baekgaard ES, Møller MH, Vester-Andersen M, Krag M. Use of vasoactive agents in non-cardiac surgery: Protocol for a scoping review. Acta Anaesthesiol Scand 2023; 67:120-122. [PMID: 36181393 PMCID: PMC10092778 DOI: 10.1111/aas.14153] [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: 09/16/2022] [Accepted: 09/19/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND An increasing number of patients undergo surgical procedures worldwide each year, and despite advances in quality and care, morbidity and mortality rates remain high. Perioperative hypotension is a well-described condition, and is associated with adverse outcomes. Both fluids and vasoactive agents are commonly used to treat hypotension, however, whether one vasoactive agent is preferable over another has yet to be explored. METHODS In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) statement, we plan to conduct a scoping review of studies assessing the use of vasoactive agents in patients undergoing non-cardiac surgery. We will provide an overview of indications, agents used and outcomes assessed. We will assess and report the certainty of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS We will provide descriptive analyses of the included studies accompanied by tabulated results. CONCLUSION The outlined scoping review will provide a summary of the body of evidence on the use of vasoactive agents in the non-cardiac surgical population.
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Affiliation(s)
- Emilie S Baekgaard
- Department of Anaesthesia and Intensive Care, Holbaek Hospital, Zealand, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Rigshospitalet, Copenhagen, Denmark.,Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Morten Vester-Andersen
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark.,Department of Anaesthesia and Intensive Care, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Mette Krag
- Department of Anaesthesia and Intensive Care, Holbaek Hospital, Zealand, Denmark.,Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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9
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Herbosa GAB, Tho NN, Gapay AA, Lorsomradee S, Thang CQ. Consensus on the Southeast Asian management of hypotension using vasopressors and adjunct modalities during cesarean section under spinal anesthesia. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:56. [PMID: 37386598 DOI: 10.1186/s44158-022-00084-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/08/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND AND AIMS This consensus statement presents a comprehensive and evidence-based set of guidelines that modify the general European or US guidelines for hypotension management with vasopressors during cesarean delivery. It is tailored to the Southeast Asian context in terms of local human and medical resources, health system capacity, and local values and preferences. METHODS AND RESULTS These guidelines were prepared using a methodological approach. Two principal sources were used to obtain the evidence: scientific evidence and opinion-based evidence. A team of five anesthesia experts from Vietnam, the Philippines, and Thailand came together to define relevant clinical questions; search for literature-based evidence using the MEDLINE, Scopus, Google Scholar, and Cochrane libraries; evaluate existing guidelines; and contextualize recommendations for the Southeast Asian region. Furthermore, a survey was developed and distributed among 183 practitioners in the captioned countries to gather representative opinions of the medical community and identify best practices for the management of hypotension with vasopressors during cesarean section under spinal anesthesia. CONCLUSIONS This consensus statement advocates proactive management of maternal hypotension during cesarean section after spinal anesthesia, which can be detrimental for both the mother and fetus, supports the choice of phenylephrine as a first-line vasopressor and offers a perspective on the use of prefilled syringes in the Southeast Asian region, where factors such as healthcare features, availability, patient safety, and cost should be considered.
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Affiliation(s)
- Grace Anne B Herbosa
- Department of Anesthesiology, University of the Philippines College of Medicine, Manila, Philippines.
| | - Nguyen Ngoc Tho
- Department of Anesthesiology and Intensive Care, Hanoi French Hospital, Hanoi, Vietnam
| | - Angelina A Gapay
- Department of Anesthesiology, Divine Word Hospital, Tacloban, Philippines
| | - Suraphong Lorsomradee
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University Hospital, Chang Mai, Thailand
| | - Cong Quyet Thang
- Vietnam Society of Anesthesiologists, Head of Department of Anesthesiology and SCIU at HuuNghi Hospital, Hanoi, Vietnam
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10
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Polyzogopoulou E, Amoiridou P, Abraham TP, Ventoulis I. Acute liver injury in COVID-19 patients hospitalized in the intensive care unit: Narrative review. World J Gastroenterol 2022; 28:6662-6688. [PMID: 36620339 PMCID: PMC9813941 DOI: 10.3748/wjg.v28.i47.6662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/14/2022] [Accepted: 12/05/2022] [Indexed: 12/19/2022] Open
Abstract
In recent years, humanity has been confronted with a global pandemic due to coronavirus disease 2019 (COVID-19), which has caused an unprecedented health and economic crisis worldwide. Apart from the respiratory symptoms, which are considered the principal manifestations of COVID-19, it has been recognized that COVID-19 constitutes a systemic inflammatory process affecting multiple organ systems. Across the spectrum of organ involvement in COVID-19, acute liver injury (ALI) has been gradually gaining increasing attention by the international scientific community. COVID-19 associated liver impairment can affect a considerable proportion of COVID-19 patients and seems to correlate with the severity of the disease course. Indeed, COVID-19 patients hospitalized in the intensive care unit (ICU) run a greater risk of developing ALI due to the severity of their clinical condition and in the context of multi-organ failure. The putative pathophysiological mechanisms of COVID-19 induced ALI in ICU patients remain poorly understood and appear to be multifactorial in nature. Several theories have been proposed to explain the occurrence of ALI in the ICU setting, such as hypoperfusion and ischemia due to hemodynamic instability, passive liver congestion as a result of congestive heart failure, ischemia-reperfusion injury, hypoxia due to respiratory failure, mechanical ventilation itself, sepsis and septic shock, cytokine storm, endotheliitis with concomitant coagulopathy, drug-induced liver injury, parenteral nutrition and direct cytopathic viral effect. It should be noted that no specific therapy for COVID-19 induced ALI exists. Therefore, the therapeutic approach lies in preventive measures and is exclusively supportive once ALI ensues. The aim of the current review is to scrutinize the existing evidence on COVID-19 associated ALI in ICU patients, explore its clinical implications, shed light on the underlying pathophysiological mechanisms and propose potential therapeutic approaches. Ongoing research on the particular scientific field will further elucidate the pathophysiology behind ALI and address unresolved issues, in the hope of mitigating the tremendous health consequences imposed by COVID-19 on ICU patients.
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Affiliation(s)
- Effie Polyzogopoulou
- Department of Emergency Medicine, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens 12462, Greece
| | - Pinelopi Amoiridou
- Department of Intensive Care, AHEPA University Hospital, Thessaloniki 54621, Greece
| | - Theodore P Abraham
- Hypertrophic Cardiomyopathy Center of Excellence, University of California, San Francisco, CA 94117, United States
| | - Ioannis Ventoulis
- Department of Occupational Therapy, University of Western Macedonia, Ptolemaida 50200, Greece
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11
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Shen XD, Zhang HS, Zhang R, Li J, Zhou ZG, Jin ZX, Wang YJ. Progress in the Clinical Assessment and Treatment of Myocardial Depression in Critically Ill Patient with Sepsis. J Inflamm Res 2022; 15:5483-5490. [PMID: 36164659 PMCID: PMC9508933 DOI: 10.2147/jir.s379905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 08/17/2022] [Indexed: 12/04/2022] Open
Abstract
Myocardial inhibition is the main cause of death in patients with sepsis.In recent years, methodological differences in the diagnosis, assessment, and treatment of septic myocardial depression have been observed, and how to objectively and accurately evaluate the degree of myocardial depression and the timing of treatment strategies have generally been the focus of this area of research. Based on the relevant research at home and abroad, the current review summarizes the clinical characteristics, methodological diagnosis, and symptomatic treatment of septic myocardial depression. The aim of doing so is to provide a reference for the early identification and treatment of patients with sepsis and myocardial depression.
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Affiliation(s)
- Xu-Dong Shen
- Department of Critical Care Medicine, Calmette Hospital Affiliated to Kunming Medical University, Kunming, 650011, People's Republic of China
| | - Hua-Sheng Zhang
- Department of Critical Care Medicine, Calmette Hospital Affiliated to Kunming Medical University, Kunming, 650011, People's Republic of China
| | - Rui Zhang
- Department of Critical Care Medicine, Calmette Hospital Affiliated to Kunming Medical University, Kunming, 650011, People's Republic of China
| | - Jun Li
- Department of Critical Care Medicine, Calmette Hospital Affiliated to Kunming Medical University, Kunming, 650011, People's Republic of China
| | - Zhi-Gang Zhou
- Department of Critical Care Medicine, Calmette Hospital Affiliated to Kunming Medical University, Kunming, 650011, People's Republic of China
| | - Zhi-Xian Jin
- Department of Respiratory Medicine, Calmette Hospital Affiliated to Kunming Medical University, Kunming, 650011, People's Republic of China
| | - Yin-Jia Wang
- Department of Critical Care Medicine, Calmette Hospital Affiliated to Kunming Medical University, Kunming, 650011, People's Republic of China
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12
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Nam E, Fitter S, Moussavi K. Comparison of push-dose phenylephrine and epinephrine in the emergency department. Am J Emerg Med 2021; 52:43-49. [PMID: 34864289 DOI: 10.1016/j.ajem.2021.11.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/27/2021] [Accepted: 11/21/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND There is limited evidence to support the efficacy and safety of push-dose vasopressor (PDP) use outside of the operating room (OR). Specifically, there are few head-to-head comparisons of different PDP in these settings. The purpose of this study was to compare the efficacy and safety of push-dose phenylephrine (PDP-PE) and epinephrine (PDP-E) in the Emergency Department (ED). METHODS This retrospective, single-center study evaluated adults given PDP-PE or PDP-E in the ED from May 2017 to November 2020. The primary outcome was a change in heart rate (HR). Secondary outcomes included changes in blood pressure, adverse effects, dosing errors, fluid and vasopressor requirements, ICU and hospital lengths of stay (LOS), and in-hospital mortality. RESULTS Ninety-six patients were included in the PDP-PE group and 39 patients in the PDP-E group. Median changes in HR were 0 [-7, 6] and - 2 [-15, 5] beats per minute (BPM) for PDP-PE and PDP-E, respectively (p = 0.138). PDP-E patients had a greater median increase in systolic blood pressure (SBP) (33 [24, 53] vs. 26 [8, 51] mmHg; p = 0.049). Dosing errors occurred more frequently in patients that received PDP-E (5/39 [12.8%] vs. 2/96 [2.1%]; p = 0.021). PDP-E patients more frequently received continuous epinephrine infusions before and after receiving PDP-E. There were no differences in adverse effects, fluid requirements, LOS, or mortality. CONCLUSION PDP-E provided a greater increase in SBP compared to PDP-PE. However, dosing errors occurred more frequently in those receiving PDP-E. Larger head-to-head studies are necessary to further evaluate the efficacy and safety of PDP-E and PDP-PE.
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Affiliation(s)
- Elizabeth Nam
- Clinical Pharmacist, Loma Linda University Medical Center, 11234 Anderson St, Loma Linda, CA 92354, USA.
| | - Scott Fitter
- Clinical Pharmacy Specialist - Emergency Medicine, Loma Linda University Medical Center, Loma Linda University School of Pharmacy, 24745 Stewart St. Shryock Hall, Loma Linda, CA 92350, USA
| | - Kayvan Moussavi
- Faculty, Clinical Education, Providence St. Joseph of Orange, Department of Pharmacy Practice, College of Pharmacy, Marshall B. Ketchum University, 2575 Yorba Linda Blvd. Fullerton, CA 92831, USA.
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13
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Tang X, Xu Y, Dai X, Xing Y, Yang D, Huang Q, Li H, Lv X, Wang Y, Lu D, Wang H. The Long-term Effect of Dobutamine on Intrinsic Myocardial Function and Myocardial Injury in Septic Rats with Myocardial Dysfunction. Shock 2021; 56:582-592. [PMID: 34524268 DOI: 10.1097/shk.0000000000001718] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
ABSTRACT Dobutamine (DOB) is recommended as an inotrope for septic patients with low cardiac output, but its long-term impact on sepsis-induced cardiomyopathy remains unclear. This study investigated the long-term effect of DOB on septic myocardial dysfunction and injury. Rats were exposed to cecal ligation and puncture (CLP), the intrinsic myocardial function, other organ functions, hemodynamics, inflammatory response, serum myocardial injury biomarkers, myocardial apoptosis, and vascular permeability were determined. At 6 h after CLP, the left ventricular ±dP/dt were significantly depressed, cardiac tumor necrosis factor-α and vascular cell adhesion molecule-1 expression were increased, but not serum cardiac troponin I (cTnI), N-terminal pro-brain natriuretic peptide (NT-proBNP), heart-type fatty acid-binding protein (H-FABP), creatinine, and urea nitrogen concentrations in CLP group compared with controls. At 9 h after CLP, hepatic dysfunction was present in CLP rats compared with controls. At 6 h after CLP, DOB treatment did not affect hemodynamics, the left ventricular ±dP/dt, cytokine levels in serum and myocardium, as well as cardiomyocyte apoptosis and cardiac vascular hyperpermeability at 20 h after CLP. However, DOB (10.0 μg/kg) increased serum IL-10 level and improved survival in septic rats. These results indicate that the intrinsic myocardial depression occurs earlier than hepatic and renal dysfunction in sepsis and serum cTnI, NT-proBNP, and H-FABP are not suitable as early biomarkers for sepsis-induced myocardial dysfunction. Although DOB treatment (10.0 μg/kg) in the presence of myocardial dysfunction improves survival in septic rats, it neither improves myocardial function and hemodynamics nor attenuates myocardial injury at the later stage of sepsis.
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Affiliation(s)
- Xiangxu Tang
- Department of Pathophysiology, Key Laboratory of State Administration of Traditional Chinese Medicine of the People's Republic of China, School of Medicine, Jinan University, Guangzhou, Guangdong, China
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14
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Lyhne MD, Dragsbaek SJ, Hansen JV, Schultz JG, Andersen A, Nielsen-Kudsk JE. Levosimendan, milrinone, and dobutamine in experimental acute pulmonary embolism. Pulm Circ 2021; 11:20458940211022977. [PMID: 34178307 PMCID: PMC8207288 DOI: 10.1177/20458940211022977] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 05/16/2021] [Indexed: 12/30/2022] Open
Abstract
Acute pulmonary embolism is a frequent condition in emergency medicine and potentially fatal. Cause of death is right ventricular failure due to increased right ventricular afterload from both pulmonary vascular obstruction and vasoconstriction. Inodilators are interesting drugs of choice as they may improve right ventricular function and lower its afterload. We aimed to investigate the cardiovascular effects of three clinically relevant inodilators: levosimendan, milrinone, and dobutamine in acute pulmonary embolism. We conducted a randomized, blinded, animal study using 18 female pigs. Animals received large autologous pulmonary embolism until doubling of baseline mean pulmonary arterial pressure and were randomized to increasing doses of each inodilator. Effects were evaluated with bi-ventricular pressure–volume loop recordings, right heart catheterization, and blood gas analyses. Induction of pulmonary embolism increased right ventricular afterload and pulmonary pressure (p < 0.05) causing right ventricular dysfunction. Levosimendan and milrinone showed beneficial hemodynamic profiles by lowering right ventricular pressures and volume (p < 0.001) and improved right ventricular function and cardiac output (p < 0.05) without increasing right ventricular mechanical work. Dobutamine increased right ventricular pressure and function (p < 0.01) but at a cost of increased mechanical work at the highest doses, showing an adverse hemodynamic profile. In a porcine model of acute pulmonary embolism, levosimendan and milrinone reduced right ventricular afterload and improved right ventricular function, whereas dobutamine at higher doses increased right ventricular afterload and right ventricular mechanical work. The study motivates clinical testing of inodilators in patients with acute pulmonary embolism and right ventricular dysfunction.
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Affiliation(s)
- Mads D Lyhne
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Simone J Dragsbaek
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jacob V Hansen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jacob G Schultz
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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15
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Ruchti VE, Wibrow BA, Seet J, Jacques A, Jha N, Anstey MH. A prospective comparison of peripheral metaraminol versus dilute noradrenaline in the intensive care unit. Anaesth Intensive Care 2021; 49:144-146. [PMID: 33853391 DOI: 10.1177/0310057x20984794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Vera Ew Ruchti
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia
| | - Bradley A Wibrow
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia.,School of Medicine, University of Western Australia, Perth, Australia
| | - Jason Seet
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia
| | - Angela Jacques
- Institute for Health Research, University of Notre Dame, Fremantle, Australia.,Department of Research, Sir Charles Gairdner Hospital, Perth, Australia
| | - Nihar Jha
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia
| | - Matthew H Anstey
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia.,School of Medicine, University of Western Australia, Perth, Australia.,School of Public Health, Curtin University Medical School, Perth, Australia
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16
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Vasoactive-Inotropic Score as an Early Predictor of Mortality in Adult Patients with Sepsis. J Clin Med 2021; 10:jcm10030495. [PMID: 33572578 PMCID: PMC7867010 DOI: 10.3390/jcm10030495] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/24/2021] [Accepted: 01/27/2021] [Indexed: 12/29/2022] Open
Abstract
Vasoactive and inotropic medications are essential for sepsis management; however, the association between the maximum Vasoactive-Inotropic score (VISmax) and clinical outcomes is unknown in adult patients with sepsis. We investigated the VISmax as a predictor for mortality among such patients in the emergency department (ED) and compared its prognostic value with that of the sequential organ failure assessment (SOFA) score. This single-center retrospective study included 910 patients diagnosed with sepsis between January 2016 and March 2020. We calculated the VISmax using the highest doses of vasopressors and inotropes administered during the first 6 h on ED admission and categorized it as 0–5, 6–15, 16–30, 31–45, and >45 points. The primary outcome was 30-day mortality. VISmax for 30-day mortality was significantly higher in non-survivors than in survivors. The mortality rates in the five VISmax groups were 17.2%, 20.8%, 33.3%, 54.6%, and 70.0%, respectively. The optimal cut-off value of VISmax to predict 30-day mortality was 31. VISmax had better prognostic value than the cardiovascular component of the SOFA score and initial lactate levels. VISmax was comparable to the APACHE II score in predicting 30-day mortality. Multivariable analysis showed that VISmax 16–30, 31–45, and >45 were independent risk factors for 30-day mortality. VISmax in ED could help clinicians to identify sepsis patients with poor prognosis.
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17
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Shrestha N, Acharya U, Shrestha PS, Acharya SP, Karki B, Dhakal SS. Topical nitroglycerin for management of peripheral extravasation of vasopressors: a case report. Oxf Med Case Reports 2020; 2020:omaa066. [PMID: 32793370 PMCID: PMC7416830 DOI: 10.1093/omcr/omaa066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/05/2020] [Accepted: 06/30/2020] [Indexed: 12/02/2022] Open
Abstract
Peripheral route for administration of vasopressors is often opted due to resource limitations or as a rescue until central venous access is established. This, however, is not devoid of complications, the most common being extravasation and tissue injury. Phentolamine is the only drug approved for management of vasopressor extravasation; however, successful use of other agents has been reported. Here we report a case of peripheral extravasation of vasopressors, successfully managed with topical nitroglycerin in intensive care unit in Kathmandu. To our knowledge, this is the first report of such kind from Nepal.
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Affiliation(s)
- Ninadini Shrestha
- Department of Anesthesiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu 44600, Nepal
| | - Utsav Acharya
- Department of Anesthesiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu 44600, Nepal
| | - Pramesh Sunder Shrestha
- Department of Anesthesiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu 44600, Nepal
| | - Subhash Prasad Acharya
- Department of Anesthesiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu 44600, Nepal
| | - Bipin Karki
- Department of Critical Care Medicine, Om Hospital and Research Centre, Kathmandu 44600, Nepal
| | - Subodh Sagar Dhakal
- Department of Pulmonology, Sleep Medicine and Critical Care, Kathmandu Medical College and Teaching Hospital, Kathmandu 44600, Nepal
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18
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Poveda-Jaramillo R. Heart Dysfunction in Sepsis. J Cardiothorac Vasc Anesth 2020; 35:298-309. [PMID: 32807603 DOI: 10.1053/j.jvca.2020.07.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 06/11/2020] [Accepted: 07/05/2020] [Indexed: 12/24/2022]
Abstract
Cardiac involvement during sepsis frequently occurs. A series of molecules induces a set of changes at the cellular level that result in the malfunction of the myocardium. The understanding of these molecular alterations has simultaneously promoted the implementation of diagnostic strategies that are much more precise and allowed the advance of the therapeutics. The heart is a vital organ for survival. Its well-being ensures the adequate supply of essential elements for organs and tissues.
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19
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Chen Y, Guo L, Shi Y, Ma G, Xue W, He L, Ma S, Ni X. Norepinephrine prophylaxis for postspinal anesthesia hypotension in parturient undergoing cesarean section: a randomized, controlled trial. Arch Gynecol Obstet 2020; 302:829-836. [PMID: 32588134 DOI: 10.1007/s00404-020-05663-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 06/18/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To investigate the efficacy and safety of prophylactic infusion of norepinephrine (NE) versus normal saline in patients undergoing cesarean section. METHODS Patients (n = 97) were randomized to receive a bolus of NE (6 μg) immediately following spinal anesthesia with maintenance NE (0.05 μg/kg/min IV) or normal saline (n = 98). The primary endpoint was the incidence of postspinal anesthesia hypotension [systolic blood pressure (SBP) < 80% of baseline] at 1-20 min following spinal anesthesia. Secondary outcomes were the overall stability of SBP control versus baseline, inferior vena cava collapsibility index (IVC-CI), other adverse events (bradycardia, nausea, vomiting, and hypertension), and neonatal outcomes (blood gas values and Apgar scores). RESULTS The rates of postspinal anesthesia hypotension and severe postspinal anesthesia hypotension (SBP < 60% of the baseline) were significantly lower in the NE group (17.5% vs. 62.2%, p < 0.001; 7.2% vs. 17.4%, p = 0.031). In the NE group, SBP remained more stable and closer to baseline (p < 0.001), and IVC-CI values were lower 5 min after spinal anesthesia and 5 min after fetal delivery (p = 0.045; p < 0.001, respectively). Other adverse effects and neonatal outcomes were not different between the two groups. CONCLUSION Prophylactic NE infusion effectively lowers the incidence of postspinal anesthesia hypotension and does not increase other adverse events in patients or neonates.
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Affiliation(s)
- Yi Chen
- Department of Anesthesiology, General Hospital of Ningxia Medical University, 804S Shengli Street, Yinchuan, 750004, Ningxia, China
| | - Lei Guo
- Department of Anesthesiology, General Hospital of Ningxia Medical University, 804S Shengli Street, Yinchuan, 750004, Ningxia, China
| | - Yongqiang Shi
- Department of Anesthesiology, General Hospital of Ningxia Medical University, 804S Shengli Street, Yinchuan, 750004, Ningxia, China
| | - Gang Ma
- Department of Anesthesiology, General Hospital of Ningxia Medical University, 804S Shengli Street, Yinchuan, 750004, Ningxia, China
| | - Wei Xue
- Department of Obstetrics, General Hospital of Ningxia Medical University, Yinchuan, 750004, Ningxia, China
| | - Ling He
- Department of Obstetrics, General Hospital of Ningxia Medical University, Yinchuan, 750004, Ningxia, China
| | - Shuqin Ma
- Department of Obstetrics, General Hospital of Ningxia Medical University, Yinchuan, 750004, Ningxia, China
| | - Xinli Ni
- Department of Anesthesiology, General Hospital of Ningxia Medical University, 804S Shengli Street, Yinchuan, 750004, Ningxia, China.
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20
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Jones TW, Smith SE, Van Tuyl JS, Newsome AS. Sepsis With Preexisting Heart Failure: Management of Confounding Clinical Features. J Intensive Care Med 2020; 36:989-1012. [PMID: 32495686 DOI: 10.1177/0885066620928299] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Preexisting heart failure (HF) in patients with sepsis is associated with worse clinical outcomes. Core sepsis management includes aggressive volume resuscitation followed by vasopressors (and potentially inotropes) if fluid is inadequate to restore perfusion; however, large fluid boluses and vasoactive agents are concerning amid the cardiac dysfunction of HF. This review summarizes evidence regarding the influence of HF on sepsis clinical outcomes, pathophysiologic concerns, resuscitation targets, hemodynamic interventions, and adjunct management (ie, antiarrhythmics, positive pressure ventilatory support, and renal replacement therapy) in patients with sepsis and preexisting HF. Patients with sepsis and preexisting HF receive less fluid during resuscitation; however, evidence suggests traditional fluid resuscitation targets do not increase the risk of adverse events in HF patients with sepsis and likely improve outcomes. Norepinephrine remains the most well-supported vasopressor for patients with sepsis with preexisting HF, while dopamine may induce more cardiac adverse events. Dobutamine should be used cautiously given its generally detrimental effects but may have an application when combined with norepinephrine in patients with low cardiac output. Management of chronic HF medications warrants careful consideration for continuation or discontinuation upon development of sepsis, and β-blockers may be appropriate to continue in the absence of acute hemodynamic decompensation. Optimal management of atrial fibrillation may include β-blockers after acute hemodynamic stabilization as they have also shown independent benefits in sepsis. Positive pressure ventilatory support and renal replacement must be carefully monitored for effects on cardiac function when HF is present.
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Affiliation(s)
- Timothy W Jones
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Augusta, GA, USA
| | - Susan E Smith
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Athens, GA, USA
| | - Joseph S Van Tuyl
- Department of Pharmacy Practice, 14408St Louis College of Pharmacy, St Louis, MO, USA
| | - Andrea Sikora Newsome
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Augusta, GA, USA.,Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
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21
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Fukata M. Acute Decompensated Heart Failure in Patients with Heart Failure with Reduced Ejection Fraction. Heart Fail Clin 2020; 16:187-200. [PMID: 32143763 DOI: 10.1016/j.hfc.2019.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Acute decompensated heart failure (ADHF) requires immediate treatments because it impairs perfusion to systemic organs and their function. Half of all patients with ADHF are diagnosed with heart failure with reduced left ventricular ejection fraction (HFrEF). The initial goal of management for ADHF is to stabilize hemodynamic status. Pulmonary edema is treated with vasodilators or diuretics. Inhibitors of the renin-angiotensin-aldosterone system and β-blockers should be started and/or increased to meet the maximum dose, ideally the target dose, that the patient can tolerate as a treatment of HFrEF. Patients with severe circulatory failure need inotropic drugs or mechanical circulatory support.
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Affiliation(s)
- Mitsuhiro Fukata
- Department of Hematology, Oncology and Cardiovascular Medicine, Heart Center, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
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22
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Cinel I, Kasapoglu US, Gul F, Dellinger RP. The initial resuscitation of septic shock. J Crit Care 2020; 57:108-117. [PMID: 32135409 DOI: 10.1016/j.jcrc.2020.02.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 01/28/2020] [Accepted: 02/05/2020] [Indexed: 12/17/2022]
Abstract
Septic shock is the most severe form of sepsis, characterized by (a) persistent hypotension despite fluid resuscitation and (b) the presence of tissue hypoperfusion. Delays in the diagnosis and initiation of treatment of septic shock is associated with increasing risk for mortality. Early and effective fluid resuscitation and vasopressor administration play a crucial role in maintaining tissue perfusion in septic shock patients. A low diastolic arterial pressure (DAP) correlates with severity of arteriolar vasodilation, compromises left ventricle oxygen supply and can be used for identifying septic shock patients that would potentially benefit from earlier vasopressor therapy. Controversy currently exists as to the balance of fluids and vasopressors to maintain target mean arterial pressure. The aim of this article is to review the rationale for fluid resuscitation and vasopressor therapy and the importance of both mean and diastolic blood pressure during the initial resuscitation of the septic shock. We relate our personal prescription of balancing fluids and vasopressors in the resuscitation of septic shock.
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Affiliation(s)
- Ismail Cinel
- Department of Critical Care Medicine, Marmara University School of Medicine, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Umut S Kasapoglu
- Department of Critical Care Medicine, Marmara University School of Medicine, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Fethi Gul
- Department of Critical Care Medicine, Marmara University School of Medicine, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - R Phillip Dellinger
- Division of Critical Care Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, USA.
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23
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Tian DH, Smyth C, Keijzers G, Macdonald SPJ, Peake S, Udy A, Delaney A. Safety of peripheral administration of vasopressor medications: A systematic review. Emerg Med Australas 2019; 32:220-227. [PMID: 31698544 DOI: 10.1111/1742-6723.13406] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 09/19/2019] [Accepted: 09/25/2019] [Indexed: 01/01/2023]
Affiliation(s)
- David H Tian
- Malcolm Fisher Department of Intensive Care MedicineRoyal North Shore Hospital Sydney New South Wales Australia
| | - Claire Smyth
- Malcolm Fisher Department of Intensive Care MedicineRoyal North Shore Hospital Sydney New South Wales Australia
| | - Gerben Keijzers
- Emergency Department, Gold Coast University Hospital, Gold Coast Queensland Australia
- School of Medicine, Bond University, Gold Coast Queensland Australia
- School of Medicine, Griffith University, Gold Coast Queensland Australia
| | - Stephen PJ Macdonald
- Centre for Clinical Research in Emergency MedicineHarry Perkins Institute of Medical Research Perth Western Australia Australia
- Emergency DepartmentRoyal Perth Hospital, The University of Western Australia Perth Western Australia Australia
| | - Sandra Peake
- Department of Intensive Care MedicineThe Queen Elizabeth Hospital Adelaide South Australia Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive MedicineMonash University Melbourne Victoria Australia
- School of Health and Medical SciencesUniversity of Adelaide Adelaide South Australia Australia
| | - Andrew Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive MedicineMonash University Melbourne Victoria Australia
- Department of Intensive Care and Hyperbaric MedicineThe Alfred Hospital Melbourne Victoria Australia
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care MedicineRoyal North Shore Hospital Sydney New South Wales Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive MedicineMonash University Melbourne Victoria Australia
- Northern Clinical School, Sydney Medical SchoolThe University of Sydney Sydney New South Wales Australia
- Division of Critical Care, The George Institute for Global HealthThe University of New South Wales Sydney New South Wales Australia
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24
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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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25
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[Consensus document for sepsis code implementation and development in the Community of Madrid]. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2019; 32:400-409. [PMID: 31345006 PMCID: PMC6719654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The consensus paper for the implementation and development of the sepsis code, finished in April 2017 is presented here. It was adopted by the Regional Office of Health as a working document for the implementation of the sepsis code in the Community of Madrid, both in the hospital setting (acute, middle and long-stay hospitals) and in Primary Care and Out-of-Hospital Emergency Services. It is now published without changes with respect to the original version, having only added the most significant bibliographical references. The document is divided into four parts: introduction, initial detection and assessment, early therapy and organizational recommendations. In the second to fourth sections, 25 statements or proposals have been included, agreed upon by the authors after several face-to-face meetings and an extensive "online" discussion. The annex includes nine tables that are intended as a practical guide to the activation of the sepsis code. Both the content of the recommendations and their formal writing have been made taking into account their applicability in all areas to which they are directed, which may have very different structural and functional characteristics and features, so that we have deliberately avoided a greater degree of concretion: the objective is not that the sepsis code is organized and applied identically in all of them, but that the health resources work in a coordinated manner aligned in the same direction.
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Versyck G, de Gheldere C, Vanclooster P. Non-occlusive mesenteric ischemia: two case reports and a short review of the literature. Acta Chir Belg 2018; 118:392-397. [PMID: 29173076 DOI: 10.1080/00015458.2017.1408280] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Non-occlusive mesenteric ischemia (NOMI) is an infrequent cause of acute mesenteric ischemia with atypical symptoms and a high mortality. PATIENTS AND METHODS We report two cases of NOMI characterized by their difference in etiology, treatment and outcome. RESULTS In the first case, the patient developed NOMI after septic shock, she was successfully treated with surgery. The second patient experienced two episodes of cardiac arrest followed by NOMI. He received only supportive care and died shortly after. We present a short review of the literature, discussing epidemiology, pathophysiology, clinical presentations, diagnosis and management of NOMI. CONCLUSION NOMI is a rare disease with a difficult diagnosis. Early recognition and treatment with supportive therapy, vasodilator drugs and possibly surgery can significantly lower mortality.
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Affiliation(s)
- Georges Versyck
- Faculty of medicine, Katholieke Universiteit Leuven, Leuven, Belgium
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Lilly CM, Swami S, Liu X, Riker RR, Badawi O. Five-Year Trends of Critical Care Practice and Outcomes. Chest 2017; 152:723-735. [PMID: 28800866 DOI: 10.1016/j.chest.2017.06.050] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 06/06/2017] [Accepted: 06/23/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Longitudinal analyses of large, detailed adult critical care datasets provide insights into practice trends and generate useful outcome and process benchmarks. METHODS Data representing 991,571 consecutive critical care visits to 160 US adult ICUs from 2009 to 2013 from the eICU Research Institute clinical practice database were used to quantitate patient characteristics, APACHE IV-based acuity predictions, treatments, and outcomes. Analyses for changes over time were performed for patient characteristics, entry and discharge locations, primary admission diagnosis, treatments, adherence to consensus ICU best practices, length of stay (LOS), and inpatient mortality. RESULTS We detected significant trends for increasing age, BMI, and risk of mortality, higher frequency of admission from an ED and stepdown unit, and more frequent hospital discharge to substance abuse centers and skilled nursing facilities. Significantly more patients were admitted for sepsis, emphysema, coma, congestive heart failure, diabetic ketoacidosis, and fewer were admitted for asthma, unspecified chest pain, coronary artery bypass graft, and stroke care. The frequency of noninvasive mechanical ventilation and adherence to critical care best practices significantly increased, whereas the duration of renal replacement therapies, frequency of transfusions, antimicrobial use, critical care complications, LOS, and inpatient mortality decreased. CONCLUSIONS Analyses of patients, practices, and outcomes from a large geographically dispersed sample of adult ICUs revealed trends of increasing age and acuity, higher rates of adherence to best practice, use of noninvasive mechanical ventilation, and decreased use of antimicrobials, transfusions, and duration of renal replacement therapies. Acuity-adjusted LOS and in hospital mortality decreased.
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Affiliation(s)
- Craig M Lilly
- Departments of Medicine, Anesthesiology, and Surgery, the Clinical and Population Health Research Program, and the Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, MA.
| | | | | | - Richard R Riker
- Maine Medical Center, Tufts University School of Medicine, Boston, MA
| | - Omar Badawi
- Philips Healthcare, Baltimore, MD; Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD
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