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Picod A, Placier S, Genest M, Callebert J, Julian N, Zalc M, Assad N, Nordin H, Santos K, Gaudry S, Chatziantoniou C, Mebazaa A, Azibani F. Circulating Dipeptidyl Peptidase 3 Modulates Systemic and Renal Hemodynamics Through Cleavage of Angiotensin Peptides. Hypertension 2024; 81:927-935. [PMID: 38334001 PMCID: PMC10956665 DOI: 10.1161/hypertensionaha.123.21913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 01/25/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND High circulating DPP3 (dipeptidyl peptidase 3) has been associated with poor prognosis in critically ill patients with circulatory failure. In such situation, DPP3 could play a pathological role, putatively via an excessive angiotensin peptides cleavage. Our objective was to investigate the hemodynamics changes induced by DPP3 in mice and the relation between the observed effects and renin-angiotensin system modulation. METHODS Ten-week-old male C57Bl/6J mice were subjected to intravenous injection of purified human DPP3 or an anti-DPP3 antibody (procizumab). Invasive blood pressure and renal blood flow were monitored throughout the experiments. Circulating angiotensin peptides and catecholamines were measured and receptor blocking experiment performed to investigate the underlying mechanisms. RESULTS DPP3 administration significantly increased renal blood flow, while blood pressure was minimally affected. Conversely, procizumab led to significantly decreased renal blood flow. Angiotensin peptides measurement and an AT1R (angiotensin II receptor type 1) blockade experiment using valsartan demonstrated that the renovascular effect induced by DPP3 is due to reduced AT1R activation via decreased concentrations of circulating angiotensin II, III, and IV. Measurements of circulating catecholamines and an adrenergic receptor blockade by labetalol demonstrated a concomitant catecholamines release that explains blood pressure maintenance upon DPP3 administration. CONCLUSIONS High circulating DPP3 increases renal blood flow due to reduced AT1R activation via decreased concentrations of circulating angiotensin peptides while blood pressure is maintained by concomitant endogenous catecholamines release.
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Affiliation(s)
- Adrien Picod
- Institut National de la Santé et de la Recherche Médicale UMR-S 942 MASCOT – Paris – Cité University, Paris, France (A.P., M.G., J.C., N.J., M.Z., N.A., H.N., A.M., F.A.)
| | - Sandrine Placier
- INSERM UMR-S 1155 CORAKID – Paris – Sorbonne University, France (S.P., S.G., C.C.)
| | - Magali Genest
- Institut National de la Santé et de la Recherche Médicale UMR-S 942 MASCOT – Paris – Cité University, Paris, France (A.P., M.G., J.C., N.J., M.Z., N.A., H.N., A.M., F.A.)
| | - Jacques Callebert
- Institut National de la Santé et de la Recherche Médicale UMR-S 942 MASCOT – Paris – Cité University, Paris, France (A.P., M.G., J.C., N.J., M.Z., N.A., H.N., A.M., F.A.)
- Department of Biochemistry and Molecular Biology, Lariboisière – Saint Louis Hospitals (J.C.), APHP, Paris, France
| | - Nathan Julian
- Institut National de la Santé et de la Recherche Médicale UMR-S 942 MASCOT – Paris – Cité University, Paris, France (A.P., M.G., J.C., N.J., M.Z., N.A., H.N., A.M., F.A.)
- Department of Anesthesiology and Intensive Care, Lariboisière – Saint Louis Hospitals (N.J., A.M.), APHP, Paris, France
| | - Maxime Zalc
- Institut National de la Santé et de la Recherche Médicale UMR-S 942 MASCOT – Paris – Cité University, Paris, France (A.P., M.G., J.C., N.J., M.Z., N.A., H.N., A.M., F.A.)
- Department of Anesthesiology and Intensive Care, Mondor Hospital (M.Z.), APHP, Paris, France
- Paris Est – Créteil University, France (M.Z.)
| | - Noma Assad
- Institut National de la Santé et de la Recherche Médicale UMR-S 942 MASCOT – Paris – Cité University, Paris, France (A.P., M.G., J.C., N.J., M.Z., N.A., H.N., A.M., F.A.)
| | - Hugo Nordin
- Institut National de la Santé et de la Recherche Médicale UMR-S 942 MASCOT – Paris – Cité University, Paris, France (A.P., M.G., J.C., N.J., M.Z., N.A., H.N., A.M., F.A.)
| | - Karine Santos
- 4TEEN4 Pharmaceuticals Gmbh, Hennigsdorf, Germany (K.S.)
| | - Stéphane Gaudry
- INSERM UMR-S 1155 CORAKID – Paris – Sorbonne University, France (S.P., S.G., C.C.)
- Sorbonne – Paris Nord University, France (S.G.)
- Medical and Surgical Intensive Care Unit, Avicenne Hospital, APHP, Bobigny, France (S.G.)
| | | | - Alexandre Mebazaa
- Institut National de la Santé et de la Recherche Médicale UMR-S 942 MASCOT – Paris – Cité University, Paris, France (A.P., M.G., J.C., N.J., M.Z., N.A., H.N., A.M., F.A.)
- Department of Anesthesiology and Intensive Care, Lariboisière – Saint Louis Hospitals (N.J., A.M.), APHP, Paris, France
| | - Feriel Azibani
- Institut National de la Santé et de la Recherche Médicale UMR-S 942 MASCOT – Paris – Cité University, Paris, France (A.P., M.G., J.C., N.J., M.Z., N.A., H.N., A.M., F.A.)
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See EJ, Chaba A, Spano S, Maeda A, Clapham C, Liu J, Khasin M, Liskaser G, Eastwood G, Bellomo R. Exploring the norepinephrine to angiotensin II conversion ratio in patients with vasodilatory hypotension: A post-hoc analysis of the ARAMIS trial. J Crit Care 2024; 79:154453. [PMID: 37890357 DOI: 10.1016/j.jcrc.2023.154453] [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: 09/24/2023] [Revised: 10/18/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023]
Abstract
PURPOSE Angiotensin II is approved for catecholamine-refractory vasodilatory shock but the conversion dose ratio from norepinephrine to angiotensin II remains unclear. METHODS We conducted a post-hoc analysis of the Acute Renal effects of Angiotensin II Management in Shock (ARAMIS) trial involving patients with vasodilatory hypotension. We determined the norepinephrine equivalent dose immediately prior to angiotensin II initiation and calculated the conversion dose ratio between norepinephrine and angiotensin II. We performed subgroup analyses based on recent exposure to angiotensin receptor blockers (ARBs) and renin levels at baseline. RESULTS In 37 patients, the median conversion dose ratio between norepinephrine equivalent and angiotensin II was to 10:1 for norepinephrine bitartrate (5:1 for norepinephrine base). The conversion ratio was not affected by the baseline renin, with a median ratio of 10 (7-21) in the high renin group versus 12 (5-22) in the low renin group. Finally, exposure to ARBs prior admission appeared to diminish the conversion ratio with a median ratio of 7 (4-13) in ARB patients vs. 12 (7-22) in non-ARB patients. CONCLUSIONS The norepinephrine to angiotensin II conversion dose ratio is 10:1 in a vasodilatory hypotension population. These findings can guide clinicians and researchers in the use, dosing, and study of angiotensin II in critical care.
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Affiliation(s)
- Emily J See
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Nephrology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Anis Chaba
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Sofia Spano
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Akinori Maeda
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Caroline Clapham
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Jasmine Liu
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Monique Khasin
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Grace Liskaser
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Australia.
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McCloskey MM, Gibson GA, Pope HE, Giacomino BD, Hampton N, Micek ST, Kollef MH, Betthauser KD. Effect of Early Administration of Vasopressin on New-Onset Arrhythmia Development in Patients With Septic Shock: A Retrospective, Observational Cohort Study. Ann Pharmacother 2024; 58:5-14. [PMID: 37056040 DOI: 10.1177/10600280221095543] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
Abstract
Background: Adjunctive vasopressin use in septic shock reduces catecholamine requirements and is associated with a lower incidence of new-onset arrhythmias (NOAs). The association of vasopressin timing on NOA development is ill-described. Objective: To determine whether early administration of vasopressin was associated with a lower incidence of NOA in septic shock patients. Methods: A retrospective analysis of intensive care unit (ICU) patients at a large, academic medical center. Septic shock patients who required vasopressin and norepinephrine were eligible for inclusion. Patients were excluded for receipt of other vasoactive agents, history of cardiac arrhythmias, or outside hospital admission. Early vasopressin was defined as receipt within 6 hours of septic shock onset. The primary outcome was incidence of NOA. Results: In total, 436 patients, 220 (50.4%) in the early and 216 (49.6%) in the late vasopressin group, were included. Early vasopressin was not associated with a lower incidence of NOA compared with late vasopressin (9% vs 7%, median absolute difference [95% confidence interval, CI]: -2.1 [-7.2, 3.0], P = 0.41). Early vasopressin patients were observed to have shorter shock duration (2 vs 4 days, median absolute difference [95% CI]: 2 [1, 2], P < 0.001), and ICU length of stay (6 vs 7 days, median absolute difference [95% CI]: 1 [0, 2], P = 0.02). Conclusions and Relevance: Early vasopressin use was not associated with a lower incidence of NOA. Additional studies are needed to elucidate the effect of vasopressin timing on NOA and other clinical outcomes.
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Affiliation(s)
| | | | - Hannah E Pope
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO, USA
| | - Bria D Giacomino
- Department of Cardiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Nicholas Hampton
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO, USA
| | - Scott T Micek
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO, USA
- Division of Specialty Care Pharmacy Practice, Saint Louis College of Pharmacy, Saint Louis, MO, USA
- Center for Health Outcomes and Education, Saint Louis College of Pharmacy, Saint Louis, MO, USA
| | - Marin H Kollef
- Department of Pulmonology, Washington University School of Medicine, Saint Louis, MO, USA
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Ye E, Ye H, Wang S, Fang X. INITIATION TIMING OF VASOPRESSOR IN PATIENTS WITH SEPTIC SHOCK: A SYSTEMATIC REVIEW AND META-ANALYSIS. Shock 2023; 60:627-636. [PMID: 37695641 DOI: 10.1097/shk.0000000000002214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
ABSTRACT Background: Vasopressor plays a crucial role in septic shock. However, the time for vasopressor initiation remains controversial. We conducted a systematic review and meta-analysis to explore its initiation timing for septic shock patients. Methods: PubMed, Cochrane Library, Embase, and Web of Sciences were searched from inception to July 12, 2023, for relevant studies. Primary outcome was short-term mortality. Meta-analysis was performed using Stata 15.0. Results: Twenty-three studies were assessed, including 2 randomized controlled trials and 21 cohort studies. The early group resulted in lower short-term mortality than the late group (OR [95% CI] = 0.775 [0.673 to 0.893], P = 0.000, I2 = 67.8%). The significance existed in the norepinephrine and vasopressin in subgroup analysis. No significant difference was considered in the association between each hour's vasopressor delay and mortality (OR [95% CI] = 1.02 [0.99 to 1.051], P = 0.195, I2 = 57.5%). The early group had an earlier achievement of target MAP ( P < 0.001), shorter vasopressor use duration ( P < 0.001), lower serum lactate level at 24 h ( P = 0.003), lower incidence of kidney injury ( P = 0.001), renal replacement therapy use ( P = 0.022), and longer ventilation-free days to 28 days ( P < 0.001). Conclusions: Early initiation of vasopressor (1-6 h within septic shock onset) would be more beneficial to septic shock patients. The conclusion needs to be further validated by more well-designed randomized controlled trials.
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Affiliation(s)
- Enci Ye
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Sacha GL, Bauer SR. Optimizing Vasopressin Use and Initiation Timing in Septic Shock: A Narrative Review. Chest 2023; 164:1216-1227. [PMID: 37479058 PMCID: PMC10635838 DOI: 10.1016/j.chest.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 07/23/2023] Open
Abstract
TOPIC IMPORTANCE This review discusses the rationale for vasopressin use, summarizes the results of clinical trials evaluating vasopressin, and focuses on the timing of vasopressin initiation to provide clinicians guidance for optimal adjunctive vasopressin initiation in patients with septic shock. REVIEW FINDINGS Patients with septic shock require vasoactive agents to restore adequate tissue perfusion. After norepinephrine, vasopressin is the suggested second-line adjunctive agent in patients with persistent inadequate mean arterial pressure. Vasopressin use in practice is heterogeneous likely because of inconsistent clinical trial findings, the lack of specific recommendations for when it should be used, and the high drug acquisition cost. Despite these limitations, vasopressin has demonstrated price inelastic demand, and its use in the United States has continued to increase. However, questions remain regarding optimal vasopressin use in patients with septic shock, particularly regarding patient selection and the timing of vasopressin initiation. SUMMARY Experimental studies evaluating the initiation timing of vasopressin in patients with septic shock are limited, and recent observational studies have revealed an association between vasopressin initiation at lower norepinephrine-equivalent doses or lower lactate concentrations and lower mortality.
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Affiliation(s)
- Gretchen L Sacha
- Department of Pharmacy, Cleveland Clinic, Case Western Reserve University, Cleveland, OH.
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Case Western Reserve University, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
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García-Álvarez R, Arboleda-Salazar R. Vasopressin in Sepsis and Other Shock States: State of the Art. J Pers Med 2023; 13:1548. [PMID: 38003863 PMCID: PMC10672256 DOI: 10.3390/jpm13111548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/19/2023] [Accepted: 10/27/2023] [Indexed: 11/26/2023] Open
Abstract
This review of the use of vasopressin aims to be comprehensive and highly practical, based on the available scientific evidence and our extensive clinical experience with the drug. It summarizes controversies about vasopressin use in septic shock and other vasodilatory states. Vasopressin is a natural hormone with powerful vasoconstrictive effects and is responsible for the regulation of plasma osmolality by maintaining fluid homeostasis. Septic shock is defined by the need for vasopressors to correct hypotension and lactic acidosis secondary to infection, with a high mortality rate. The Surviving Sepsis Campaign guidelines recommend vasopressin as a second-line vasopressor, added to norepinephrine. However, these guidelines do not address specific debates surrounding the use of vasopressin in real-world clinical practice.
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Affiliation(s)
- Raquel García-Álvarez
- Department of Anesthesiology and Surgical Intensive Care, University Hospital 12 de Octubre, 28022 Madrid, Spain
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Wieruszewski PM, Bellomo R, Busse LW, Ham KR, Zarbock A, Khanna AK, Deane AM, Ostermann M, Wunderink RG, Boldt DW, Kroll S, Greenfeld CR, Hodges T, Chow JH. Initiating angiotensin II at lower vasopressor doses in vasodilatory shock: an exploratory post-hoc analysis of the ATHOS-3 clinical trial. Crit Care 2023; 27:175. [PMID: 37147690 PMCID: PMC10163684 DOI: 10.1186/s13054-023-04446-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 04/17/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND High dose vasopressors portend poor outcome in vasodilatory shock. We aimed to evaluate the impact of baseline vasopressor dose on outcomes in patients treated with angiotensin II (AT II). METHODS Exploratory post-hoc analysis of the Angiotensin II for the Treatment of High-Output Shock (ATHOS-3) trial data. The ATHOS-3 trial randomized 321 patients with vasodilatory shock, who remained hypotensive (mean arterial pressure of 55-70 mmHg) despite receiving standard of care vasopressor support at a norepinephrine-equivalent dose (NED) > 0.2 µg/kg/min, to receive AT II or placebo, both in addition to standard of care vasopressors. Patients were grouped into low (≤ 0.25 µg/kg/min; n = 104) or high (> 0.25 µg/kg/min; n = 217) NED at the time of study drug initiation. The primary outcome was the difference in 28-day survival between the AT II and placebo subgroups in those with a baseline NED ≤ 0.25 µg/kg/min at the time of study drug initiation. RESULTS Of 321 patients, the median baseline NED in the low-NED subgroup was similar in the AT II (n = 56) and placebo (n = 48) groups (median of each arm 0.21 µg/kg/min, p = 0.45). In the high-NED subgroup, the median baseline NEDs were also similar (0.47 µg/kg/min AT II group, n = 107 vs. 0.45 µg/kg/min placebo group, n = 110, p = 0.75). After adjusting for severity of illness, those randomized to AT II in the low-NED subgroup were half as likely to die at 28-days compared to placebo (HR 0.509; 95% CI 0.274-0.945, p = 0.03). No differences in 28-day survival between AT II and placebo groups were found in the high-NED subgroup (HR 0.933; 95% CI 0.644-1.350, p = 0.71). Serious adverse events were less frequent in the low-NED AT II subgroup compared to the placebo low-NED subgroup, though differences were not statistically significant, and were comparable in the high-NED subgroups. CONCLUSIONS This exploratory post-hoc analysis of phase 3 clinical trial data suggests a potential benefit of AT II introduction at lower doses of other vasopressor agents. These data may inform design of a prospective trial. TRIAL REGISTRATION The ATHOS-3 trial was registered in the clinicaltrials.gov repository (no. NCT02338843). Registered 14 January 2015.
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Affiliation(s)
| | - Rinaldo Bellomo
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Parkville, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Laurence W Busse
- Department of Medicine, Emory University, Atlanta, GA, USA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA, USA
| | - Kealy R Ham
- Department of Critical Care Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, University Münster, Munster, Germany
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
- Perioperative Outcomes and Informatics Collaborative, Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Adam M Deane
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Parkville, Australia
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Richard G Wunderink
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - David W Boldt
- Department of Anesthesiology and Critical Care Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Stew Kroll
- La Jolla Pharmaceutical Company, Waltham, MA, USA
| | | | - Tony Hodges
- La Jolla Pharmaceutical Company, Waltham, MA, USA
| | - Jonathan H Chow
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, 2700 M St. NW, 7Th Floor, Room 709, Washington, DC, 20037, USA.
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Brokmeier HM, Seelhammer TG, Nei SD, Gerberi DJ, Mara KC, Wittwer ED, Wieruszewski PM. Hydroxocobalamin for Vasodilatory Hypotension in Shock: A Systematic Review With Meta-Analysis for Comparison to Methylene Blue. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00241-0. [PMID: 37147207 DOI: 10.1053/j.jvca.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/30/2023] [Accepted: 04/03/2023] [Indexed: 05/07/2023]
Abstract
Hydroxocobalamin inhibits nitric oxide-mediated vasodilation, and has been used in settings of refractory shock. However, its effectiveness and role in treating hypotension remain unclear. The authors systematically searched Ovid Medline, Embase, EBM Reviews, Scopus, and Web of Science Core Collection for clinical studies reporting on adult persons who received hydroxocobalamin for vasodilatory shock. A meta-analysis was performed with random-effects models comparing the hemodynamic effects of hydroxocobalamin to methylene blue. The Risk of Bias in Nonrandomized Studies of Interventions tool was used to assess the risk of bias. A total of 24 studies were identified and comprised mainly of case reports (n = 12), case series (n = 9), and 3 cohort studies. Hydroxocobalamin was applied mainly for cardiac surgery vasoplegia, but also was reported in the settings of liver transplantation, septic shock, drug-induced hypotension, and noncardiac postoperative vasoplegia. In the pooled analysis, hydroxocobalamin was associated with a higher mean arterial pressure (MAP) at 1 hour than methylene blue (mean difference 7.80, 95% CI 2.63-12.98). There were no significant differences in change in MAP (mean difference -4.57, 95% CI -16.05 to 6.91) or vasopressor dosage (mean difference -0.03, 95% CI -0.12 to 0.06) at 1 hour compared to baseline between hydroxocobalamin and methylene blue. Mortality was also similar (odds ratio 0.92, 95% CI 0.42-2.03). The evidence supporting the use of hydroxocobalamin for shock is limited to anecdotal reports and a few cohort studies. Hydroxocobalamin appears to positively affect hemodynamics in shock, albeit similar to methylene blue.
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Affiliation(s)
| | | | - Scott D Nei
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | | | - Kristin C Mara
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | | | - Patrick M Wieruszewski
- Department of Pharmacy, Mayo Clinic, Rochester, MN; Department of Anesthesiology, Mayo Clinic, Rochester, MN.
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Pannu A. Circulatory shock in adults in emergency department. Turk J Emerg Med 2023. [PMID: 37529784 PMCID: PMC10389095 DOI: 10.4103/2452-2473.367400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Circulatory shock is a common condition that carries high morbidity and mortality. This review aims to update the critical steps in managing common types of shock in adult patients admitted to medical emergency and intensive care units. A literature review was performed by searching PubMed, EMBASE Ovid, and Cochrane Library, using the following search items: ("shock" OR "circulatory shock" OR "septic shock" OR "cardiogenic shock") AND ("management" OR "treatment" OR "resuscitation"). The review emphasizes prompt shock identification with tissue hypoperfusion, knowledge of the underlying pathophysiological mechanism, initial fluid resuscitation with balanced crystalloids, norepinephrine as the preferred vasopressor in septic and profound cardiogenic shock, and tailored intervention addressing specific etiologies. Point-of-care ultrasound may help evaluate an undifferentiated shock and determine fluid responsiveness. The approach to septic shock is improving; however, confirmatory studies are required for many existing (e.g., amount of initial fluids and steroids) and emerging (e.g., angiotensin II) therapies. Knowledge gaps and wide variations persist in managing cardiogenic shock that needs urgent addressing to improve outcomes.
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Wieruszewski PM, Seelhammer TG, Barreto EF, Busse LW, Chow JH, Davison DL, Gaglani B, Khanna AK, ten Lohuis CC, Mara KC, Wittwer ED. Angiotensin II for Vasodilatory Hypotension in Patients Requiring Mechanical Circulatory Support. J Intensive Care Med 2022; 38:464-471. [PMID: 36524274 DOI: 10.1177/08850666221145864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background: Patients supported on mechanical circulatory support devices experience vasodilatory hypotension due to high surface area exposure to nonbiological and non-endothelialized surfaces. Angiotensin II has been studied in general settings of vasodilatory shock, however concerns exist regarding the use of this vasopressor in patients with pre-existing cardiac failure. The objective of this study was to assess the systemic and central hemodynamic effects of angiotensin II in patients with primary cardiac or respiratory failure requiring treatment with mechanical circulatory support devices. Methods: Multicenter retrospective observational study of adults supported on a mechanical circulatory support device who received angiotensin II for vasodilatory shock. The primary outcome was the intraindividual change from baseline in mean arterial pressure (MAP) and vasopressor dosage after angiotensin II. Results: Fifty patients were included with mechanical circulatory devices that were primarily used for cardiac failure (n = 41) or respiratory failure (n = 9). At angiotensin II initiation, the norepinephrine equivalent vasopressor dosage was 0.44 (0.34, 0.64) and 0.47 (0.33, 0.73) mcg/kg/min in the cardiac and respiratory groups, respectively. In the cardiac group, MAP increased from 60 to 70 mmHg (intraindividual P < .001) in the 1 h after angiotensin II initiation and the vasopressor dosage declined by 0.04 mcg/kg/min (intraindividual P < .001). By 12 h, the vasopressor dosage declined by 0.16 mcg/kg/min ( P = .001). There were no significant changes in cardiac index or mean pulmonary artery pressure throughout the 12 h following angiotensin II. In the respiratory group, similar but nonsignificant effects at 1 h on MAP (61-81 mmHg, P = .26) and vasopressor dosage (decline by 0.13 mcg/kg/min, P = .06) were observed. Conclusions: In patients requiring mechanical circulatory support for cardiac failure, angiotensin II produced beneficial systemic hemodynamic effects without negatively impacting cardiac function or pulmonary pressures. The systemic hemodynamic effects in those with respiratory failure were nonsignificant due to limited sample size.
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Affiliation(s)
- Patrick M. Wieruszewski
- Department of Anesthesiology and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN, USA
| | - Troy G. Seelhammer
- Department of Anesthesiology and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN, USA
| | - Erin F. Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN, USA
| | - Laurence W. Busse
- Department of Medicine, Emory University, Emory Critical Care Center, Atlanta, GA, USA
| | - Jonathan H. Chow
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Danielle L. Davison
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Bhavita Gaglani
- Department of Anesthesiology, Section on Critical Care Medicine, Perioperative Outcomes and Informatics Collaborative, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
- Department of Internal Medicine and Infectious Diseases, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Ashish K. Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Perioperative Outcomes and Informatics Collaborative, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Caitlin C. ten Lohuis
- Department of Medicine, Emory University, Emory Critical Care Center, Atlanta, GA, USA
| | - Kristin C. Mara
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Erica D. Wittwer
- Department of Anesthesiology and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN, USA
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11
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Effects of Collagen Antibacterial Functional Dressing plus Continuous Nursing on Lower Extremity Skin Injury Caused by Norepinephrine in Patients with Septic Shock. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:4160637. [PMID: 36034962 PMCID: PMC9410798 DOI: 10.1155/2022/4160637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/03/2022] [Accepted: 07/05/2022] [Indexed: 11/18/2022]
Abstract
Background This study was designed to explore the effects of collagen antibacterial functional dressing plus continuous care on norepinephrine-induced lower extremity skin injury in patients with septic shock. Methods In this prospective, randomized, controlled study, 120 patients with septic shock receiving norepinephrine in our hospital from February 2020 to February 2021 were recruited. All the enrollments were randomized into the experimental group (n = 60) and the control group (n = 60). The control group received continuous care, while the experimental group additionally received collagen antibacterial functional dressing. Outcome measures included skin sensation scores, incidence of lower extremity skin injuries, recovery time, inflammatory factor levels, and care satisfaction. Results Collagen antibacterial functional dressing plus continuous care resulted in significantly lower skin sensation scores and a lower incidence of skin injuries versus continuous care alone. Patients in the experimental group had faster recovery of lower extremity skin injury than those in the control group. Collagen antibacterial functional dressing plus continuous care was associated with significantly lower levels of inflammatory factors and a higher satisfaction rate than continuous care alone. Conclusion Collagen antibacterial functional dressing plus continuous care improves the local skin condition of patients with septic shock receiving norepinephrine, regulates the levels of inflammatory factors, reduces the risk of skin injuries, and enhances care satisfaction.
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12
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Effect Evaluation of Norepinephrine on Cardiac Function in Patients with Sepsis by Cardiac Ultrasound Imaging. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:5896791. [PMID: 35770120 PMCID: PMC9236790 DOI: 10.1155/2022/5896791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/01/2022] [Accepted: 06/03/2022] [Indexed: 12/05/2022]
Abstract
In order to investigate the therapeutic effect of norepinephrine on patients with sepsis and the effect of echocardiography on the diagnosis of cardiac function in patients with sepsis, 86 patients with sepsis were selected as research objects and randomly divided into two groups. Patients in the control group (N = 43 cases) received conventional treatment (1~15 μg/kg∗min dopamine), and those in the experimental group (N = 43 cases) received conventional treatment+norepinephrine therapy (0.05~0.5 μg∗kg−1/min). The clinical efficacy, cardiac ultrasonography results, and hemodynamic indexes of patients between the two groups were analyzed and compared. The results showed that the total effective rate of treatment in the experimental group (97.7%) was significantly higher than that in the control group (81.4%) (P < 0.05). The maximum, minimum, and average values of mitral valve E peak flow velocity (VEpeak) and left ventricular outflow tract peak flow velocity (Vpeak), respiratory variability of mitral valve E peak flow velocity (ΔVEpeak), and respiratory variability of peak flow velocity (ΔVpeak) were all significantly greater than those of the control group (P < 0.05). The area under the receiver operating characteristic curve (AUC) of ΔVEpeak and ΔVpeak for predicting positive volume response in patients with sepsis was 0.934 and 0.913, respectively; the sensitivity was 0.828 and 0.827; the specificity was 0.936 and 0.893; and the Youden indices were 0.765 and 0.712, respectively. In short, norepinephrine had a high total response rate in patients with sepsis, and echocardiography can well evaluate the effect of norepinephrine on cardiac function in patients with sepsis, which is worthy of further promotion.
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Prevalence of New-Onset Atrial Fibrillation and Associated Outcomes in Patients with Sepsis: A Systematic Review and Meta-Analysis. J Pers Med 2022; 12:jpm12040547. [PMID: 35455662 PMCID: PMC9026551 DOI: 10.3390/jpm12040547] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/22/2022] [Accepted: 03/24/2022] [Indexed: 12/26/2022] Open
Abstract
Background: New-onset atrial fibrillation (NOAF) is a common complication in patients with sepsis, although its prevalence and impact on outcomes are still unclear. We aim to provide a systematic review and meta-analysis on the prevalence of NOAF in patients with sepsis, and its impact on in-hospital mortality and intensive care unit (ICU) mortality. Methods: PubMed and EMBASE were systematically searched on 26 December 2021. Studies reporting on the prevalence of NOAF and/or its impact on in-hospital mortality or ICU mortality in patients with sepsis or septic shock were included. The pooled prevalence and 95% confidence intervals (CI) were calculated, as well as the risk ratios (RR), 95%CI and 95% prediction intervals (PI) for outcomes. Subgroup analyses and meta-regressions were performed to account for heterogeneity. Results: Among 4988 records retrieved from the literature search, 22 articles were included. Across 207,847 patients with sepsis, NOAF was found in 13.5% (95%CI: 8.9–20.1%), with high heterogeneity between studies; significant subgroup differences were observed, according to the geographical location, study design and sample size of the included studies. A multivariable meta-regression model showed that sample size and geographical location account for most of the heterogeneity. NOAF patients showed an increased risk of both in-hospital mortality (RR: 1.69, 95%CI: 1.47–1.96, 95%PI: 1.15–2.50) and ICU mortality (RR: 2.12, 95%CI: 1.86–2.43, 95%PI: 1.71–2.63), with moderate to no heterogeneity between the included studies. Conclusions: NOAF is a common complication during sepsis, being present in one out of seven individuals. Patients with NOAF are at a higher risk of adverse events during sepsis, and may need specific therapeutical interventions.
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Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2022. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2022 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA. .,Outcomes Research Consortium, Cleveland, OH, USA.
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