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Leone M, Joosten A, Legrand M. Intraoperative hypotension is bad but could the treatment be even worse? Anaesth Crit Care Pain Med 2023; 42:101226. [PMID: 37030394 DOI: 10.1016/j.accpm.2023.101226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 04/10/2023]
Affiliation(s)
- Marc Leone
- Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Department of Anesthesiology and Intensive Care Unit, North Hospital, Marseille, France; Centre for CardioVascular and Nutrition Research (C2VN), Inserm 1263, Inrae 1260, Marseille, France.
| | - Alexandre Joosten
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Matthieu Legrand
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA; INI-CRCT Network, Nancy, France
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Kharrat A, Jain A. Hemodynamic dysfunction in neonatal sepsis. Pediatr Res 2022; 91:413-424. [PMID: 34819654 DOI: 10.1038/s41390-021-01855-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 10/20/2021] [Accepted: 10/31/2021] [Indexed: 11/09/2022]
Abstract
Cardiovascular disturbances are a frequent occurrence in neonatal sepsis. Preterm and term infants are particularly vulnerable due to the unique features of their cardiovascular function and reserve, compared to older children and adults. The clinical manifestations of neonatal sepsis are a product of the variable inflammatory pathways involved (warm vs. cold shock physiology), developmental state of the cardiovascular system, and hormonal responses. Targeted neonatal echocardiography has played an important role in advancing our knowledge, may help delineate specific hemodynamic phenotypes in real-time, and supports an individualized physiology-based management of sepsis-associated cardiovascular dysfunction. IMPACT: Cardiovascular dysfunction is a common sequela of sepsis. This review aims to highlight the pathophysiological mechanisms involved in hemodynamic disturbance in neonatal sepsis, provide insights from targeted neonatal echocardiography-based clinical studies, and suggest its potential incorporation in day-to-day management.
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Affiliation(s)
- Ashraf Kharrat
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada. .,Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
| | - Amish Jain
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada
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3
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Liu DH, Ning YL, Lei YY, Chen J, Liu YY, Lin XF, Yang ZQ, Xian SX, Chen WT. Levosimendan versus dobutamine for sepsis-induced cardiac dysfunction: a systematic review and meta-analysis. Sci Rep 2021; 11:20333. [PMID: 34645892 PMCID: PMC8514594 DOI: 10.1038/s41598-021-99716-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 09/27/2021] [Indexed: 12/14/2022] Open
Abstract
Levosimendan and dobutamine are extensively used to treat sepsis-associated cardiovascular failure in ICU. Nevertheless, the role and mechanism of levosimendan in patients with sepsis-induced cardiomyopathy remains unclear. Moreover, previous studies on whether levosimendan is superior to dobutamine are still controversial. More importantly, these studies did not take changes (before-after comparison to the baseline) in quantitative parameters such as ejection fraction into account with the baseline level. Here, we aimed to determine the pros and cons of the two medicines by assessing the changes in cardiac function and blood lactate, mortality, with the standardized mean difference used as a summary statistic. Relevant studies were obtained by a thorough and disciplined literature search in several notable academic databases, including Google Scholar, PubMed, Cochrane Library and Embase until November 2020. Outcomes included changes in cardiac function, lactic acid, mortality and length of hospital stay. A total of 6 randomized controlled trials were included in this study, including 192 patients. Compared with dobutamine, patients treated with levosimendan had a greater improvement of cardiac index (ΔCI) (random effects, SMD = 0.90 [0.20,1.60]; I2 = 76%, P < 0.01) and left ventricular stroke work index (ΔLVSWI) (random effects, SMD = 1.56 [0.90,2.21]; I2 = 65%, P = 0.04), a significant decrease of blood lactate (Δblood lactate) (random effects, MD = - 0.79 [- 1.33, - 0.25]; I2 = 68%, P < 0.01) at 24-h after drug intervention, respectively. There was no significant difference between levosimendan and dobutamine on all-cause mortality in ICU (fixed effect, OR = 0.72 [0.39,1.33]; I2 = 0%, P = 0.99). We combine effect sizes related to different measurement parameters to evaluate cardiac function, which implied that septic patients with myocardial dysfunction might have a better improvement of cardiac function by levosimendan than dobutamine (random effects, SMD = 1.05 [0.69,1.41]; I2 = 67%, P < 0.01). This study suggested a significant improvement of CI, LVSWI, and decrease of blood lactate in septic patients with myocardial dysfunction in ICU after 24-h administration of levosimendan than dobutamine. However, the administration of levosimendan has neither an impact on mortality nor LVEF. Septic patients with myocardial dysfunction may partly benefit from levosimendan than dobutamine, mainly embodied in cardiac function improvement.
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Affiliation(s)
- Dong-Hua Liu
- Department of Critical Care Medicine, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 16, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China
- The First Clinical School, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Yi-Le Ning
- Department of Critical Care Medicine, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 16, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China
- Ling-Nan Medical Research Center, Guangzhou University of Chinese Medicine, No. 12, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China
| | - Yan-Yan Lei
- Department of Critical Care Medicine, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 16, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China
| | - Jing Chen
- Department of Critical Care Medicine, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 16, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China
- The First Clinical School, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Yan-Yan Liu
- Department of Critical Care Medicine, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 16, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China
| | - Xin-Feng Lin
- Department of Critical Care Medicine, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 16, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China
| | - Zhong-Qi Yang
- Ling-Nan Medical Research Center, Guangzhou University of Chinese Medicine, No. 12, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China.
- The First Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 16, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China.
| | - Shao-Xiang Xian
- Ling-Nan Medical Research Center, Guangzhou University of Chinese Medicine, No. 12, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China.
- The First Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 16, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China.
| | - Wei-Tao Chen
- Department of Critical Care Medicine, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 16, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China.
- The First Clinical School, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
- Ling-Nan Medical Research Center, Guangzhou University of Chinese Medicine, No. 12, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China.
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Vasopressor Responsiveness Beyond Arterial Pressure: A Conceptual Systematic Review Using Venous Return Physiology. Shock 2021; 56:352-359. [PMID: 33756500 DOI: 10.1097/shk.0000000000001762] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT We performed a systematic review to investigate the effects of vasopressor-induced hemodynamic changes in adults with shock. We applied a physiological approach using the interacting domains of intravascular volume, heart pump performance, and vascular resistance to structure the interpretation of responses to vasopressors. We hypothesized that incorporating changes in determinants of cardiac output and vascular resistance better reflect the vasopressor responsiveness beyond mean arterial pressure alone.We identified 28 studies including 678 subjects in Pubmed, EMBASE, and CENTRAL databases.All studies demonstrated significant increases in mean arterial pressure (MAP) and systemic vascular resistance during vasopressor infusion. The calculated mean systemic filling pressure analogue increased (16 ± 3.3 mmHg to 18 ± 3.4 mmHg; P = 0.02) by vasopressors with variable effects on central venous pressure and the pump efficiency of the heart leading to heterogenous changes in cardiac output. Changes in the pressure gradient for venous return and cardiac output, scaled by the change in MAP, were positively correlated (r2 = 0.88, P < 0.001). Changes in the mean systemic filling pressure analogue and heart pump efficiency were negatively correlated (r2 = 0.57, P < 0.001) while no correlation was found between changes in MAP and heart pump efficiency.We conclude that hemodynamic changes induced by vasopressor therapy are inadequately represented by the change in MAP alone despite its common use as a clinical endpoint. The more comprehensive analysis applied in this review illustrates how vasopressor administration may be optimized.
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Impact of cardiac function, refractory ascites and beta blockers on the outcome of patients with cirrhosis listed for liver transplantation. J Hepatol 2020; 72:463-471. [PMID: 31622697 DOI: 10.1016/j.jhep.2019.10.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/27/2019] [Accepted: 10/07/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Whether non-selective beta blockers (NSBBs) are deleterious in patients with end-stage cirrhosis and refractory ascites has been widely debated. We hypothesized that only the subset of patients on the liver transplant waiting list who had impaired cardiac performance would be at increased risk of mortality if receiving NSBBs. METHODS This study included 584 consecutive patients with cirrhosis evaluated for transplantation between 1999 and 2014. All patients had right heart catheterization with hemodynamic measurements at evaluation. Fifty percent received NSBBs. Refractory ascites was present in 33%. Cardiac performance was assessed by left ventricular stroke work index (LVSWI). Waiting list mortality without liver transplantation was explored using competing risk analysis. RESULTS LVSWI was significantly lower in patients with refractory ascites. In multivariate analysis using competing risk, refractory ascites, NSBBs and LVSWI were associated with waiting list mortality in the whole population, with a statistically significant interaction between NSBBs and LVSWI. The most discriminant value of LVSWI was 64.1 g-m/m2. In the final model, refractory ascites (subdistribution hazard ratio 1.52; 95% CI1.01-2.28; p = 0.0083) and treatment by NSBBs with LVSWI <64.1 g-m/m2 (subdistribution hazard ratio 1.96; 95% CI 1.32-2.90; p = 0.0009) were significantly associated with waiting list mortality, taking into account serum sodium and the model for end-stage liver disease score. CONCLUSIONS This study suggests that compromised cardiac performance is more common in patients with refractory ascites and that NSBBs are deleterious in cirrhotic patients with compromised cardiac performance. These results highlight the prognostic value of cardiac function in patients with end-stage cirrhosis. LAY SUMMARY There are still controversies concerning the impact of non-selective beta blockers on outcomes in patients with decompensated cirrhosis, especially in those with refractory ascites. In this study of 584 cirrhotic patients evaluated for liver transplantation, who underwent right heart catheterization, we have shown that global cardiac performance measured by left ventricular stroke work index is lower in patients with refractory ascites. Administration of non-selective beta blockers in patients with compromised cardiac performance may increase waiting list mortality. These results highlight the prognostic value of global cardiac performance in patients with end-stage cirrhosis.
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Abstract
As vascular tone depression is a hallmark of septic shock, administration of norepinephrine is logical in this setting. In this article, we provide and develop the following arguments for an early use of norepinephrine-the recommended first-line vasopressor-in septic shock: (I) prevention of prolonged severe hypotension, (II) increase in cardiac output through an increase in cardiac preload and/or contractility, (III) improvement of microcirculation and tissue oxygenation, (IV) prevention of fluid overload, and (V) improvement of outcome. Presence of a low diastolic arterial pressure as a marker of depressed vascular tone can be used as a trigger to initiate norepinephrine urgently.
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Affiliation(s)
- Olfa Hamzaoui
- Service de réanimation polyvalente, Hôpital Antoine Béclère, AP-HP, Hôpitaux universitaires Paris-Sud, Clamart, France
| | - Rui Shi
- INSERM-UMR_S999 LabEx - LERMIT, Hôpital Marie-Lannelongue, Le Plessis Robinson, France.,Service de médecine intensive - réanimation, Hôpital Bicêtre, AP-HP, Hôpitaux universitaires Paris-Sud, Le Kremlin-Bicêtre, France
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7
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Duclos G, Baumstarck K, Dünser M, Zieleskiewicz L, Leone M. Effects of the discontinuation sequence of norepinephrine and vasopressin on hypotension incidence in patients with septic shock: A meta-analysis. Heart Lung 2019; 48:560-565. [DOI: 10.1016/j.hrtlng.2019.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 01/26/2023]
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Norepinephrine exerts an inotropic effect during the early phase of human septic shock. Br J Anaesth 2018; 120:517-524. [DOI: 10.1016/j.bja.2017.11.065] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2017] [Indexed: 01/05/2023] Open
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Lief L, Arbo J, Berlin DA. The Physiology of Early Goal-Directed Therapy for Sepsis. J Intensive Care Med 2016; 32:567-573. [PMID: 27708007 DOI: 10.1177/0885066616671705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In 2001, Rivers and colleagues published a randomized controlled trial of early goal-directed therapy (EGDT) for the treatment of sepsis. More than a decade later, it remains a landmark achievement. The study proved the benefits of early aggressive treatment of sepsis. However, many questions remain about specific aspects of the complex EGDT algorithm. Recently, 3 large trials attempted to replicate these results. None of the studies demonstrated a benefit of an EGDT protocol for sepsis. This review explores the physiologic basis of goal-directed therapy, including the hemodynamic targets and the therapeutic interventions. An understanding of the physiologic basis of EGDT helps reconcile the results of the clinical trials.
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Affiliation(s)
- Lindsay Lief
- 1 Weill Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - John Arbo
- 2 Division of Emergency Medicine, Weill Cornell Medicine, New York, NY, USA
| | - David A Berlin
- 1 Weill Department of Medicine, Weill Cornell Medicine, New York, NY, USA
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10
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Abstract
Vasopressors and inotropes are used in septic shock in patients who remain hypotensive despite adequate fluid resuscitation. The goal is to increase blood pressure to optimize perfusion to organs. Generally, goal-directed therapy to supra-normal oxygen transport variables cannot be recommended due to lack of benefit. Traditionally, vasopressors and inotropes in septic shock have been started in a step-wise fashion starting with dopamine. Recent data suggest that there may be true differences among vasopressors and inotropes on local tissue perfusion as measured by regional hemodynamic and oxygen transport. When started early in septic shock, norepinephrine decreases mortality, optimizes hemodynamic variables, and improves systemic and regional (eg, renal, gastric mucosal, splanchnic) perfusion. Epinephrine causes a greater increase in cardiac index (CI) and oxygen delivery (DO2 ) and increases gastric mucosal flow, but increases lactic acid and may not adequately preserve splanchnic circulation owing to its predominant vasoconstrictive alpha (α ) effects. Epinephrine may be particularly useful when used earlier in the course of septic shock in young patients and those who do not have any known cardiac abnormalities. Unlike epinephrine, dopamine does not preferentially increase the proportion of CI that preferentially goes to the splanchnic circulation. Dopamine is further limited because it cannot increase CI by more than 35% and is accompanied by tachycardia or tachydysrhythmias. Dopamine, as opposed to norepinephrine, may worsen splanchnic oxygen consumption (VO2 ) and oxygen extraction ratio (O2 ER). Low-dose dopamine has not been shown to consistently increase the glomerular filtration rate or prevent renal failure, and, indeed, worsens splanchnic tissue oxygen use. Routine use of concurrently administered dopamine with vasopressors is not recommended. Phenylephrine should be used when a pure vasoconstrictor is desired in patients who may not require or do not tolerate the beta (β ) effects of dopamine or norepinephrine with or without dobutamine. Patients with high filling pressure and hypotension may benefit from the combination of phenylephrine and dobutamine. Investigational approaches to vasopressor-refractory hypotension in septic shock include the use of vasopressin and corticosteroids.
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Affiliation(s)
- Maria I. Rudis
- USC Schools of Pharmacy and Medicine, 1985 Zonal Avenue, PSC 700, Los Angeles, CA 90033,
| | - Clarence Chant
- St. Michael’s Hospital and University of Toronto Faculty of Pharmacy, Toronto, ON, Canada
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Loss of duplexmiR-223 (5p and 3p) aggravates myocardial depression and mortality in polymicrobial sepsis. Biochim Biophys Acta Mol Basis Dis 2014; 1842:701-11. [PMID: 24486439 DOI: 10.1016/j.bbadis.2014.01.012] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 01/07/2014] [Accepted: 01/23/2014] [Indexed: 12/12/2022]
Abstract
Sepsis is the leading cause of death in critically ill patients. While myocardial dysfunction has been recognized as a major manifestation in severe sepsis, the underlying molecular mechanisms associated with septic cardiomyopathy remain unclear. In this study, we performed a miRNA array analysis in hearts collected from a severe septic mouse model induced by cecal ligation and puncture (CLP). Among the 19 miRNAs that were dys-regulated in CLP-mouse hearts, miR-223(3p) and miR-223*(5p) were most significantly downregulated, compared with sham-operated mouse hearts. To test whether a drop of miR-223 duplex plays any roles in sepsis-induced cardiac dysfunction and inflammation, a knockout (KO) mouse model with a deletion of the miR-223 gene locus and wild-type (WT) mice were subjected to CLP or sham surgery. We observed that sepsis-induced cardiac dysfunction, inflammatory response and mortality were remarkably aggravated in CLP-treated KO mice, compared with control WTs. Using Western-blotting and luciferase reporter assays, we identified Sema3A, an activator of cytokine storm and a neural chemorepellent for sympathetic axons, as an authentic target of miR-223* in the myocardium. In addition, we validated that miR-223 negatively regulated the expression of STAT-3 and IL-6 in mouse hearts. Furthermore, injection of Sema3A protein into WT mice revealed an exacerbation of sepsis-triggered inflammatory response and myocardial depression, compared with control IgG1 protein-treated WT mice following CLP surgery. Taken together, these data indicate that loss of miR-223/-223* causes an aggravation of sepsis-induced inflammation, myocardial dysfunction and mortality. Our study uncovers a previously unrecognized mechanism underlying septic cardiomyopathy and thereby, may provide a new strategy to treat sepsis.
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Romero-Bermejo FJ, Ruiz-Bailen M, Gil-Cebrian J, Huertos-Ranchal MJ. Sepsis-induced cardiomyopathy. Curr Cardiol Rev 2013; 7:163-83. [PMID: 22758615 PMCID: PMC3263481 DOI: 10.2174/157340311798220494] [Citation(s) in RCA: 188] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2011] [Revised: 02/24/2011] [Accepted: 02/24/2011] [Indexed: 01/20/2023] Open
Abstract
Myocardial dysfunction is one of the main predictors of poor outcome in septic patients, with mortality rates next to 70%. During the sepsis-induced myocardial dysfunction, both ventricles can dilate and diminish its ejection fraction, having less response to fluid resuscitation and catecholamines, but typically is assumed to be reversible within 7-10 days. In the last 30 years, It´s being subject of substantial research; however no explanation of its etiopathogenesis or effective treatment have been proved yet. The aim of this manuscript is to review on the most relevant aspects of the sepsis-induced myocardial dysfunction, discuss its clinical presentation, pathophysiology, etiopathogenesis, diagnostic tools and therapeutic strategies proposed in recent years.
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Affiliation(s)
- Francisco J Romero-Bermejo
- Intensive Care Unit, Critical Care and Emergency Department, Puerto Real University Hospital, Cadiz, Spain.
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Understanding the divergent effects of norepinephrine on cardiac output: go with the flow. Crit Care Med 2013; 41:352-4. [PMID: 23269148 DOI: 10.1097/ccm.0b013e318270e67e] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Adverse cardiac events during catecholamine vasopressor therapy: a prospective observational study. Intensive Care Med 2012. [PMID: 22527060 DOI: 10.1007/s00134-012-2531-2.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To determine the incidence of and risk factors for adverse cardiac events during catecholamine vasopressor therapy in surgical intensive care unit patients with cardiovascular failure. METHODS The occurrence of any of seven predefined adverse cardiac events (prolonged elevated heart rate, tachyarrhythmia, myocardial cell damage, acute cardiac arrest or death, pulmonary hypertension-induced right heart dysfunction, reduction of systemic blood flow) was prospectively recorded during catecholamine vasopressor therapy lasting at least 12 h. RESULTS Fifty-four of 112 study patients developed a total of 114 adverse cardiac events, an incidence of 48.2 % (95 % CI, 38.8-57.6 %). New-onset tachyarrhythmia (49.1 %), prolonged elevated heart rate (23.7 %), and myocardial cell damage (17.5 %) occurred most frequently. Aside from chronic liver diseases, factors independently associated with the occurrence of adverse cardiac events included need for renal replacement therapy, disease severity (assessed by the Simplified Acute Physiology Score II), number of catecholamine vasopressors (OR, 1.73; 95 % CI, 1.08-2.77; p = 0.02) and duration of catecholamine vasopressor therapy (OR, 1.01; 95 % CI, 1-1.01; p = 0.002). Patients developing adverse cardiac events were on catecholamine vasopressors (p < 0.001) and mechanical ventilation (p < 0.001) for longer and had longer intensive care unit stays (p < 0.001) and greater mortality (25.9 vs. 1.7 %; p < 0.001) than patients who did not. CONCLUSIONS Adverse cardiac events occurred in 48.2 % of surgical intensive care unit patients with cardiovascular failure and were related to morbidity and mortality. The extent and duration of catecholamine vasopressor therapy were independently associated with and may contribute to the pathogenesis of adverse cardiac events.
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Schmittinger CA, Torgersen C, Luckner G, Schröder DCH, Lorenz I, Dünser MW. Adverse cardiac events during catecholamine vasopressor therapy: a prospective observational study. Intensive Care Med 2012; 38:950-8. [PMID: 22527060 DOI: 10.1007/s00134-012-2531-2] [Citation(s) in RCA: 159] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2011] [Accepted: 03/05/2012] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine the incidence of and risk factors for adverse cardiac events during catecholamine vasopressor therapy in surgical intensive care unit patients with cardiovascular failure. METHODS The occurrence of any of seven predefined adverse cardiac events (prolonged elevated heart rate, tachyarrhythmia, myocardial cell damage, acute cardiac arrest or death, pulmonary hypertension-induced right heart dysfunction, reduction of systemic blood flow) was prospectively recorded during catecholamine vasopressor therapy lasting at least 12 h. RESULTS Fifty-four of 112 study patients developed a total of 114 adverse cardiac events, an incidence of 48.2 % (95 % CI, 38.8-57.6 %). New-onset tachyarrhythmia (49.1 %), prolonged elevated heart rate (23.7 %), and myocardial cell damage (17.5 %) occurred most frequently. Aside from chronic liver diseases, factors independently associated with the occurrence of adverse cardiac events included need for renal replacement therapy, disease severity (assessed by the Simplified Acute Physiology Score II), number of catecholamine vasopressors (OR, 1.73; 95 % CI, 1.08-2.77; p = 0.02) and duration of catecholamine vasopressor therapy (OR, 1.01; 95 % CI, 1-1.01; p = 0.002). Patients developing adverse cardiac events were on catecholamine vasopressors (p < 0.001) and mechanical ventilation (p < 0.001) for longer and had longer intensive care unit stays (p < 0.001) and greater mortality (25.9 vs. 1.7 %; p < 0.001) than patients who did not. CONCLUSIONS Adverse cardiac events occurred in 48.2 % of surgical intensive care unit patients with cardiovascular failure and were related to morbidity and mortality. The extent and duration of catecholamine vasopressor therapy were independently associated with and may contribute to the pathogenesis of adverse cardiac events.
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Affiliation(s)
- Christian A Schmittinger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Norepinephrine increases cardiac preload and reduces preload dependency assessed by passive leg raising in septic shock patients. Crit Care Med 2011; 39:689-94. [PMID: 21263328 DOI: 10.1097/ccm.0b013e318206d2a3] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the effects of norepinephrine on cardiac preload, cardiac index, and preload dependency during septic shock. DESIGN Prospective interventional study. SETTING Medical Intensive Care Unit. PATIENTS We included 25 septic shock patients (62 ± 13 yrs old, Simplified Acute Physiology Score II 53 ± 12, lactate 3.5 ± 2.1 mmol/L, all receiving norepinephrine at baseline at 0.24 [25%-75% interquartile range: 0.12-0.48] μg/kg/min) with a positive passive leg raising test (defined by an increase in cardiac index ≥ 10%) and a diastolic arterial pressure ≤ 40 mm Hg. INTERVENTIONS We performed a passive leg raising test (during 1 min) at baseline. Immediately after, we increased the dose of norepinephrine (to 0.48 [0.36-0.71] μg/kg/min) and, when the hemodynamic status was stabilized, we performed a second passive leg raising test (during 1 min). We finally infused 500 mL saline. MEASUREMENTS AND MAIN RESULTS Increasing the dose of norepinephrine significantly increased central venous pressure (+23% ± 12%), left ventricular end-diastolic area (+9% ± 6%), E mitral wave (+19% ± 23%), and global end-diastolic volume (+9% ± 6%). Simultaneously, cardiac index significantly increased by 11% ± 7%, suggesting that norepinephrine had recruited some cardiac preload reserve. The second passive leg raising test increased cardiac index to a lesser extent than the baseline test (13% ± 8% vs. + 19% ± 6%, p < .05), suggesting that norepinephrine had decreased the degree of preload dependency. Volume infusion significantly increased cardiac index by 26% ± 15%. However, cardiac index increased by <15% in four patients (fluid unresponsive patients) while the baseline passive leg raising test was positive in these patients. In three of these four patients, the second passive leg raising test was also negative, i.e., the second passive leg raising test (after norepinephrine increase) predicted fluid responsiveness with a sensitivity of 95 [76-99]% and a specificity of 100 [30-100]%. CONCLUSIONS In septic patients with a positive passive leg raising test at baseline suggesting the presence of preload dependency, norepinephrine increased cardiac preload and cardiac index and reduced the degree of preload dependency.
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Abstract
The ultimate goals of hemodynamic therapy in shock are to restore effective tissue perfusion and to normalize cellular metabolism. In sepsis, both global and regional perfusion must be considered. In addition, mediators of sepsis can perturb cellular metabolism, leading to inadequate use of oxygen and other nutrients despite adequate perfusion; one would not expect organ dysfunction mediated by such abnormalities to be corrected by hemodynamic therapy. Despite the complex pathophysiology of sepsis, an underlying approach to its hemodynamic support can be formulated that is particularly pertinent with respect to vasoactive agents. Both arterial pressure and tissue perfusion must be taken into account when choosing therapeutic interventions and the efficacy of hemodynamic therapy should be assessed by monitoring a combination of clinical and hemodynamic parameters. It is relatively easy to raise blood pressure, but somewhat harder to raise cardiac output in septic patients. How to optimize regional blood and microcirculatory blood flow remains uncertain. Specific end points for therapy are debatable and are likely to evolve. Nonetheless, the idea that clinicians should define specific goals and end points, titrate therapies to those end points, and evaluate the results of their interventions on an ongoing basis remains a fundamental principle. The practice parameters were intended to emphasize the importance of such an approach so as to provide a foundation for the rational choice of vasoactive agents in the context of evolving monitoring techniques and therapeutic approaches.
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Affiliation(s)
- Steven M Hollenberg
- Divisions of Cardiovascular Disease and Critical Care Medicine, Coronary Care Unit, Cooper University Hospital, Camden, NJ 08103, USA.
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Hamzaoui O, Georger JF, Monnet X, Ksouri H, Maizel J, Richard C, Teboul JL. Early administration of norepinephrine increases cardiac preload and cardiac output in septic patients with life-threatening hypotension. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R142. [PMID: 20670424 PMCID: PMC2945123 DOI: 10.1186/cc9207] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 06/29/2010] [Accepted: 07/29/2010] [Indexed: 12/15/2022]
Abstract
Introduction We sought to examine the cardiac consequences of early administration of norepinephrine in severely hypotensive sepsis patients hospitalized in a medical intensive care unit of a university hospital. Methods We included 105 septic-shock patients who already had received volume resuscitation. All received norepinephrine early because of life-threatening hypotension and the need to achieve a sufficient perfusion pressure rapidly and to maintain adequate flow. We analyzed the changes in transpulmonary thermodilution variables associated with the increase in mean arterial pressure (MAP) induced by norepinephrine when the achieved MAP was ≥65 mm Hg. Results Norepinephrine significantly increased MAP from 54 ± 8 to 76 ± 9 mm Hg, cardiac index (CI) from 3.2 ± 1.0 to 3.6 ± 1.1 L/min/m2, stroke volume index (SVI) from 34 ± 12 to 39 ± 13 ml/m2, global end-diastolic volume index (GEDVI) from 694 ± 148 to 742 ± 168 ml/m2, and cardiac function index (CFI) from 4.7 ± 1.5 to 5.0 ± 1.6 per min. Beneficial hemodynamic effects on CI, SVI, GEDVI, and CFI were observed in the group of 71 patients with a baseline echocardiographic left ventricular ejection fraction (LVEF) >45%, as well as in the group of 34 patients with a baseline LVEF ≤45%. No change in CI, SVI, GEDVI, or CFI was observed in the 17 patients with baseline LVEF ≤45% for whom values of MAP ≥75 mm Hg were achieved with norepinephrine. Conclusions Early administration of norepinephrine aimed at rapidly achieving a sufficient perfusion pressure in severely hypotensive septic-shock patients is able to increase cardiac output through an increase in cardiac preload and cardiac contractility. This effect remained in patients with poor cardiac contractility except when values of MAP ≥75 mm Hg were achieved.
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Affiliation(s)
- Olfa Hamzaoui
- Service de réanimation médicale, Centre Hospitalo-Universitaire de Bicêtre, Assistance Publique-Hôpitaux de Paris, EA 4046, Université Paris Sud, 78 rue du Général Leclerc, 94 270 Le Kremlin-Bicêtre, France.
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Abstract
When fluid administration fails to restore an adequate arterial pressure and organ perfusion in patients with septic shock, therapy with vasoactive agents should be initiated. The ultimate goals of such therapy in shock are to restore effective tissue perfusion and to normalize cellular metabolism. The efficacy of hemodynamic therapy in sepsis should be assessed by monitoring a combination of clinical and hemodynamic parameters. Although specific end points for therapy are debatable, and therapies will inevitably evolve as new information becomes available, the idea that clinicians should define specific goals and end points, titrate therapies to those end points, and evaluate the results of their interventions on an ongoing basis remains a fundamental principle.
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Affiliation(s)
- Steven M Hollenberg
- Divisions of Cardiovascular Disease and Critical Care Medicine, Cooper University Hospital, Camden, NJ 08103, USA.
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Girbes ARJ, Beishuizen A, Strack van Schijndel RJM. Pharmacological treatment of sepsis. Fundam Clin Pharmacol 2008; 22:355-61. [PMID: 18705746 DOI: 10.1111/j.1472-8206.2008.00606.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The incidence of sepsis, the combination of a systemic inflammatory response syndrome and documented infection, is as high as up to 95 cases per 100,000 people per year. The understanding of the pathophysiology of sepsis has much increased over the last 20 years. However, sepsis combined with shock is still associated with a high mortality rate varying from 35 to 55%. Causative treatment, source control and antibiotics started as soon as possible, are the cornerstone of therapy in combination with symptomatic treatment in the ICU. The pharmacological interventions, including fluid resuscitation, vasoactive drugs and adjunctive drugs such as steroids, activated protein C are discussed. The possible beneficial role of strict glucose control is also addressed. Since many drug intervention studies were negative, lessons should be learned from earlier experiences for future trials. Source control and level of intensive care should be eliminated as confounders.
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Tourneux P, Rakza T, Bouissou A, Krim G, Storme L. Pulmonary circulatory effects of norepinephrine in newborn infants with persistent pulmonary hypertension. J Pediatr 2008; 153:345-9. [PMID: 18534241 DOI: 10.1016/j.jpeds.2008.03.007] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2007] [Revised: 01/14/2008] [Accepted: 03/10/2008] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the respiratory and the pulmonary circulatory effects of norepinephrine in newborn infants with persistent pulmonary hypertension (PPHN)-induced cardiac dysfunction. STUDY DESIGN Inclusion criteria were: 1) Newborn infants >35 weeks gestational age; 2) PPHN treated with inhaled nitric oxide; and 3) symptoms of circulatory failure despite adequate fluid resuscitation. Lung function and pulmonary hemodynamic variables assessed with Doppler echocardiography were recorded prospectively before and after starting norepinephrine. RESULTS Eighteen newborns were included (gestational age: 37 +/- 3 weeks; birth weight: 2800 +/- 700 g). After starting norepinephrine, systemic pressure and left ventricular output increased respectively from 33 +/- 4 mm Hg to 49 +/- 4 mm Hg and from 172 +/- 79 mL/kg/min to 209+/-90 mL/kg/min (P < .05). Although the mechanical ventilatory variables have not been changed, the post-ductal transcutaneous arterial oxygen saturation increased from 89% +/- 1% to 95% +/- 4%, whereas the oxygen need decreased from 51% +/- 24% to 41% +/- 20% (P < .05). The pulmonary/systemic pressure ratio decreased from 0.98 +/- 0.1 to 0.87 +/- 0.1 (P < .05). Mean left pulmonary artery blood flow velocity increased by 20% (P < .05). CONCLUSION Norepinephrine may improve lung function in newborn infants with PPHN through a decrease in pulmonary/systemic artery pressure ratio and improved cardiac performance.
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Affiliation(s)
- Pierre Tourneux
- Clinique de Médecine Néonatale, Hôpital Jeanne de Flandre, CHRU de Lille, Lille, France
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Senz A, Nunnink L. Review article: inotrope and vasopressor use in the emergency department. Emerg Med Australas 2008; 21:342-51. [PMID: 19694785 DOI: 10.1111/j.1742-6723.2009.01210.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Shock is a common presentation to the ED, with the incidence of septic shock increasing in Australasia over the last decade. The choice of inotropic agent is likely dependent on previous experience and local practices of the emergency and other critical care departments. The relatively short duration of stay in the ED before transfer leaves little room for evaluating the appropriateness of and response to the agent chosen. Delays in transfer to inpatient facilities means that patients receive advanced critical care within the ED for longer, requiring initiation and titration of vasoactive agents in the ED. This article discusses the general concepts of shock and the indicators for inotrope and vasopressor use, revises the various agents available and reviews the current evidence for their use.
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Affiliation(s)
- Ainslie Senz
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD 4006, Australia.
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Tourneux P, Rakza T, Abazine A, Krim G, Storme L. Noradrenaline for management of septic shock refractory to fluid loading and dopamine or dobutamine in full-term newborn infants. Acta Paediatr 2008; 97:177-80. [PMID: 18177443 DOI: 10.1111/j.1651-2227.2007.00601.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To determine the effects of noradrenaline in full-term newborns with refractory septic shock. METHODS Newborns of >35 weeks' gestation with persistent septic shock, despite adequate fluid resuscitation and high dose of dopamine/dobutamine were eligible. In this prospective observational study, we recorded respiratory and hemodynamic parameters prior to and 3 h after starting noradrenaline infusion. RESULTS Twenty-two newborns were included (gestational age [GA] 39 +/- 1.7 weeks, birth weight (BW) 3110 +/- 780 g). Before starting noradrenaline, the infants received a mean volume expansion of 31 +/- 15 mL/kg and a mean infusion rate of dopamine of 14 +/- 5 microg/kg/min or dobutamine of 12 +/- 6 microg/kg/min. Three hours after starting noradrenaline (rate 0.5 +/- 0.4 microg/kg/min), the mean arterial blood pressure rose from 36 +/- 5 to 51 +/- 7 mmHg (p < 0.001). Urine output increased from 1 +/- 0.5 to 1.7 +/- 0.4 mL/kg/h (p < 0.05). Blood lactate concentration decreased from 4.8 +/- 2.3 to 3.3 +/- 1.8 mmol/L (p < 0.01). Despite an initial correction of hypotension, four infants died later. CONCLUSION Noradrenaline was effective in increasing systemic blood pressure. An increase in urine output and a decrease in blood lactate concentration suggest that noradrenaline may have improved cardiac function and tissue perfusion.
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Affiliation(s)
- Pierre Tourneux
- Clinique de Médecine Néonatale, Hôpital Jeanne de Flandre, CHRU de Lille, France.
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Leone M, Boyadjiev I, Boulos E, Antonini F, Visintini P, Albanèse J, Martin C. A reappraisal of isoproterenol in goal-directed therapy of septic shock. Shock 2006; 26:353-7. [PMID: 16980881 DOI: 10.1097/01.shk.0000226345.55657.66] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The goal of the study was to evaluate the effect of isoproterenol prescribed in goal-directed therapy for septic shock. Out of a cohort of 89 patients with septic shock, 14 patients treated with fluid and norepinephrine had inappropriate mixed venous oxygen saturation (SvO2<70%) not responding to correction of hypoxemia and anemia (>8 g.dL-1). Isoproterenol administration was started at a dose of 0.04 microg.kg-1.minute-1 with 0.025 microg.kg-1.minute-1 increments every 30 minutes until SvO2 was greater than 70%. Mean arterial pressure was maintained>or=65 mm.Hg by adjusting the norepinephrine infusion. Hemodynamic, oxygen, and renal variables were collected during a 12-h period. Patients with a known prior history of coronary disease were not eligible. Isoproterenol administration increased significantly SvO2 (62%+/-10% to 71%+/-9%), cardiac index (3.1+/-0.6 to 4.4+/-1.4 L.min-1.m-2), stroke index (27+/-3.4 to 38+/-6.1 mL.m-2), and left ventricular stroke work index (24+/-3.4 to 40+/-5.0 g.m-1.m-2). Heart rate rise did not reach a significant level. Arterial lactate concentration decreased significantly during the study period (5.7+/-2.8 to 3.4+/-1.6 mmol.L-1). No cardiac adverse events occurred with any electrocardiographic aspects of myocardial ischemia. This study suggests that isoproterenol is efficient to improve hemodynamics and oxygen variables in septic shock patients. There is a need for future investigations in larger groups of patients to determine whether isoproterenol can be an alternative to dobutamine.
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Affiliation(s)
- Marc Leone
- Département d'Anesthésie et de Réanimation, UPRES Equipe d'Accueil 3784, Centre Hospitalier Universitaire Nord, 13915 Marseille cedex 20, France.
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Hollis A, Ousey J, Palmer L, Stoneham S, Corley K. Effects of Norepinephrine and a Combined Norepinephrine and Dobutamine Infusion on Systemic Hemodynamics and Indices of Renal Function in Normotensive Neonatal Thoroughbred Foals. J Vet Intern Med 2006. [DOI: 10.1111/j.1939-1676.2006.tb00763.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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Uemura K, Kamiya A, Hidaka I, Kawada T, Shimizu S, Shishido T, Yoshizawa M, Sugimachi M, Sunagawa K. Automated drug delivery system to control systemic arterial pressure, cardiac output, and left heart filling pressure in acute decompensated heart failure. J Appl Physiol (1985) 2005; 100:1278-86. [PMID: 16373447 DOI: 10.1152/japplphysiol.01206.2005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pharmacological support with inotropes and vasodilators to control decompensated hemodynamics requires strict monitoring of patient condition and frequent adjustments of drug infusion rates, which is difficult and time-consuming, especially in hemodynamically unstable patients. To overcome this difficulty, we have developed a novel automated drug delivery system for simultaneous control of systemic arterial pressure (AP), cardiac output (CO), and left atrial pressure (Pla). Previous systems attempted to directly control AP and CO by estimating their responses to drug infusions. This approach is inapplicable because of the difficulties to estimate simultaneous AP, CO, and Pla responses to the infusion of multiple drugs. The circulatory equilibrium framework developed previously (Uemura K, Sugimachi M, Kawada T, Kamiya A, Jin Y, Kashihara K, and Sunagawa K. Am J Physiol Heart Circ Physiol 286: H2376-H2385, 2004) indicates that AP, CO, and Pla are determined by an equilibrium of the pumping ability of the left heart (SL), stressed blood volume (V), and systemic arterial resistance (R). Our system directly controls SL with dobutamine, V with dextran/furosemide, and R with nitroprusside, thereby controlling the three variables. We evaluated the efficacy of our system in 12 anesthetized dogs with acute decompensated heart failure. Once activated, the system restored SL, V, and R within 30 min, resulting in the restoration of normal AP, CO, and Pla. Steady-state deviations from target values were small for AP [4.4 mmHg (SD 2.6)], CO [5.4 ml x min(-1) x kg(-1) (SD 2.4)] and Pla [0.8 mmHg (SD 0.6)]. In conclusion, by directly controlling the mechanical determinants of circulation, our system has enabled simultaneous control of AP, CO, and Pla with good accuracy and stability.
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Affiliation(s)
- Kazunori Uemura
- Department of Cardiovascular Dynamics, National Cardiovascular Center Research Institute, 5-7-1 Fujishirodai, Suita 565-8565, Japan.
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Bourgoin A, Leone M, Delmas A, Garnier F, Albanèse J, Martin C. Increasing mean arterial pressure in patients with septic shock: effects on oxygen variables and renal function. Crit Care Med 2005; 33:780-6. [PMID: 15818105 DOI: 10.1097/01.ccm.0000157788.20591.23] [Citation(s) in RCA: 204] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To measure the effects of increasing mean arterial pressure on oxygen variables and renal function in septic shock. DESIGN Prospective, open-label, randomized, controlled study. SETTING Medical-surgical intensive care unit of a tertiary care teaching hospital. PATIENTS Twenty-eight patients with a diagnosis of septic shock who required fluid resuscitation and pressor agents to increase and maintain mean arterial pressure > or =60 mm Hg. INTERVENTIONS Patients were treated with fluid and norepinephrine to achieve and maintain a mean arterial pressure of 65 mm Hg. Then they were randomized in two groups: In the first group (control group, n = 14), mean arterial pressure was maintained at 65 mm Hg, and in the second group (n = 14), mean arterial pressure was increased to 85 mm Hg by increasing the dose of norepinephrine. MEASUREMENTS AND MAIN RESULTS Hemodynamic variables (mean arterial pressure, heart rate, mean pulmonary artery pressure, pulmonary artery occlusion pressure, cardiac index, systemic vascular resistance index, pulmonary vascular resistance index, left and right ventricular stroke indexes), metabolic variables (oxygen delivery, oxygen consumption-calorimetric method, arterial lactate), and renal function variables (urine flow, serum creatinine, creatinine clearance) were measured. After introduction of norepinephrine, similar values of hemodynamic, metabolic, and renal function variables were obtained in both groups. No changes were observed in group 1 during the study period. Increasing mean arterial pressure from 65 to 85 mm Hg with norepinephrine in group 2 resulted in a significant increase in cardiac index from 4.8 (3.8-6.0) to 5.8 (4.3-6.9) L.min.m. Arterial lactate and oxygen consumption did not change. No changes were observed in renal function variables: urine flow, 63 (14-127) and 70 (15-121) mL; serum creatinine, 170 (117-333) and 153 (112-310) mumol.L; and creatinine clearance, 50 (12-77) and 67 (13-89) mL.min.1.73 m. CONCLUSIONS Increasing mean arterial pressure from 65 to 85 mm Hg with norepinephrine neither affects metabolic variables nor improves renal function.
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Affiliation(s)
- Aurélie Bourgoin
- Department of Intensive Care Medicine and Trauma Center, Hospital Nord, 13915 Marseille Cedex 20, France
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Affiliation(s)
- Elizabeth J. Bridges
- Elizabeth Bridges was formerly the deputy commander of the 59th Clinical Research Squadron and a senior nurse researcher at the 59th Medical Wing, Lackland Air Force Base, San Antonio, Tex. She is now an assistant professor at the University of Washington School of Nursing and a clinical nurse researcher at the University of Washington Medical Center, Seattle, Wash
| | - Susan Dukes
- Susan Dukes is a critical care clinical nurse specialist in the 759th Surgical Operations Squadron, Wilford Hall Medical Center, at Lackland Air Force Base
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Affiliation(s)
- Stephan M Jakob
- Department of Intensive Care Medicine, University Hospital Bern, Bern, Switzerland
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Affiliation(s)
- Tom Ahrens
- Barnes-Jewish Hospital, St Louis, Mo, and Critical Care Curriculum, Louisville, Ky
| | - Deborah Tuggle
- Barnes-Jewish Hospital, St Louis, Mo, and Critical Care Curriculum, Louisville, Ky
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Hollenberg SM, Ahrens TS, Annane D, Astiz ME, Chalfin DB, Dasta JF, Heard SO, Martin C, Napolitano LM, Susla GM, Totaro R, Vincent JL, Zanotti-Cavazzoni S. Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update. Crit Care Med 2004; 32:1928-48. [PMID: 15343024 DOI: 10.1097/01.ccm.0000139761.05492.d6] [Citation(s) in RCA: 372] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To provide the American College of Critical Care Medicine with updated guidelines for hemodynamic support of adult patients with sepsis. DATA SOURCE Publications relevant to hemodynamic support of septic patients were obtained from the medical literature, supplemented by the expertise and experience of members of an international task force convened from the membership of the Society of Critical Care Medicine. STUDY SELECTION Both human studies and relevant animal studies were considered. DATA SYNTHESIS The experts articles reviewed the literature and classified the strength of evidence of human studies according to study design and scientific value. Recommendations were drafted and graded levels based on an evidence-based rating system described in the text. The recommendations were debated, and the task force chairman modified the document until <10% of the experts disagreed with the recommendations. CONCLUSIONS An organized approach to the hemodynamic support of sepsis was formulated. The fundamental principle is that clinicians using hemodynamic therapies should define specific goals and end points, titrate therapies to those end points, and evaluate the results of their interventions on an ongoing basis by monitoring a combination of variables of global and regional perfusion. Using this approach, specific recommendations for fluid resuscitation, vasopressor therapy, and inotropic therapy of septic in adult patients were promulgated.
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Morimatsu H, Singh K, Uchino S, Bellomo R, Hart G. Early and exclusive use of norepinephrine in septic shock. Resuscitation 2004; 62:249-54. [PMID: 15294412 DOI: 10.1016/j.resuscitation.2004.03.016] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2003] [Revised: 03/04/2004] [Accepted: 03/18/2004] [Indexed: 11/16/2022]
Abstract
BACKGROUND The timing and use of norepinephrine (noradrenaline) (NE) in septic shock remain a matter of controversy. AIM To study the outcome of septic patients treated with early and exclusive NE. SETTING Tertiary Intensive Care Unit. PATIENTS 142 patients with septic shock. INTERVENTION Exclusive NE infusion within 24 hours of admission to ICU. METHODS AND MAIN RESULTS Retrospective analysis of data from a unit database identified 142 patients. Their median admission simplified acute physiology score (SAPS II) score was 46 [38, 56] with 98 (69%) receiving mechanical ventilation. Mean arterial pressure (MAP) at the start of NE infusion was 60 [58, 68]mmHg. NE infusion was started at a median of 1.3 [0.3, 5.0]h after ICU admission. Restoration and maintenance of target MAP was achieved initially in all patients and, in 61.3%, within 30 min. The median peak dose of NE was 0.28 [0.14, 0.61]microg/(kg min) and the duration of infusion was 88 [42, 175]h. SAPS II predicted mortality was 40.8%, however, only 34.5% (P = 0.27) died. Among the most severely ill patients (SAPS II score >56) actual mortality was 50.0% versus 74.7% predicted (P = 0.07). CONCLUSIONS Early and exclusive use of NE in hyperdynamic septic shock achieved a stable MAP >75 mmHg in all patients. Survival compared favorably with that predicted by illness severity scores.
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Affiliation(s)
- Hiroshi Morimatsu
- Department of Intensive Care and Department of Medicine, Austin and Repatriation Medical Centre, Melbourne, Australia
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Abstract
Protection of renal function and prevention of acute renal failure (ARF) are important goals of resuscitation in critically ill patients. Beyond fluid resuscitation and avoidance of nephrotoxins, little is known about how such prevention can be achieved. Vasoactive drugs are often administered to improve either cardiac output or mean arterial pressure in the hope that renal blood flow will also be improved and, thereby, renal protection achieved. Some of these drugs (especially low-dose dopamine) have even been proposed to have a specific beneficial effect on renal blood flow. However, when all studies dealing with vasoactive drugs and their effects on the kidney are reviewed, it is clear that none have been demonstrated to achieve clinically important benefits in terms of renal protection. It is also clear that, with the exception of low-dose dopamine, there have been no randomized controlled trials of sufficient statistical power to detect differences in clinically meaningful outcomes. In the absence of such data, all that is available is based on limited physiological gains (changes in renal blood flow or urine output) with one or another drug in one or another subpopulation of patients. Furthermore, given our lack of understanding of the pathogenesis of ARF, it is unclear whether haemodynamic manipulation is an appropriate avenue to achieve renal protection. There is a great need for large randomized controlled trials to test the clinical, instead of physiological, effects of vasoactive drugs in critical illness.
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Hu S, Sheng ZY. The effects of anisodamine and dobutamine on gut mucosal blood flow during gut ischemia/reperfusion. World J Gastroenterol 2002; 8:555-7. [PMID: 12046091 PMCID: PMC4656442 DOI: 10.3748/wjg.v8.i3.555] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine if anisodamine is able to augment mucosal perfusion during gut I/R ischemia-reperfusion.
METHODS: A jejunal sac was formed in Sprague Dawley rat. A Laser Doppler probe and a tonometer were inserted into the sac which was filled with saline. The superior mesenteric artery was occluded (SMAO) for 60 minutes followed by 90 minutes of reperfusion. At the end of 60 minutes of SMAO, either 0.2 mg/kg of anisodmine or dobutamine was injected into the jejunal sac. Laser Doppler mucosal blood flow and regional PCO2 (PrCO2) measurements were made.
RESULTS: Mucosal blood flow was significantly increased at 30, 60 and 90 minutes of reperfusion (R30, R60, R90) when intraluminal anisodamine or dobutamine was present compared to intraluminal saline only (44 ± 3.3% or 48 ± 4.1% vs 37 ± 2.6% at R30, 57 ± 5.0% or 56 ± 4.7% vs 45 ± 2.7% at R60, 64 ± 3.3% or 56 ± 4.2% vs 48 ± 3.4% at R90, respectively P < 0.05). Blood flow changes were also reflected by lowering of jejunal PrCO2 measurements after intraluminal anisodamine or dobutamine compared with that of the saline controls (41 ± 3.1 mmHg or 44 ± 3.0 mmHg vs 49 ± 3.7 mmHg at R30, 38 ± 3.7 mmHg or 40 ± 2.1 mmHg vs 47 ± 3.8 mmHg at R60, 34 ± 2.1 mmHg or 39 ± 3.0 mmHg vs 46 ± 3.4 mmHg at R90, respectively, P < 0.05). Most interesting finding was that there were significantly higher mucosal blood flow and lower jejunal PrCO2 in anisodamine group than those in dobutamine group at 90 minutes of reperfusion (64 ± 3.3% vs 56 ± 4.2% for blood flow or 34 ± 2.1 mmHg vs 39 ± 3.0 mmHg for PrCO2, respectively, P < 0.05), suggesting that anisodamine had a more lasting effect on mucosal perfusion than dobutamine.
CONCLUSION: Intraluminal anisodamine and dobutamine can augment mucosal blood flow during gut I/R and alleviate mucosal acidosis. The results provided benificial effects on the treatment of splanchnic hypoperfusion following traumatic or burn shock.
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Affiliation(s)
- Sen Hu
- Burns Institute, 304th Hospital of PLA, 51 Fu Cheng Road, Beijing 100037, China
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Rudis MI, Hoang DQ. The Year in Review: Critical Care Medicine. J Pharm Pract 2001. [DOI: 10.1106/8y8w-9ftr-p57j-5t9x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Background: There have been significant recent advances in the pharmacotherapeutic management of critically ill patients. The purpose of this article is to review and discuss the most pertinent published literature in the areas of neurology, cardiovascular diseases, infectious diseases, nephrology, hematology, and gastroenterology as it pertains to critical care in order to provide an update for the critical care practitioner. Methods: We performed a Medline search from July 1999 to December 2000 utilizing terms relating to the pharmacotherapy of the specific aforementioned topics in critical care medicine. We focused on English-language clinical studies performed in adult intensive care unit (ICU) patients. From these articles we selected those that would have a practical impact on drug therapy in the ICU or the development of drug usage guidelines for critically ill patients. Review articles were generally not included. Results: The following topics were found to be either new developments or of potentially significant impact in the management of adult critically ill patients. In the area of neurology, advances were found with respect to optimization of regimens for sedative and neuromuscular blocking agents, validation of sedation scales and tools, and in the treatment of head injury patients. In the cardiovascular diseases, most studies related to the hemodynamic support of septic shock. We focus on developments in fluid resuscitation, optimization of global and regional oxygen transport variables, the repositioning of vasopressor agents, and a return to the use of steroids. Given the high mortality rate associated with the development of acute renal failure in the ICU, there has been a consistent attempt to develop preventative and treatment strategies for these patients, including optimization of antimicrobial dosing methods. Several epidemiological and longitudinal studies document changes in multi-drug antimicrobial resistance patterns. The use of treatment guidelines for antimicrobials in the critically ill improves outcomes in most patients. Significant attention has focused on the characterization of anemia in the ICU and the development of alternative pharmacological strategies in its treatment. Finally, in gastroenterology, the main focus has been the investigation of methods to optimize the delivery of enteral nutrition given its proven benefits in critically ill patients. Conclusions: Significant advances in the areas of neurological, cardiovascular, infectious diseases, renal, hematological, and gastrointestinal issues in the pharmacotherapy of critically ill patients have been published over the course of the past year. Many of these studies have yielded data that may be incorporated into the pharmacotherapeutic management of ICU patients, hence maximizing outcomes.
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Affiliation(s)
- Maria I. Rudis
- Department of Clinical Pharmacy and Emergency Medicine, University of Southern California School of Pharmacy, 1985 Zonal Ave., PSC-700, Los Angeles, CA 90033,
| | - David Q. Hoang
- University of Southern California School of Pharmacy, 1985 Zonal Ave., PSC-700, Los Angeles, CA 90033
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Corley K, McKenzie H, Amoroso L, Furr M. Initial Experience with Norepinephrine Infusion in Hypotensive Critically III Foals. J Vet Emerg Crit Care (San Antonio) 2000. [DOI: 10.1111/j.1476-4431.2000.tb00012.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Lim TW, Lee S, NG KS. Vasopressin effective in reversing catecholamine-resistant vasodilatory shock. Anaesth Intensive Care 2000; 28:313-7. [PMID: 10853217 DOI: 10.1177/0310057x0002800312] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A patient with perforated appendicitis developed progressive vasodilatory shock which was complicated by perioperative acute myocardial infarction. Cardiovascular support included dopamine infusion, and later, intra-aortic balloon counterpulsation balloon pump and noradrenaline and dobutamine infusion. Vasopressin was introduced as a final attempt to reverse the refractory shock and was associated with recovery. The experience with this case suggests that vasopressin may be a valuable adjunct to the treatment of catecholamine-resistant vasodilatory shock.
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Affiliation(s)
- T W Lim
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
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Further benefits of norepinephrine in septic shock. Crit Care 1999. [DOI: 10.1186/ccf-1999-2161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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