1
|
Lichter Y, Gal Oz A, Adi N, Nini A, Angel Y, Nevo A, Aviram D, Moshkovits I, Wald R, Stavi D, Goder N. Linear Correlation Between Mean Arterial Pressure and Urine Output in Critically Ill Patients. Crit Care Explor 2024; 6:e1141. [PMID: 39120069 DOI: 10.1097/cce.0000000000001141] [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: 08/10/2024] Open
Abstract
OBJECTIVE Mean arterial pressure (MAP) plays a significant role in regulating tissue perfusion and urine output (UO). The optimal MAP target in critically ill patients remains a subject of debate. We aimed to explore the relationship between MAP and UO. DESIGN A retrospective observational study. SETTING A general ICU in a tertiary medical center. PATIENTS All critically ill patients admitted to the ICU for more than 10 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS MAP values and hourly UO were collected in 5,207 patients. MAP levels were categorized into 10 groups of 5 mm Hg (from MAP < 60 mm Hg to MAP > 100 mg Hg), and 656,423 coupled hourly mean MAP and UO measurements were analyzed. Additionally, we compared the UO of individual patients in each MAP group with or without norepinephrine (NE) support or diuretics, as well as in patients with acute kidney injury (AKI).Hourly UO rose incrementally between MAP values of 65-100 mm Hg. Among 2,226 patients treated with NE infusion, mean UO was significantly lower in the MAP less than 60 mm Hg group (53.4 mL/hr; 95% CI, 49.3-57.5) compared with all other groups (p < 0.001), but no differences were found between groups of 75 less than or equal to MAP. Among 2500 patients with AKI, there was a linear increase in average UO from the MAP less than 60 mm Hg group (57.1 mL/hr; 95% CI, 54.2-60.0) to the group with MAP greater than or equal to 100 mm Hg (89.4 mL/hr; 95% CI, 85.7-93.1). When MAP was greater than or equal to 65 mm Hg, we observed a statistically significant trend of increased UO in periods without NE infusion. CONCLUSIONS Our analysis revealed a linear correlation between MAP and UO within the range of 65-100 mm Hg, also observed in the subgroup of patients treated with NE or diuretics and in those with AKI. These findings highlight the importance of tissue perfusion to the maintenance of diuresis and achieving adequate fluid balance in critically ill patients.
Collapse
Affiliation(s)
- Yael Lichter
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Critical Care Department, University College London Hospital NHS Foundation Trust, London, United Kingdom
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Amir Gal Oz
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Nimrod Adi
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Asaph Nini
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Yoel Angel
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Andrey Nevo
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Aviram
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Critical Care Department, University College London Hospital NHS Foundation Trust, London, United Kingdom
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Itay Moshkovits
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Ron Wald
- Division of Nephrology, St. Michael's Hospital and the University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
| | - Dekel Stavi
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Noam Goder
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Division of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| |
Collapse
|
2
|
Huh J, Kwon H, Park H, Park SC, Yun SS, Chae MS. Impact of Norepinephrine and Dopamine Infusion on Renal Arterial Resistive Index during Pre-Emptive Living Donor Kidney Transplantation: Propensity Score Matching Analysis. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1066. [PMID: 39064495 PMCID: PMC11278998 DOI: 10.3390/medicina60071066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 06/26/2024] [Accepted: 06/26/2024] [Indexed: 07/28/2024]
Abstract
Background: Living donor kidney transplantation (LDKT) is a crucial treatment for end-stage renal disease, with pre-emptive LDKT (transplantation before dialysis initiation) offering significant benefits in graft function and patient survival. The selection of a vasopressor during LDKT, particularly between norepinephrine and dopamine, and its impact on renal arterial hemodynamics measured using the renal arterial resistive index (RARI) is poorly understood. Methods: This retrospective observational cohort study enrolled 347 eligible pre-emptive LDKT recipients from the Seoul St. Mary's Hospital between January 2019 and June 2023. Utilizing propensity score matching (PSM), the patients were categorized into dopamine and norepinephrine groups to compare the effects of these vasopressors on the intraoperative RARI, postoperative estimated glomerular filtration rate (eGFR), and hourly urine output. The RARI was measured via the Doppler ultrasonography of the renal hilum and parenchyma post-graft vascular and ureteral anastomoses. Results: The preoperative differences in the recipients' and donors' characteristics were mitigated following PSM. The dopamine group exhibited higher intraoperative RARI values at the renal hilum (0.77 ± 0.11 vs. 0.66 ± 0.13, p < 0.001) and parenchyma (0.71 ± 0.1 vs. 0.6 ± 0.1, p < 0.001) compared to those of the norepinephrine group. However, these differences were not statistically significant on postoperative day 7. The norepinephrine infusion adjusted for the propensity scores was associated with significantly lower odds of an RARI > 0.8 (hilum: OR = 0.214, 95% CI = 0.12-0.382, p < 0.001; parenchyma: OR = 0.1, 95% CI = 0.029-0.348, p < 0.001). The early postoperative outcomes showed a higher eGFR (day 1: 30.0 ± 13.3 vs. 25.1 ± 17.4 mL/min/1.73 m2, p = 0.004) and hourly urine output (day 1: 41.8 ± 16.9 vs. 36.5 ± 14.4 mL/kg/h, p = 0.002) in the norepinephrine group. Furthermore, the long-term outcomes were comparable between the groups. Conclusions: Norepinephrine infusion during pre-emptive LDKT is associated with more favorable intraoperative renal arterial hemodynamics, as evidenced by a lower RARI and improved early postoperative renal function compared to those of dopamine. These findings suggest a potential preferential role for norepinephrine in optimizing perioperative management and early graft functions in LDKT recipients. Given the retrospective nature of this study, further prospective studies are needed to confirm these observations. Additionally, the study limitations include the potential for unmeasured confounding factors and the inability to determine causality due to its observational design.
Collapse
Affiliation(s)
- Jaewon Huh
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Hyejin Kwon
- Department of Anesthesiology and Pain Medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Hunwoo Park
- Department of Anesthesiology and Pain Medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Sun Cheol Park
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Sang Seob Yun
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| |
Collapse
|
3
|
Soliman MM, Marshall C, Kimball JP, Choudhary T, Clermont G, Pinsky MR, Buchman TG, Coopersmith CM, Inan OT, Kamaleswaran R. Parsimonious Waveform-derived Features consisting of Pulse Arrival Time and Heart Rate Variability Predicts the Onset of Septic Shock. Biomed Signal Process Control 2024; 92:105974. [PMID: 38559667 PMCID: PMC10977921 DOI: 10.1016/j.bspc.2024.105974] [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] [Indexed: 04/04/2024]
Abstract
Sepsis is a major public health emergency and one of the leading causes of morbidity and mortality in critically ill patients. For each hour treatment is delayed, shock-related mortality increases, so early diagnosis and intervention is of utmost importance. However, earlier recognition of shock requires active monitoring, which may be delayed due to subclinical manifestations of the disease at the early phase of onset. Machine learning systems can increase timely detection of shock onset by exploiting complex interactions among continuous physiological waveforms. We use a dataset consisting of high-resolution physiological waveforms from intensive care unit (ICU) of a tertiary hospital system. We investigate the use of mean arterial blood pressure (MAP), pulse arrival time (PAT), heart rate variability (HRV), and heart rate (HR) for the early prediction of shock onset. Using only five minutes of the aforementioned vital signals from 239 ICU patients, our developed models can accurately predict septic shock onset 6 to 36 hours prior to clinical recognition with area under the receiver operating characteristic (AUROC) of 0.84 and 0.8 respectively. This work lays foundations for a robust, efficient, accurate and early prediction of septic shock onset which may help clinicians in their decision-making processes. This study introduces machine learning models that provide fast and accurate predictions of septic shock onset times up to 36 hours in advance. BP, PAT and HR dynamics can independently predict septic shock onset with a look-back period of only 5 mins.
Collapse
Affiliation(s)
- Moamen M. Soliman
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, 30332, GA, USA
| | - Curtis Marshall
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, 30322, GA, USA
| | - Jacob P. Kimball
- School of Biomedical and Electrical Engineering, University of Portland, Portland, 97203, OR, USA
| | - Tilendra Choudhary
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, 30322, GA, USA
| | - Gilles Clermont
- School of Medicine, University of Pittsburgh, Pittsburgh, 15213, PA, USA
| | - Michael R. Pinsky
- School of Medicine, University of Pittsburgh, Pittsburgh, 15213, PA, USA
| | - Timothy G. Buchman
- Department of Surgery and Emory Critical Care Center, Emory University School of Medicine, Atlanta, 30322, GA, USA
| | - Craig M. Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University School of Medicine, Atlanta, 30322, GA, USA
| | - Omer T. Inan
- School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, 30332, GA, USA
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, 30332, GA, USA
| | - Rishikesan Kamaleswaran
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, 30322, GA, USA
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, 30332, GA, USA
| |
Collapse
|
4
|
Gattarello S, Lombardo F, Romitti F, D'Albo R, Velati M, Fratti I, Pozzi T, Nicolardi R, Fioccola A, Busana M, Collino F, Herrmann P, Camporota L, Quintel M, Moerer O, Saager L, Meissner K, Gattinoni L. Determinants of acute kidney injury during high-power mechanical ventilation: secondary analysis from experimental data. Intensive Care Med Exp 2024; 12:31. [PMID: 38512544 PMCID: PMC10957825 DOI: 10.1186/s40635-024-00610-1] [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: 08/15/2023] [Accepted: 02/29/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND The individual components of mechanical ventilation may have distinct effects on kidney perfusion and on the risk of developing acute kidney injury; we aimed to explore ventilatory predictors of acute kidney failure and the hemodynamic changes consequent to experimental high-power mechanical ventilation. METHODS Secondary analysis of two animal studies focused on the outcomes of different mechanical power settings, including 78 pigs mechanically ventilated with high mechanical power for 48 h. The animals were categorized in four groups in accordance with the RIFLE criteria for acute kidney injury (AKI), using the end-experimental creatinine: (1) NO AKI: no increase in creatinine; (2) RIFLE 1-Risk: increase of creatinine of > 50%; (3) RIFLE 2-Injury: two-fold increase of creatinine; (4) RIFLE 3-Failure: three-fold increase of creatinine; RESULTS: The main ventilatory parameter associated with AKI was the positive end-expiratory pressure (PEEP) component of mechanical power. At 30 min from the initiation of high mechanical power ventilation, the heart rate and the pulmonary artery pressure progressively increased from group NO AKI to group RIFLE 3. At 48 h, the hemodynamic variables associated with AKI were the heart rate, cardiac output, mean perfusion pressure (the difference between mean arterial and central venous pressures) and central venous pressure. Linear regression and receiving operator characteristic analyses showed that PEEP-induced changes in mean perfusion pressure (mainly due to an increase in CVP) had the strongest association with AKI. CONCLUSIONS In an experimental setting of ventilation with high mechanical power, higher PEEP had the strongest association with AKI. The most likely physiological determinant of AKI was an increase of pleural pressure and CVP with reduced mean perfusion pressure. These changes resulted from PEEP per se and from increase in fluid administration to compensate for hemodynamic impairment consequent to high PEEP.
Collapse
Affiliation(s)
- Simone Gattarello
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany.
| | - Fabio Lombardo
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Federica Romitti
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Rosanna D'Albo
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Mara Velati
- Department of Anesthesia and Intensive Care Medicine Department, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Isabella Fratti
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Tommaso Pozzi
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Rosmery Nicolardi
- Department of Anesthesia and Intensive Care Medicine Department, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Antonio Fioccola
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Mattia Busana
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Francesca Collino
- Department of Anesthesia, Intensive Care and Emergency, "Città Della Salute E Della Scienza" Hospital, Turin, Italy
| | - Peter Herrmann
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Michael Quintel
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
- Department of Anesthesiology, Intensive Care and Emergency Medicine Donau-Isar-Klinikum Deggendorf, Deggendorf, Germany
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Leif Saager
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Konrad Meissner
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| |
Collapse
|
5
|
Pruna A, Bonaccorso A, Belletti A, Turi S, Di Prima AL, D'amico F, Zangrillo A, Kotani Y, Landoni G. Methylene Blue Reduces Mortality in Critically Ill and Perioperative Patients: A Meta-Analysis of Randomized Trials. J Cardiothorac Vasc Anesth 2024; 38:268-274. [PMID: 37880041 DOI: 10.1053/j.jvca.2023.09.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 08/26/2023] [Accepted: 09/26/2023] [Indexed: 10/27/2023]
Abstract
Vasodilatory hypotension is common in critically ill and perioperative patients, and is associated with adverse outcomes. As a nitric oxide production inhibitor, methylene blue (MB) exerts its vasoconstrictor property and is an adjuvant for catecholamine-refractory vasodilatory shock. However, the effects of MB on clinically relevant outcomes remain unclear. Therefore, the authors performed a meta-analysis of randomized trials on MB in critically ill and perioperative patients. The authors searched through databases for randomized trials on MB in critically ill and perioperative patients, which yielded 11 studies consisting of 556 patients. The primary outcome was mortality at the longest follow-up. Secondary outcomes included hemodynamic parameters and organ dysfunction (PROSPERO: CRD42023409243). Nine out of the 11 included randomized trials reported mortality, which was significantly lower in the MB group (risk ratio, 0.60 [95% CI 0.43-0.84] p = 0.003), with findings confirmed in septic shock and cardiac surgery subgroups. The authors found reduced lengths of stay in the intensive care unit (mean difference [MD], -0.9 days [95% CI -1.06 to -0.77] p < 0.001) and in the hospital (MD, -2.2 days [95% CI, -2.68 to -1.70] p < 0.001) in the MB group. MB was associated with increased mean arterial pressure (MD, 8.4 mmHg [95% CI 5.01-11.75] p < 0.001) and systemic vascular resistance (MD, 94.5 dyn/s/cm5 [95% CI 17.73-171.15] p = 0.02), with no difference in cardiac output (standardized MD, 0.16 [95% CI, -0.25 to 0.57] p = 0.45). This meta-analysis showed that MB reverses vasodilation in critically ill and perioperative patients and might improve survival. Further adequately powered randomized trials are needed to confirm these findings.
Collapse
Affiliation(s)
- Alessandro Pruna
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandra Bonaccorso
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Turi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ambra Licia Di Prima
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Filippo D'amico
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
| |
Collapse
|
6
|
Laurikkala J, Ameloot K, Reinikainen M, Palmers PJ, De Deyne C, Bert F, Dupont M, Janssens S, Dens J, Hästbacka J, Jakkula P, Loisa P, Birkelund T, Wilkman E, Vaara ST, Skrifvars MB. The effect of higher or lower mean arterial pressure on kidney function after cardiac arrest: a post hoc analysis of the COMACARE and NEUROPROTECT trials. Ann Intensive Care 2023; 13:113. [PMID: 37987871 PMCID: PMC10663425 DOI: 10.1186/s13613-023-01210-0] [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: 06/25/2023] [Accepted: 11/06/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND We aimed to study the incidence of acute kidney injury (AKI) in out-of-hospital cardiac arrest (OHCA) patients treated according to low-normal or high-normal mean arterial pressure (MAP) targets. METHODS A post hoc analysis of the COMACARE (NCT02698917) and Neuroprotect (NCT02541591) trials that randomized patients to lower or higher targets for the first 36 h of intensive care. Kidney function was defined using the Kidney Disease Improving Global Outcome (KDIGO) classification. We used Cox regression analysis to identify factors associated with AKI after OHCA. RESULTS A total of 227 patients were included: 115 in the high-normal MAP group and 112 in the low-normal MAP group. Eighty-six (38%) patients developed AKI during the first five days; 40 in the high-normal MAP group and 46 in the low-normal MAP group (p = 0.51). The median creatinine and daily urine output were 85 μmol/l and 1730 mL/day in the high-normal MAP group and 87 μmol/l and 1560 mL/day in the low-normal MAP group. In a Cox regression model, independent AKI predictors were no bystander cardiopulmonary resuscitation (p < 0.01), non-shockable rhythm (p < 0.01), chronic hypertension (p = 0.03), and time to the return of spontaneous circulation (p < 0.01), whereas MAP target was not an independent predictor (p = 0.29). CONCLUSION Any AKI occurred in four out of ten OHCA patients. We found no difference in the incidence of AKI between the patients treated with lower and those treated with higher MAP after CA. Higher age, non-shockable initial rhythm, and longer time to ROSC were associated with shorter time to AKI. CLINICAL TRIAL REGISTRATION COMACARE (NCT02698917), NEUROPROTECT (NCT02541591).
Collapse
Affiliation(s)
- Johanna Laurikkala
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 9, 00290 HUS, Helsinki, Finland.
| | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Pieter-Jan Palmers
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
| | - Cathy De Deyne
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
- Department of Anesthesiology and Critical Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Ferdinande Bert
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
| | - Stefan Janssens
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Joseph Dens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Johanna Hästbacka
- Department of Anesthesia and Intensive Care, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Pekka Jakkula
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 9, 00290 HUS, Helsinki, Finland
| | - Pekka Loisa
- Department of Intensive Care, Päijät-Häme Central Hospital, Lahti, Finland
| | | | - Erika Wilkman
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 9, 00290 HUS, Helsinki, Finland
| | - Suvi T Vaara
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 9, 00290 HUS, Helsinki, Finland
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| |
Collapse
|
7
|
Schaffer AJ, Li G, McIlroy DR, Lopez MG, Freundlich RE. Effects of Postoperative Blood Pressure Management on Delirium Among Patients in the Intensive Care Unit After Cardiac Surgery: An Observational Cohort Study. J Cardiothorac Vasc Anesth 2023; 37:1683-1690. [PMID: 37244820 PMCID: PMC10524613 DOI: 10.1053/j.jvca.2023.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/17/2023] [Accepted: 05/05/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVES This study aimed to determine whether blood pressure control in the early postoperative period was associated with postoperative delirium in the cardiovascular intensive care unit (ICU). DESIGN Observational cohort study. SETTING Single large academic institution with a high volume of cardiac surgery. PARTICIPANTS Cardiac surgery patients admitted to the cardiovascular ICU after surgery. INTERVENTIONS Observational study. MEASUREMENTS AND MAIN RESULTS A total of 517 cardiac surgery patients had mean arterial pressure (MAP) data recorded minute-by-minute for 12 postoperative hours. The time spent in each of the 7 prespecified blood pressure bands was calculated, and the development of delirium was recorded in the ICU. A multivariate Cox regression model was developed using the least absolute shrinkage and selection operator approach to identify associations between time spent in each MAP range band and delirium. Compared with the reference band of 60-to-69 mmHg, longer durations spent in 3 bands were independently associated with a lower risk of delirium: 50-to-59 mmHg band (adjusted hazard ratio [HR] 0.907 [per 10 minutes]; 95% CI 0.861-0.955); 70-to-79 mmHg band (adjusted HR 0.923 [per 10 minutes]; 95% CI 0.902-0.944); 90-to-99 mmHg band (adjusted HR 0.898 [per 10 minutes]; 95% CI 0.853-0.945). CONCLUSIONS The MAP range bands above and below the authors' reference band of 60-to- 69 mmHg were associated with decreased risk of ICU delirium development; however, this was difficult to reconcile with a plausible biologic mechanism. Therefore, the authors did not find a correlation between early postoperative MAP control and increased risk of the development of ICU delirium after cardiac surgery.
Collapse
Affiliation(s)
| | - Gen Li
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David R McIlroy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Anaesthesia & Perioperative Medicine, Monash University, Melbourne, Australia
| | - Marcos G Lopez
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert E Freundlich
- Department of Anesthesiology, Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee.
| |
Collapse
|
8
|
Putowski Z, Gołdyn M, Pluta MP, Krzych ŁJ, Hernández G, Kattan E. Correlation Between Mean Arterial Pressure and Capillary Refill Time in Patients with Septic Shock: A Systematic Review and Meta-analysis. J Intensive Care Med 2023; 38:838-846. [PMID: 37042043 DOI: 10.1177/08850666231168038] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
Background: The initial hemodynamic goal during septic shock resuscitation is to achieve a mean arterial pressure (MAP) above 65 mm Hg, although this does not assure a normal tissue perfusion. Capillary refill time (CRT), a marker of skin blood flow, has been validated as a marker of the reperfusion process. The aim of the study was to explore the relationship between MAP and CRT in patients in septic shock. Methods: We systematically reviewed studies which reported CRT and MAP in septic shock patients. Authors of eligible studies were asked to provide necessary data for performing a meta-correlation of Spearman's rank correlation coefficients. Subgroup analyses were performed, including studies of good quality and studies with higher/lower norepinephrine doses. Results: We identified 10 studies, comprising 917 patients. There were 5 studies considered to be of good quality. A meta-correlation showed a statistically significant but poor negative correlation between MAP and CRT (R = -0.158, range -0.221 to -0.093, P < .001, I2 = 0.0%). Subgroup analysis of best-quality studies gave similar results (R = -0.201, range -0.282 to -0.116, P < .001, I2 = 0.0%). In subanalysis concerning norepinephrine doses, no significant correlations were found. Conclusions: In patients with septic shock, there is poor inverse correlation between MAP and CRT. MAP > 65 mm Hg does not guarantee normalization of CRT.Registration code: PROSPERO: CRD42022355996. Registered on 5 September 2022.
Collapse
Affiliation(s)
- Zbigniew Putowski
- Centre for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Mateusz Gołdyn
- Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences, Medical University of Silesia, Katowice, Poland
| | - Michał P Pluta
- Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences, Medical University of Silesia, Katowice, Poland
| | - Łukasz J Krzych
- Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences, Medical University of Silesia, Katowice, Poland
| | - Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| |
Collapse
|
9
|
Sahoo P, Kothari N, Sharma A, Goyal S. Author Reply: Comparison of Norepinephrine and Terlipressin vs Norepinephrine Alone for Management of Septic Shock: A Randomized Control Study. Indian J Crit Care Med 2023; 27:603-604. [PMID: 37636857 PMCID: PMC10452768 DOI: 10.5005/jp-journals-10071-24514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
How to cite this article: Sahoo P, Kothari N, Sharma A, Goyal S. Author Reply: Comparison of Norepinephrine and Terlipressin vs Norepinephrine Alone for Management of Septic Shock: A Randomized Control Study. Indian J Crit Care Med 2023;27(8):603-604.
Collapse
Affiliation(s)
- Pallavi Sahoo
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Nikhil Kothari
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Ankur Sharma
- Department of Trauma and Emergency (Anaesthesia), All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Shilpa Goyal
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| |
Collapse
|
10
|
Hamzaoui O, Goury A, Teboul JL. The Eight Unanswered and Answered Questions about the Use of Vasopressors in Septic Shock. J Clin Med 2023; 12:4589. [PMID: 37510705 PMCID: PMC10380663 DOI: 10.3390/jcm12144589] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/05/2023] [Accepted: 07/08/2023] [Indexed: 07/30/2023] Open
Abstract
Septic shock is mainly characterized-in addition to hypovolemia-by vasoplegia as a consequence of a release of inflammatory mediators. Systemic vasodilatation due to depressed vascular tone results in arterial hypotension, which induces or worsens organ hypoperfusion. Accordingly, vasopressor therapy is mandatory to correct hypotension and to reverse organ perfusion due to hypotension. Currently, two vasopressors are recommended to be used, norepinephrine and vasopressin. Norepinephrine, an α1-agonist agent, is the first-line vasopressor. Vasopressin is suggested to be added to norepinephrine in cases of inadequate mean arterial pressure instead of escalating the doses of norepinephrine. However, some questions about the bedside use of these vasopressors remain. Some of these questions have been well answered, some of them not clearly addressed, and some others not yet answered. Regarding norepinephrine, we firstly reviewed the arguments in favor of the choice of norepinephrine as a first-line vasopressor. Secondly, we detailed the arguments found in the recent literature in favor of an early introduction of norepinephrine. Thirdly, we reviewed the literature referring to the issue of titrating the doses of norepinephrine using an individualized resuscitation target, and finally, we addressed the issue of escalation of doses in case of refractory shock, a remaining unanswered question. For vasopressin, we reviewed the rationale for adding vasopressin to norepinephrine. Then, we discussed the optimal time for vasopressin administration. Subsequently, we addressed the issue of the optimal vasopressin dose, and finally we discussed the best strategy to wean these two vasopressors when combined.
Collapse
Affiliation(s)
- Olfa Hamzaoui
- Service de Médecine intensive réanimation polyvalente, Hôpital Robert Debré, CHU de Reims Université de Reims, 51092 Reims, France
- "Hémostase et Remodelage Vasculaire Post-Ischémie"-EA 3801, Unité HERVI, 51100 Reims, France
| | - Antoine Goury
- Service de Médecine intensive réanimation polyvalente, Hôpital Robert Debré, CHU de Reims Université de Reims, 51092 Reims, France
| | - Jean-Louis Teboul
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, AP-HP, Université Paris-Saclay, DMU CORREVE, FHU SEPSIS, 94270 Le Kremlin-Bicêtre, France
- INSERM-UMR_S999 LabEx-LERMIT, Hôpital Marie-Lannelongue, 92350 Le Plessis Robinson, France
| |
Collapse
|
11
|
Chen Y, Peng JM, Hu XY, Li S, Wan XX, Liu RT, Wang CY, Jiang W, Dong R, Su LX, He HW, Long Y, Weng L, Du B. Tissue oxygen saturation is predictive of lactate clearance in patients with circulatory shock. BMC Anesthesiol 2023; 23:179. [PMID: 37231341 DOI: 10.1186/s12871-023-02139-4] [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: 03/30/2023] [Accepted: 05/14/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Tissue oxygen saturation (StO2) decrease could appear earlier than lactate alteration. However, the correlation between StO2 and lactate clearance was unknown. METHODS This was a prospective observational study. All consecutive patients with circulatory shock and lactate over 3 mmol/L were included. Based on the rule of nines, a BSA (body surface area) weighted StO2 was calculated from four sites of StO2 (masseter, deltoid, thenar and knee). The formulation was as follows: masseter StO2 × 9% + (deltoid StO2 + thenar StO2) × (18% + 27%)/ 2 + knee StO2 × 46%. Vital signs, blood lactate, arterial and central venous blood gas were measured simultaneously within 48 h of ICU admission. The predictive value of BSA-weighted StO2 on 6-hour lactate clearance > 10% since StO2 initially monitored was assessed. RESULTS A total of 34 patients were included, of whom 19 (55.9%) had a lactate clearance higher than 10%. The mean SOFA score was lower in cLac ≥ 10% group compared with cLac < 10% group (11 ± 3 vs. 15 ± 4, p = 0.007). Other baseline characteristics were comparable between groups. Compared to non-clearance group, StO2 in deltoid, thenar and knee were significantly higher in clearance group. The area under the receiver operating curves (AUROC) of BSA-weighted StO2 for prediction of lactate clearance (0.92, 95% CI [Confidence Interval] 0.82-1.00) was significantly higher than StO2 of masseter (0.65, 95% CI 0.45-0.84; p < 0.01), deltoid (0.77, 95% CI 0.60-0.94; p = 0.04), thenar (0.72, 95% CI 0.55-0.90; p = 0.01), and similar to knee (0.87, 0.73-1.00; p = 0.40), mean StO2 (0.85, 0.73-0.98; p = 0.09). Additionally, BSA-weighted StO2 model had continuous net reclassification improvement (NRI) over the knee StO2 and mean StO2 model (continuous NRI 48.1% and 90.2%, respectively). The AUROC of BSA-weighted StO2 was 0.91(95% CI 0.75-1.0) adjusted by mean arterial pressure and norepinephrine dose. CONCLUSIONS Our results suggested that BSA-weighted StO2 was a strong predictor of 6-hour lactate clearance in patients with shock.
Collapse
Affiliation(s)
- Yan Chen
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Jin-Min Peng
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xiao-Yun Hu
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Shan Li
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xi-Xi Wan
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Rui-Ting Liu
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Chun-Yao Wang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Wei Jiang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Run Dong
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Long-Xiang Su
- Department of Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Huai-Wu He
- Department of Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Li Weng
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Bin Du
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China.
| |
Collapse
|
12
|
Association of systolic, diastolic, mean, and pulse pressure with morbidity and mortality in septic ICU patients: a nationwide observational study. Ann Intensive Care 2023; 13:9. [PMID: 36807233 PMCID: PMC9941378 DOI: 10.1186/s13613-023-01101-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 01/21/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Intensivists target different blood pressure component values to manage intensive care unit (ICU) patients with sepsis. We aimed to evaluate the relationship between individual blood pressure components and organ dysfunction in critically ill septic patients. METHODS In this retrospective observational study, we evaluated 77,328 septic patients in 364 ICUs in the eICU Research Institute database. Primary exposure was the lowest cumulative value of each component; mean, systolic, diastolic, and pulse pressure, sustained for at least 120 min during ICU stay. Primary outcome was ICU mortality and secondary outcomes were composite outcomes of acute kidney injury or death and myocardial injury or death during ICU stay. Multivariable logistic regression spline and threshold regression adjusting for potential confounders were conducted to evaluate associations between exposures and outcomes. Sensitivity analysis was conducted in 4211 patients with septic shock. RESULTS Lower values of all blood pressures components were associated with a higher risk of ICU mortality. Estimated change-points for the risk of ICU mortality were 69 mmHg for mean, 100 mmHg for systolic, 60 mmHg for diastolic, and 57 mmHg for pulse pressure. The strength of association between blood pressure components and ICU mortality as determined by slopes of threshold regression were mean (- 0.13), systolic (- 0.11), diastolic (- 0.09), and pulse pressure (- 0.05). Equivalent non-linear associations between blood pressure components and ICU mortality were confirmed in septic shock patients. We observed a similar relationship between blood pressure components and secondary outcomes. CONCLUSION Blood pressure component association with ICU mortality is the strongest for mean followed by systolic, diastolic, and weakest for pulse pressure. Critical care teams should continue to follow MAP-based resuscitation, though exploratory analysis focusing on blood pressure components in different sepsis phenotypes in critically ill ICU patients is needed.
Collapse
|
13
|
Carayannopoulos KL, Pidutti A, Upadhyaya Y, Alshamsi F, Basmaji J, Granholm A, Alhazzani W, Lewis K. Mean Arterial Pressure Targets and Patient-Important Outcomes in Critically Ill Adults: A Systematic Review and Meta-Analysis of Randomized Trials. Crit Care Med 2023; 51:241-253. [PMID: 36661452 DOI: 10.1097/ccm.0000000000005726] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To conduct a systematic review and meta-analysis to determine whether targeting a higher mean arterial pressure (MAP) compared with a lower MAP in adults with shock results in differences in patient important outcomes. DATA SOURCES We searched MEDLINE, EMBASE, the Cochrane Library, and ClinicalTrials.gov through May 2021. STUDY SELECTION Titles and abstracts were screened independently and in duplicate to identify potentially eligible studies, then full text for final eligibility. We included parallel-group randomized controlled trials in adult patients with a diagnosis of shock requiring vasoactive medications. The higher MAP group was required to receive vasoactive medications to target a higher MAP as established by study authors, whereas the lower MAP group received vasoactive medications to target lower MAP. DATA EXTRACTION In triplicate, reviewers independently extracted data using a prepiloted abstraction form. Statistical analyses were conducted using the RevMan software Version 5.3. DATA SYNTHESIS Six randomized controlled trials (n = 3,690) met eligibility criteria. Targeting a higher MAP (75-85 mm Hg) compared with lower MAP of 65 mm Hg resulted in no difference in mortality (relative risk [RR], 1.06; 95% CI, 0.98-1.15; I2 = 0%; p = 0.12; moderate certainty. Targeting a higher MAP resulted in no difference in the risk of undergoing renal replacement therapy (RR, 0.96; 95% CI, 0.83-1.11; I2 = 24%; p = 0.57; moderate certainty); however, a subgroup analysis comparing patients with and without chronic hypertension demonstrated that a higher MAP may reduce the risk of undergoing renal replacement therapy (RR, 0.83; 95% CI, 0.71-0.98; I2 = 0%; p = 0.02). CONCLUSIONS In conclusion, our systematic review and meta-analysis demonstrated with moderate certainty that there is no difference in mortality when a higher MAP is targeted in critically ill adult patients with shock. Further studies are needed to determine the impact of mean arterial pressure on need for renal replacement therapy in this population.
Collapse
Affiliation(s)
| | - Andrew Pidutti
- Department of Medicine, Virginia Commonwealth University, Richmond, VA
| | | | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - John Basmaji
- Department of Medicine & Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Impact and Evidence, McMaster University, Hamilton, ON, Canada
| | - Kimberley Lewis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Impact and Evidence, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
14
|
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.
Collapse
|
15
|
Effects of Norepinephrine on Renal Cortical and Medullary Blood Flow in Atherosclerotic Rabbits. Curr Med Sci 2022; 42:1172-1177. [PMID: 36083378 DOI: 10.1007/s11596-022-2626-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 01/25/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The aim of this study was to explore the effect of norepinephrine (NE) on renal cortical and medullary blood flow in atherosclerotic rabbits without renal artery stenosis. METHODS Atherosclerosis was induced in 21 New Zealand white rabbits by feeding them a cholesterol-rich diet for 16 weeks. Thirteen healthy New Zealand white rabbits were randomly selected as controls. After atherosclerosis induction, standard ultrasonography was performed to confirm that there was no plaque or accelerated flow at the origin of the renal artery. Contrast-enhanced ultrasound (CEUS) was performed at baseline and during intravenous injection of NE. The degree of contrast enhancement of renal cortex and medulla after the injection of contrast agents was quantified by calculating the enhanced intensity. RESULTS The serum nitric oxide (NO) level in atherosclerotic rabbits was higher than that in healthy rabbits (299.6±152 vs. 136.5±49.5, P<0.001). The infusion of NE induced a significant increase in the systolic blood pressure (112±14 mmHg vs. 84±9 mmHg, P=0.016) and a significant decrease in the enhanced intensity in renal cortex (17.78±2.07 dB vs. 21.19±2.03 dB, P<0.001) and renal medulla (14.87±1.82 dB vs. 17.14±1.89 dB, P<0.001) during CEUS. However, the enhanced intensity in the cortex and medulla of healthy rabbits after NE infusion showed no significant difference from that at baseline. CONCLUSION NE may reduce renal cortical and medullary blood flow in atherosclerotic rabbits without renal artery stenosis, partly by reducing the serum NO level.
Collapse
|
16
|
Zhao L, Liu B, Wang Y, Wang Z, Xie K, Li Y. New Strategies to Optimize Hemodynamics for Sepsis-Associated Encephalopathy. J Pers Med 2022; 12:jpm12121967. [PMID: 36556188 PMCID: PMC9784429 DOI: 10.3390/jpm12121967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/07/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
Background: Sepsis-associated encephalopathy (SAE) is associated with high morbidity and mortality. Hemodynamic dysfunction plays a significant role in the incidence and mortality of SAE. Therefore, this study aimed to explore the relationship between hemodynamic indicators and SAE. Methods: 9033 patients with sepsis 3.0 were selected in a prospective study cohort. The LASSO regression model was used to select characteristic variables and remove the collinearity between them. In addition, a generalized additive model was used to find the optimal hemodynamic index value for patients with SAE. Multivariate logistic regression models, propensity matching scores, inverse probability weighting, and doubly robust estimation confirmed the reliability of the study results (i.e., the optimal hemodynamic indicators targeting patients with SAE). Results: A mean arterial pressure ≥ 65 mmHg, systolic blood pressure ≥ 90 mmHg, and lactate levels ≤ 3.5 mmol/L decrease the incidence of SAE, whereas a mean arterial pressure ≥ 59 mmHg and lactate levels ≤ 4.5 mmol/L decrease the 28-day mortality in patients with SAE. Conclusions: The hemodynamic indices of patients with SAE should be maintained at certain levels to reduce the incidence and mortality in patients with SAE, such that the mean arterial pressure is ≥65 mmHg, lactate levels are ≤3.5 mmol/L, and systolic blood pressure is ≥90 mmHg. These hemodynamic indicators should be targeted in patients with SAE.
Collapse
Affiliation(s)
- Lina Zhao
- Department of Critical Care Medicine, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Bin Liu
- Department of Emergency, Chongqing University Central Hospital, Chongqing Emergency Medical Center, No.1 Jiankang Road, Yuzhong District, Chongqing 400014, China
| | - Yunying Wang
- Department of Critical Care Medicine, Chifeng Municipal Hospital, Chifeng Clinical Medical College of Inner Mongolia Medical University, Chifeng 024000, China
| | - Zhiwei Wang
- Department of Critical Care Medicine, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Keliang Xie
- Department of Critical Care Medicine, Tianjin Medical University General Hospital, Tianjin 300052, China
- Department of Anesthesiology, Tianjin Institute of Anesthesiology, Tianjin Medical University General Hospital, Tianjin 300052, China
- Correspondence:
| | - Yun Li
- Department of Anesthesiology, Tianjin Institute of Anesthesiology, Tianjin Medical University General Hospital, Tianjin 300052, China
| |
Collapse
|
17
|
Klanovicz TM, Franzosi OS, Nunes DSL, Loss SH, Batassini É, Turra EE, Teixeira C, Vieira SRR. Acute gastrointestinal failure is associated with worse hemodynamic and perfusion parameters over 48 h after admission in patients with septic shock: Retrospective cohort study. Nutr Clin Pract 2022; 38:617-627. [PMID: 36351616 DOI: 10.1002/ncp.10928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 09/01/2022] [Accepted: 10/02/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND This study aimed to investigate the relationship between acute gastrointestinal injury (AGI) and hemodynamic and perfusion parameters in the first week of intensive care unit (ICU) admission and evaluate the association of AGI with ICU and hospital outcomes in patients with septic shock undergoing mechanical ventilation. METHODS This retrospective cohort study applied the criteria proposed by the European Society of Intensive Medicine to classify the participants into risk/dysfunction group (AGI grade I and II) and failure group (AGI grade III and IV). Hemodynamic and perfusion parameters data previously collected in the first 48 h after ICU admission (admission, 12, 24, 48 h) were analyzed. RESULTS A total of 163 were included and classified into AGI grades I (n = 79), II (n = 64), III (n = 20), and IV (none). Groups consisted of AGI risk/dysfunction (n = 143, 87.8%) and AGI failure (n = 20, 12.2%) patients. Patients with AGI failure had higher heart rate and mottling score (MS) at admission, lower mean arterial pressure, and an oliguria incidence at 12 h compared with those without AGI failure. Skin MS and abdominal primary site of infection were risk factors for AGI failure. AGI failure tended to be a risk factor for ICU mortality (risk ratio [95% CI]: 1.37 [0.99-1.89]; P = 0.053). CONCLUSION AGI was frequently observed in patients with septic shock in the first week of ICU admission. Higher heart rate and MS and lower mean arterial pressure and incidence of oliguria were identified in patients with AGI failure compared with those without. AGI failure was associated with ICU mortality.
Collapse
Affiliation(s)
- Tamires M. Klanovicz
- Medical Sciences Postgraduate Program, Faculdade de Medicina Universidade Federal do Rio Grande do Sul Porto Alegre RS Brazil
| | - Oellen S. Franzosi
- Medical Sciences Postgraduate Program, Faculdade de Medicina Universidade Federal do Rio Grande do Sul Porto Alegre RS Brazil
- Nutrition and Dietetic Division, Hospital de Clínicas de Porto Alegre Universidade Federal do Rio Grande do Sul Porto Alegre RS Brazil
| | - Diego S. L. Nunes
- Medical Sciences Postgraduate Program, Faculdade de Medicina Universidade Federal do Rio Grande do Sul Porto Alegre RS Brazil
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre Porto Alegre RS Brazil
| | - Sergio H. Loss
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre Porto Alegre RS Brazil
- Medical Sciences Postgraduate Program: Endocrinology Faculdade de Medicina Universidade Federal do Rio Grande do Sul Porto Alegre RS Brazil
| | - Érica Batassini
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre Porto Alegre RS Brazil
| | - Eduardo E. Turra
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre Porto Alegre RS Brazil
| | - Cassiano Teixeira
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre Porto Alegre RS Brazil
| | - Silvia R. R. Vieira
- Medical Sciences Postgraduate Program, Faculdade de Medicina Universidade Federal do Rio Grande do Sul Porto Alegre RS Brazil
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre Porto Alegre RS Brazil
| |
Collapse
|
18
|
Murphy KM, Rishniw M, Silverstein DC. Use of vasopressors for treatment of vasodilatory hypotension in dogs and cats by Diplomates of the American College of Veterinary Emergency and Critical Care. J Vet Emerg Crit Care (San Antonio) 2022; 32:714-722. [PMID: 35829666 DOI: 10.1111/vec.13230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 04/30/2021] [Accepted: 06/20/2021] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To identify the most common practices of Diplomates of the American College of Veterinary Emergency and Critical Care (DACVECCs) as they relate to the recognition and treatment of hypotension in dogs and cats, particularly concerning the use of vasopressors in vasodilatory shock states. DESIGN A survey regarding vasopressor use was sent to all active DACVECCs using the Veterinary Information Network. Questions focused on respondent characteristics, method of recognition of hypotension, triggers for initiation of vasopressor therapy, first- and second-line vasopressor choice, and methods of determining response to therapy. SUBJECTS A total of 734 DACVECCs were invited to participate, and 203 Diplomates (27.7%) completed the survey. RESULTS For both dogs and cats, the most common first-line vasopressor was norepinephrine (87.9% in dogs and 83.1% in cats). The most common second-choice vasopressor was vasopressin (44.2% in dogs and 39.0% in cats). Cutoff values for initiating vasopressor therapy varied between species and modality used for blood pressure measurement. In general, most DACVECCs chose to initiate vasopressor therapy at a Doppler blood pressure <90 mm Hg or a mean arterial pressure of <60 or <65 mm Hg when using oscillometric or direct arterial blood pressure measurements in dogs and cats. CONCLUSIONS Most DACVECCs adhere to published human guidelines when choosing a first-line vasopressor. However, there is significant variability in blood pressure measurement technique, cutoffs for initiation of vasopressor use, and choice of second-line vasopressors.
Collapse
Affiliation(s)
- Kellyann M Murphy
- Department of Clinical Studies and Advanced Medicine, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania, USA
| | - Mark Rishniw
- Veterinary Information Network, Davis, California, USA
| | - Deborah C Silverstein
- Department of Clinical Studies and Advanced Medicine, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania, USA
| |
Collapse
|
19
|
Prehospital Bundle of Care Based on Antibiotic Therapy and Hemodynamic Optimization Is Associated With a 30-Day Mortality Decrease in Patients With Septic Shock. Crit Care Med 2022; 50:1440-1448. [PMID: 35904262 DOI: 10.1097/ccm.0000000000005625] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This study aims to investigate the association between the 30-day mortality in patients with septic shock (SS) and a prehospital bundle of care completion, antibiotic therapy administration, and hemodynamic optimization defined as a fluid expansion of at least 10 mL.kg-1.hr-1. DESIGN To assess the association between prehospital BUndle of Care (BUC) completion and 30-day mortality, the inverse probability treatment weighting (IPTW) propensity method was performed. SETTING International guidelines recommend early treatment implementation in order to reduce SS mortality. More than one single treatment, a bundle of care, including antibiotic therapy and hemodynamic optimization, is more efficient. PATIENTS From May 2016 to March 2021, patients with SS requiring prehospital mobile ICU (mICU) intervention were retrospectively analyzed. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among the 529 patients with SS requiring action by the mICU enrolled in this study, 354 (67%) were analyzed. Presumed pulmonary, digestive, and urinary infections were the cause of the SS in 49%, 25%, and 13% of the cases, respectively. The overall 30-day mortality was 32%. Seventy-one patients (20%) received prehospital antibiotic therapy and fluid expansion. Log binomial regression weighted with IPTW resulted in a significant association between 30-day mortality and prehospital BUC completion (respiratory rate [RR] of 0.56 [0.33-0.89]; p = 0.02 and adjusted RR 0.52 [0.27-0.93]; p = 0.03). CONCLUSIONS A prehospital bundle of care, based on antibiotic therapy and hemodynamic optimization, is associated with a 30-day mortality decrease among patients suffering from SS cared for by an mICU.
Collapse
|
20
|
Raia L, Zafrani L. Endothelial Activation and Microcirculatory Disorders in Sepsis. Front Med (Lausanne) 2022; 9:907992. [PMID: 35721048 PMCID: PMC9204048 DOI: 10.3389/fmed.2022.907992] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/16/2022] [Indexed: 11/19/2022] Open
Abstract
The vascular endothelium is crucial for the maintenance of vascular homeostasis. Moreover, in sepsis, endothelial cells can acquire new properties and actively participate in the host's response. If endothelial activation is mostly necessary and efficient in eliminating a pathogen, an exaggerated and maladaptive reaction leads to severe microcirculatory damage. The microcirculatory disorders in sepsis are well known to be associated with poor outcome. Better recognition of microcirculatory alteration is therefore essential to identify patients with the worse outcomes and to guide therapeutic interventions. In this review, we will discuss the main features of endothelial activation and dysfunction in sepsis, its assessment at the bedside, and the main advances in microcirculatory resuscitation.
Collapse
Affiliation(s)
- Lisa Raia
- Medical Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Lara Zafrani
- Medical Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique des Hôpitaux de Paris, Paris, France
- INSERM UMR 976, University of Paris Cité, Paris, France
- *Correspondence: Lara Zafrani
| |
Collapse
|
21
|
Andaluz-Ojeda D, Cantón-Bulnes M, Pey Richter C, Garnacho-Montero J. Fármacos vasoactivos en el tratamiento del shock séptico. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
22
|
Jouffroy R, Hajjar A, Gilbert B, Tourtier JP, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye PN. Prehospital norepinephrine administration reduces 30-day mortality among septic shock patients. BMC Infect Dis 2022; 22:345. [PMID: 35387608 PMCID: PMC8988327 DOI: 10.1186/s12879-022-07337-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 02/21/2022] [Indexed: 11/23/2022] Open
Abstract
Background Despite differences in time of sepsis recognition, recent studies support that early initiation of norepinephrine in patients with septic shock (SS) improves outcome without an increase in adverse effects. This study aims to investigate the relationship between 30-day mortality in patients with SS and prehospital norepinephrine infusion in order to reach a mean blood pressure (MAP) > 65 mmHg at the end of the prehospital stage. Methods From April 06th, 2016 to December 31th, 2020, patients with SS requiring prehospital Mobile Intensive Care Unit intervention (MICU) were retrospectively analysed. To consider cofounders, the propensity score method was used to assess the relationship between prehospital norepinephrine administration in order to reach a MAP > 65 mmHg at the end of the prehospital stage and 30-day mortality.
Results Four hundred and seventy-eight patients were retrospectively analysed, among which 309 patients (65%) were male. The mean age was 69 ± 15 years. Pulmonary, digestive, and urinary infections were suspected among 44%, 24% and 17% patients, respectively. One third of patients (n = 143) received prehospital norepinephrine administration with a median dose of 1.0 [0.5–2.0] mg h−1, among which 84 (69%) were alive and 38 (31%) were deceased on day 30 after hospital-admission. 30-day overall mortality was 30%. Cox regression analysis after the propensity score showed a significant association between prehospital norepinephrine administration and 30-day mortality, with an adjusted hazard ratio of 0.42 [0.25–0.70], p < 10–3. Multivariate logistic regression of IPTW retrieved a significant decrease of 30-day mortality among the prehospital norepinephrine group: ORa = 0.75 [0.70–0.79], p < 10–3.
Conclusion In this study, we report that prehospital norepinephrine infusion in order to reach a MAP > 65 mmHg at the end of the prehospital stage is associated with a decrease in 30-day mortality in patients with SS cared for by a MICU in the prehospital setting. Further prospective studies are needed to confirm that very early norepinephrine infusion decreases septic shock mortality.
Collapse
Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique Hôpitaux Paris and Paris Saclay University, 9 avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France. .,Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique, Hôpitaux Paris, Paris, France. .,Centre de Recherche en Epidémiologie et Santé des Populations, U1018 INSERM, Paris Saclay University, Paris, France. .,Institut de Recherche bioMédicale et d'Epidémiologie du Sport, EA7329, INSEP, Paris University, Paris, France. .,EA 7525 Université des Antilles, Pointe-à-Pitre, France.
| | - Adèle Hajjar
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique Hôpitaux Paris and Paris Saclay University, 9 avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France
| | - Basile Gilbert
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | | | - Emmanuel Bloch-Laine
- Emergency Department, Cochin Hospital, Paris, France.,Emergency Department, SMUR, Hôtel Dieu Hospital, Assistance Publique, Hôpitaux Paris, Paris, France
| | - Patrick Ecollan
- Intensive Care Unit, SMUR, Pitie Salpêtriere Hospital, Assistance Publique, Hôpitaux Paris, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Josiane Boularan
- SAMU 31, Centre Hospitalier Intercommunal Castres-Mazamet, Castres, France
| | - Vincent Bounes
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | - Benoit Vivien
- Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique, Hôpitaux Paris, Paris, France
| | - Papa-Ngalgou Gueye
- EA 7525 Université des Antilles, Pointe-à-Pitre, France.,SAMU 972 University Hospital of Martinique, Fort-de-France, Martinique, France
| |
Collapse
|
23
|
Andaluz-Ojeda D, Cantón-Bulnes ML, Pey Richter C, Garnacho-Montero J. [Vasoactive drugs in the treatment of septic shock]. Med Intensiva 2022; 46 Suppl 1:26-37. [PMID: 38341258 DOI: 10.1016/j.medine.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/03/2022] [Indexed: 02/12/2024]
Abstract
Septic shock is a high mortality complication frequently associated with sepsis. Early initiation of vasopressor treatment, even before completion of initial fluid resuscitation, is a determining factor in prognosis. In this sense, norepinephrine continues to be the drug of first choice, although there is increasing evidence of benefit combining it with other non-adrenergic drugs, such as vasopressin, instead of escalating norepinephrine doses. The pathophysiology of septic shock is multifactorial, and sometimes is associated with a situation of myocardial dysfunction that contributes to hemodynamic instability. It is essential to identify this situation since it worsens the prognosis and may benefit from combined treatment with inotropic drugs. There are novel vasoactive agents under study, more selective than the classic ones that in a next future could help to design more individualized and precise treatments. In the present work, the current knowledge about vasoactive drugs and their use in the management of septic shock is summarized according to the most recent scientific evidence.
Collapse
Affiliation(s)
- D Andaluz-Ojeda
- Servicio de Medicina Intensiva, Hospital Universitario HM Sanchinarro. Hospitales Madrid, Madrid, España.
| | - M L Cantón-Bulnes
- Unidad Clínica de Cuidados Intensivos. Hospital Universitario Virgen Macarena, Sevilla, España
| | - C Pey Richter
- Servicio de Medicina Intensiva, Hospital Universitario HM Sanchinarro. Hospitales Madrid, Madrid, España
| | - J Garnacho-Montero
- Unidad Clínica de Cuidados Intensivos. Hospital Universitario Virgen Macarena, Sevilla, España
| |
Collapse
|
24
|
Nam K, Jeon Y. Microcirculation during surgery. Anesth Pain Med (Seoul) 2022; 17:24-34. [PMID: 35139609 PMCID: PMC8841265 DOI: 10.17085/apm.22127] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 01/13/2022] [Indexed: 11/17/2022] Open
Abstract
Throughout the long history of surgery, there has been great advancement in the hemodynamic management of surgical patients. Traditionally, hemodynamic management has focused on macrocirculatory monitoring and intervention to maintain appropriate oxygen delivery. However, even after optimization of macro-hemodynamic parameters, microcirculatory dysfunction, which is related to higher postoperative complications, occurs in some patients. Although the clinical significance of microcirculatory dysfunction has been well reported, little is known about interventions to recover microcirculation and prevent microcirculatory dysfunction. This may be at least partly caused by the fact that the feasibility of monitoring tools to evaluate microcirculation is still insufficient for use in routine clinical practice. However, considering recent advancements in these research fields, with more popular use of microcirculation monitoring and more clinical trials, clinicians may better understand and manage microcirculation in surgical patients in the future. In this review, we describe currently available methods for microcirculatory evaluation. The current knowledge on the clinical relevance of microcirculatory alterations has been summarized based on previous studies in various clinical settings. In the latter part, pharmacological and clinical interventions to improve or restore microcirculation are also presented.
Collapse
Affiliation(s)
| | - Yunseok Jeon
- Corresponding author: Yunseok Jeon, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: 82-2-2072-3108, Fax: 82-2-747-8363 E-mail:
| |
Collapse
|
25
|
Karanvir, Gupta S, Kumar V. Practices of Initiation of Vasoactive Drugs in Relation to Resuscitation Fluids in Children with Septic Shock: A Prospective Observational Study. Indian J Crit Care Med 2021; 25:928-933. [PMID: 34733036 PMCID: PMC8559758 DOI: 10.5005/jp-journals-10071-23954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: The role of vasoactive medications in septic shock is well-defined, but the appropriate time of initiation of these medications in reference to fluid boluses is not clear. We planned to study prospectively the practices and outcome of initiation of vasoactive infusions with respect to resuscitation fluids boluses in pediatric septic shock. Patients and methods: Children aged 1 month to 18 years diagnosed with septic shock were enrolled to receive fluid resuscitation boluses along with vasoactive drugs. The primary outcome was to look at various practices of the initiation of vasoactive infusions; accordingly, patients were categorized into three groups: N1 received vasoactive infusions after completion of the first bolus (20 mL/kg), N2 after the second (40 mL/kg), and N3 after the third fluid (60 mL/kg) bolus. Secondary outcomes were to compare the time taken, amount of fluid required to achieve hemodynamic stability, total fluid required, and complications in the first 24 hours of treatment and mortality. Results: Hundred children were enrolled and grouped into N1, N2, and N3 with 46, 10, and 44 patients, respectively. The volume of fluid required to achieve the resolution of shock in N1 (40 ± 10 mL/kg) was significantly less than in N2 (70 ± 10 mL/kg) and N3 (70 ± 20 mL/kg); p = 0.02. The time taken to achieve hemodynamic stability was significantly less in N1 (115 ± 45 minutes) than in N2 (196 ± 32 minutes) and N3 (212 ± 44 minutes); p = 0.02. The volume of intravenous fluid required in the first 24 hours (p = 0.02) and complications were lower in the N1 group (p = 0.04). No statistical difference in mortality was seen. Conclusion: Early initiation of vasoactive infusions (after the first bolus) resulted in less total fluid volume, lesser time to achieve hemodynamic stability, less fluid boluses, less length of stay in the pediatric intensive care unit, and lesser complications in the first 24 hours. Highlight: Early initiation of vasoactive infusions—after completion of the first fluid bolus resulted in less need for further fluid boluses, lesser time for shock resolution, lesser fluid overload, and less PICU stay—in pediatric septic shock. How to cite this article: Karanvir, Gupta S, Kumar V. Practices of Initiation of Vasoactive Drugs in Relation to Resuscitation Fluids in Children with Septic Shock: A Prospective Observational Study. Indian J Crit Care Med 2021;25(8):928–933.
Collapse
Affiliation(s)
- Karanvir
- Department of Pediatrics, ESIC Hospital and Medical College, Faridabad, Haryana, India
| | - Shalu Gupta
- Division of Pediatric Critical Care, Department of Pediatrics, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, Delhi, India
| | - Virendra Kumar
- Division of Pediatric Critical Care, Department of Pediatrics, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, Delhi, India
| |
Collapse
|
26
|
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063-e1143. [PMID: 34605781 DOI: 10.1097/ccm.0000000000005337] [Citation(s) in RCA: 891] [Impact Index Per Article: 297.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
27
|
Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Møller MH, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47:1181-1247. [PMID: 34599691 PMCID: PMC8486643 DOI: 10.1007/s00134-021-06506-y] [Citation(s) in RCA: 1449] [Impact Index Per Article: 483.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, Hospital of São Paulo, São Paulo, Brazil
| | | | | | - Hallie C Prescott
- University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Steven Simpson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - W Joost Wiersinga
- ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, Emirates University, Al Ain, United Arab Emirates
| | - Derek C Angus
- University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Pittsburgh, PA, USA
| | - Yaseen Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Luciano Azevedo
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | - Lisa Burry
- Mount Sinai Hospital & University of Toronto (Leslie Dan Faculty of Pharmacy), Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy.,Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Angel Coz Yataco
- Lexington Veterans Affairs Medical Center/University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - Kent Doi
- The University of Tokyo, Tokyo, Japan
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martin de La Plata, Buenos Aires, Argentina
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | | | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Younsuck Koh
- ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Anand Kumar
- University of Manitoba, Winnipeg, MB, Canada
| | - Arthur Kwizera
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Suzana Lobo
- Intensive Care Division, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Henry Masur
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | | | | | - Yatin Mehta
- Medanta the Medicity, Gurugram, Haryana, India
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Nunnally
- New York University School of Medicine, New York, NY, USA
| | - Simon Oczkowski
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tiffany Osborn
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Michael Puskarich
- University of Minnesota/Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jason Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | | | | | | | - Charles L Sprung
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Tobias Welte
- Medizinische Hochschule Hannover and German Center of Lung Research (DZL), Hannover, Germany
| | - Janice Zimmerman
- World Federation of Intensive and Critical Care, Brussels, Belgium
| | - Mitchell Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island & Rhode Island Hospital, Providence, RI, USA
| |
Collapse
|
28
|
Heterogeneous impact of hypotension on organ perfusion and outcomes: a narrative review. Br J Anaesth 2021; 127:845-861. [PMID: 34392972 DOI: 10.1016/j.bja.2021.06.048] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/08/2021] [Accepted: 06/25/2021] [Indexed: 12/20/2022] Open
Abstract
Arterial blood pressure is the driving force for organ perfusion. Although hypotension is common in acute care, there is a lack of accepted criteria for its definition. Most practitioners regard hypotension as undesirable even in situations that pose no immediate threat to life, but hypotension does not always lead to unfavourable outcomes based on experience and evidence. Thus efforts are needed to better understand the causes, consequences, and treatments of hypotension. This narrative review focuses on the heterogeneous underlying pathophysiological bases of hypotension and their impact on organ perfusion and patient outcomes. We propose the iso-pressure curve with hypotension and hypertension zones as a way to visualize changes in blood pressure. We also propose a haemodynamic pyramid and a pressure-output-resistance triangle to facilitate understanding of why hypotension can have different pathophysiological mechanisms and end-organ effects. We emphasise that hypotension does not always lead to organ hypoperfusion; to the contrary, hypotension may preserve or even increase organ perfusion depending on the relative changes in perfusion pressure and regional vascular resistance and the status of blood pressure autoregulation. Evidence from RCTs does not support the notion that a higher arterial blood pressure target always leads to improved outcomes. Management of blood pressure is not about maintaining a prespecified value, but rather involves ensuring organ perfusion without undue stress on the cardiovascular system.
Collapse
|
29
|
Abstract
Liver transplantation (LT) has revolutionized outcomes for cirrhotic patients. Current liver allocation policies dictate patients with highest short-term mortality receive the highest priority, thus, several patients become increasingly ill on the waitlist. Given cirrhosis is a progressive disease, it can be complicated by the occurrence of acute-on-chronic liver failure (ACLF), a syndrome defined by an acute deterioration of liver function associated with extrahepatic organ failures requiring intensive care support and a high short-term mortality. Successfully bridging to transplant includes accurate prognostication and prioritization of ACLF patients awaiting LT, optimizing intensive care support pre-LT, and tailoring immunosuppressive and anti-infective therapies post-LT. Furthermore, predicting futility (too sick to undergo LT) in ACLF is challenging. In this review, we summarize the role of LT in ACLF specifically highlighting (a) current prognostic scores in ACLF, (b) critical care management of the ACLF patient awaiting LT, (c) donor issues to consider in transplant in ACLF, and (d) exploring of recent post-LT outcomes in ACLF and potential opportunities to improve outcomes including current care gaps and unmet research needs.
Collapse
|
30
|
Magnin M, Amson H, Vacheron CH, Thiollière F, Piriou V, Junot S, Bonnet Garin JM, Allaouchiche B. Associations between peripheral perfusion disorders, mean arterial pressure and dose of norepinephrine administrated in the early phase of septic shock. Clin Exp Pharmacol Physiol 2021; 48:1327-1335. [PMID: 34133795 DOI: 10.1111/1440-1681.13540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 09/11/2020] [Accepted: 06/14/2021] [Indexed: 11/27/2022]
Abstract
The aim of the study was to explore the correlations between peripheral perfusion, mean arterial pressure and the dose-rate of norepinephrine (NE) infused for the treatment of septic shock. The study is retrospective analysis of data acquired prospectively on 57 patients during the first 24 hours after the occurrence of the shock. Clinical and haemodynamic characteristics, skin perfusion parameters (capillary refill time [CRT], mottling score and temperature gradients) and the dose rate of NE infusion were collected. Negative correlations between mean arterial pressure (MAP) and temperature gradients (core-to-toe: P = .03, core-to-index: P = .04) were found and abnormal CRT was associated with lower MAP (P = .02). The dose rate of NE was negatively correlated with temperature gradients (core-to-toe: P = .02, core-to-index: P = .01, forearm-to-index: P = .008) in the overall population. In patients receiving NE for at least 12 hours, the NE dose rate positively was correlated with the mottling score (P = .006), temperature gradients (core-to-toe: P = .04, forearm-to-index: P = .02, core-to-index: P = .005) and CRT (P = .001). The dose of NE administrated was associated with 14-days mortality (odds ration [OR] = 1.21 [1.06-1.38], P = .006) and with 28-days mortality (OR = 1.17 [1.01-1.36], P = 0.04). In conclusion, the study described the presence of correlations between peripheral perfusion and MAP and between peripheral perfusion and the dose rate of NE infusion.
Collapse
Affiliation(s)
- Mathieu Magnin
- University of Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis (Pulmonary and circulatory disorders in sepsis), VetAgro Sup, Marcy l'Etoile, France.,Physiology, University of Lyon, VetAgro Sup, Marcy l'Etoile, France
| | - Harry Amson
- Intensive care unit, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, University of Lyon, Pierre-Bénite, France.,PHE3ID, Centre International de Recherche en Infectiologie, Institut National de la Santé et de la Recherche Médicale U1111, CNRS UMR 5308, Université Claude Bernard Lyon 1, Lyon, France.,Service de Biostatistique - Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France
| | - Charles-Hervé Vacheron
- Intensive care unit, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, University of Lyon, Pierre-Bénite, France.,PHE3ID, Centre International de Recherche en Infectiologie, Institut National de la Santé et de la Recherche Médicale U1111, CNRS UMR 5308, Université Claude Bernard Lyon 1, Lyon, France.,Service de Biostatistique - Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France
| | - Fabrice Thiollière
- Intensive care unit, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, University of Lyon, Pierre-Bénite, France
| | - Vincent Piriou
- Intensive care unit, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, University of Lyon, Pierre-Bénite, France
| | - Stéphane Junot
- University of Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis (Pulmonary and circulatory disorders in sepsis), VetAgro Sup, Marcy l'Etoile, France.,Anesthesiology, University of Lyon, VetAgro Sup, Marcy l'Etoile, France
| | - Jeanne-Marie Bonnet Garin
- University of Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis (Pulmonary and circulatory disorders in sepsis), VetAgro Sup, Marcy l'Etoile, France.,Physiology, University of Lyon, VetAgro Sup, Marcy l'Etoile, France
| | - Bernard Allaouchiche
- University of Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis (Pulmonary and circulatory disorders in sepsis), VetAgro Sup, Marcy l'Etoile, France.,Intensive care unit, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, University of Lyon, Pierre-Bénite, France
| |
Collapse
|
31
|
Associations Between Mean Arterial Pressure and Poor ICU Outcomes in Critically Ill Patients With Cirrhosis: Is 65 The Sweet Spot? Crit Care Med 2021; 48:e753-e760. [PMID: 32618694 DOI: 10.1097/ccm.0000000000004442] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Mean arterial pressure is critically important in patients with cirrhosis in the ICU, however, there is limited data to guide therapies and targets. DESIGN Retrospective observational study. SETTING Tertiary care ICU. PATIENTS Two hundred and seventy-three critically ill patients with cirrhosis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We performed a comprehensive time-weighted mean arterial pressure analysis (time-weighted-average-mean arterial pressure and cumulative-time-below various mean arterial pressure-thresholds) during the first 24-hours after ICU admission (median: 25 mean arterial pressure measurements per-patient). Time-weighted-average-mean arterial pressure captures both the severity and duration of hypotension below a mean arterial pressure threshold and cumulative-time-below is the total time spent below a mean arterial pressure threshold. Individual univariable and multivariable logistic regression models were assessed for each time-weighted-average-mean arterial pressure and cumulative-time-below mean arterial pressure threshold (55, 60, 65, 70, and 75 mm Hg) for ICU-mortality. Time-weighted-average-mean arterial pressure: for 1 mm Hg decrease in mean arterial pressure below 75, 70, 65, 60, and 55 mm Hg, the odds for ICU-mortality were 14%, 18%, 26%, 41%, and 74%, respectively (p < 0.01, all thresholds). The association between time-weighted-average-mean arterial pressure and ICU-mortality for each threshold remained significant after adjusting for model for end-stage liver disease-sodium score, mechanical ventilation, vasopressor use, renal replacement therapy, grade 3/4 hepatic encephalopathy, WBC count, and albumin. Cumulative-time-below: odds for ICU-mortality were 4%, 6%, 10%, 12%, and 12% for each-hour spent below 75, 70, 65, 60, and 55 mm Hg, respectively. In the adjusted models, significant associations only remained for mean arterial pressure less than 65 mm Hg (odds ratio, 1.07; 95% CI, 1.00-1.14; p = 0.05) and < 60 mm Hg (odds ratio, 1.10; 95% CI, 1.01-1.18; p = 0.04). CONCLUSIONS These data suggest that maintaining a mean arterial pressure of greater than 65 mm Hg may be a reasonable target in patients with cirrhosis admitted to the ICU. However, further prospective randomized trials are needed to determine the optimal mean arterial pressure-targets in this patient population.
Collapse
|
32
|
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.
Collapse
|
33
|
Tang B, Su L, Li D, Wang Y, Liu Q, Shan G, Long Y, Liu D, Zhou X. Stepwise lactate kinetics in critically ill patients: prognostic, influencing factors, and clinical phenotype. BMC Anesthesiol 2021; 21:86. [PMID: 33740886 PMCID: PMC7977296 DOI: 10.1186/s12871-021-01293-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 03/01/2021] [Indexed: 11/25/2022] Open
Abstract
Background To investigate the optimal target e of lactate kinetics at different time during the resuscitation, the factors that influence whether the kinetics achieve the goals, and the clinical implications of different clinical phenotypes. Methods Patients with hyperlactatemia between May 1, 2013 and December 31, 2018 were retrospectively analyzed. Demographic data, basic organ function, hemodynamic parameters at ICU admission (T0) and at 6 h, 12 h, 24 h, 48 h, and 72 h, arterial blood lactate and blood glucose levels, cumulative clinical treatment conditions at different time points and final patient outcomes were collected. Results A total of 3298 patients were enrolled, and the mortality rate was 12.2%. The cutoff values of lactate kinetics for prognosis at 6 h, 12 h, 24 h, 48 h, and 72 h were 21%, 40%, 57%, 66%, and 72%. The APACHE II score, SOFA score, heart rate (HR), and blood glucose were risk factors that correlated with whether the lactate kinetics attained the target goal. Based on the pattens of the lactate kinetics, eight clinical phenotypes were proposed. The odds ratios of death for clinical phenotypes VIII, IV, and II were 4.39, 4.2, and 5.27-fold of those of clinical phenotype I, respectively. Conclusion Stepwise recovery of lactate kinetics is an important resuscitation target for patients with hyperlactatemia. The APACHE II score, SOFA score, HR, and blood glucose were independent risk factors that influenced achievement of lactate kinetic targets. The cinical phenotypes of stepwise lactate kinetics are closely related to the prognosis. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01293-x.
Collapse
Affiliation(s)
- Bo Tang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.,China & State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Longxiang Su
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.,China & State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Dongkai Li
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.,China & State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Ye Wang
- Department of Epidemiology and Statistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, 100730, China
| | - Qianqian Liu
- Chinese Center for Disease Control and prevention, Beijing, 100050, China
| | - Guangliang Shan
- Department of Epidemiology and Statistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, 100730, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.,China & State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.,China & State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Xiang Zhou
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China. .,China & State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.
| |
Collapse
|
34
|
[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
35
|
Prehospital hemodynamic optimisation is associated with a 30-day mortality decrease in patients with septic shock. Am J Emerg Med 2021; 45:105-111. [PMID: 33684866 DOI: 10.1016/j.ajem.2021.02.060] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 02/01/2021] [Accepted: 02/24/2021] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Septic shock (SS) is characterized by low blood pressure resulting in organ failure and poor prognosis. Among SS treatments, in hospital studies reported a beneficial effect of early hemodynamic resuscitation on mortality rate. This study aims to investigate the relationship between prehospital hemodynamic optimisation and 30-day mortality in patients with SS. METHODS From April 6th, 2016 to December 31th, 2019, patients with SS requiring prehospital Mobile Intensive Care Unit intervention (mICU) were included. Prehospital hemodynamic optimisation was defined as a arterial blood pressure of >65 mmHg, or >75 mmHg if previous hypertension history, at the end of the prehospital stage. RESULTS Three hundred thirty-seven patients were retrospectively analysed. The mean age was 69 ± 15 years, and 226 patients (67%) were male. One hundred and thirty-six patients (40%) had previous hypertension history. Pulmonary, digestive and urinary infections were the suspected cause of the SS in respectively 46%, 23% and 15% of the cases. 30-day overall mortality was 30%. Prehospital hemodynamic optimisation was complete for 204 patients (61%). Cox regression analysis reports a significant association between prehospital hemodynamic optimisation and 30-day mortality (HRa = 0.52 95%CI [0.31-0.86], p = 0.01). CONCLUSION In this study, we report that prehospital hemodynamic optimisation is associated with a decrease in 30-day mortality in patients with SS cared for by a mICU in the prehospital setting. An individualized mean arterial pressure target, based on previous hypertension history, may be considered from the prehospital stage of SS resuscitation.
Collapse
|
36
|
Abstract
PURPOSE OF REVIEW This review discusses the macrocirculatory and microcirculatory aspects of renal perfusion, as well as novel methods by which to measure renal blood flow. Finally, therapeutic options are briefly discussed, including renal-specific microcirculatory effects. RECENT FINDINGS The optimal mean arterial pressure (MAP) needed for preservation of renal function has been debated but is most likely a MAP of 60-80 mmHg. In addition, attention should be paid to renal outflow pressure, typically central venous pressure. Heterogeneity in microcirculation can exist and may be mitigated through appropriate use of vasopressors with unique microcirculatory effects. Excessive catecholamines have been shown to be harmful and should be avoided. Both angiotensin II and vasopressin may improve glomerular flow through a number of mechanisms. Macrocirculatory and microcirculatory blood flow can be measured through a number of bedside ultrasound modalities, sublingual microscopy and urinary oxygen measurement, SUMMARY: Acute kidney injury (AKI) is a common manifestation of organ failure in shock, and avoidance of hemodynamic instability can mitigate this risk. Measurement of renal haemodynamics is not routinely performed but may help to guide therapeutic goals. A thorough understanding of pathophysiology, measurement techniques and therapeutic options may allow for a personalized approach to blood pressure management in patients with septic shock and may ultimately mitigate AKI.
Collapse
|
37
|
Mok G, Hendin A, Reardon P, Hickey M, Gray S, Yadav K. Macrocirculatory and Microcirculatory Endpoints in Sepsis Resuscitation. J Intensive Care Med 2020; 36:1385-1391. [PMID: 33375916 DOI: 10.1177/0885066620982585] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Sepsis is a common disease process encountered by physicians. Sepsis can lead to septic shock, which carries a hospital mortality rate in excess of 40%. Although the Surviving Sepsis Guidelines recommend targeting a mean arterial pressure (MAP) of 65 mmHg and normalization of lactate, these endpoints do not necessarily result in tissue perfusion in states of shock. While MAP and lactate are commonly used markers in resuscitation, clinicians may be able to improve their resuscitation by broadening their assessment of the microcirculation, which more adequately reflects tissue perfusion. As such, in order to achieve a successful resuscitation, clinicians must optimize both macrocirculatory (MAP, cardiac output) and microcirculatory (proportion of perfused vessels, lactate, mottling, capillary refill time) endpoints. This review will summarize various macrocirculatory and microcirculatory markers of perfusion that can be used to guide the initial resuscitation of patients with sepsis.
Collapse
Affiliation(s)
- Garrick Mok
- Department of Emergency Medicine, The Ottawa Hospital, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Ariel Hendin
- Department of Emergency Medicine, The Ottawa Hospital, 6363University of Ottawa, Ottawa, Ontario, Canada.,Department of Critical Care Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Reardon
- Department of Emergency Medicine, The Ottawa Hospital, 6363University of Ottawa, Ottawa, Ontario, Canada.,Department of Critical Care Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Hickey
- Department of Medicine, Division of Critical Care, St. Joseph's Health Centre, University of Toronto, Toronto, Canada
| | - Sara Gray
- Division of Emergency Medicine and the Interdepartmental Division of Critical Care, 7938University of Toronto, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, The Ottawa Hospital, 6363University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
38
|
Abstract
Asia is the largest and most populous continent and has huge differences in socioeconomic status, development, and health care between the different countries and regions within each country. This manifests in the varied causes of acute kidney injury (AKI), particularly higher rates of community-acquired AKI and in the differential access to health care for the population. Because of resource limitations, prevention and treatment of AKI is a difficult challenge. This review highlights the differences in AKI in Asia compared with the developed world and discusses prevention and treatment of AKI within the context of resource limitations.
Collapse
|
39
|
Lonsdale DO, Shah RV, Lipman J. Infection, Sepsis and the Inflammatory Response: Mechanisms and Therapy. Front Med (Lausanne) 2020; 7:588863. [PMID: 33344475 PMCID: PMC7738462 DOI: 10.3389/fmed.2020.588863] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/02/2020] [Indexed: 12/29/2022] Open
Abstract
Sepsis secondary to bacterial infection remains a significant cause of morbidity and mortality globally. Recent decades have seen the evolution of international collaborations to improve care for these patients and identify areas for research. In this article we discuss the pathophysiology underlying the condition, review the current recommended management strategies, discuss areas of controversy, and highlight the need for ongoing research, particularly in diagnostics.
Collapse
Affiliation(s)
- Dagan O Lonsdale
- Department of Clinical Pharmacology, St George's University of London, London, United Kingdom.,Department of Critical Care, St George's University Hospitals National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Reya V Shah
- Department of Clinical Pharmacology, St George's University of London, London, United Kingdom.,Department of Critical Care, St George's University Hospitals National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Jeffrey Lipman
- Department of Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, NÎmes University Hospital, University of Montpellier, NÎmes, France
| |
Collapse
|
40
|
Abstract
PURPOSE OF REVIEW Currently, the treatment of patients with shock is focused on the clinical symptoms of shock. In the early phase, this is usually limited to heart rate, blood pressure, lactate levels and urine output. However, as the ultimate goal of resuscitation is the improvement in microcirculatory perfusion the question is whether these currently used signs of shock and the improvement in these signs actually correspond to the changes in the microcirculation. RECENT FINDINGS Recent studies have shown that during the development of shock the deterioration in the macrocirculatory parameters are followed by the deterioration of microcirculatory perfusion. However, in many cases the restoration of adequate macrocirculatory parameters is frequently not associated with improvement in microcirculatory perfusion. This relates not only to the cause of shock, where there are some differences between different forms of shock, but also to the type of treatment. SUMMARY The improvement in macrohemodynamics during the resuscitation is not consistently followed by subsequent changes in the microcirculation. This may result in both over-resuscitation and under-resuscitation leading to increased morbidity and mortality. In this article the principles of coherence and the monitoring of the microcirculation are reviewed.
Collapse
|
41
|
Beier L, Davis J, Esener D, Grant C, Fields JM. Carotid Ultrasound to Predict Fluid Responsiveness: A Systematic Review. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:1965-1976. [PMID: 32314817 DOI: 10.1002/jum.15301] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 03/09/2020] [Accepted: 03/17/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To perform a systematic review of the accuracy of carotid ultrasound measures in determining volume responsiveness in adults. METHODS We conducted a systematic review of Ovid MEDLINE and Scopus from conception until January 1, 2019. Two independent reviewers used an iterative process to identify relevant articles and abstract information from them. The quality and risk of bias were assessed with the Quality Assessment of Diagnostic Accuracy Studies version 2 tool. RESULTS We identified 17 relevant articles with 956 patients. The 2 most frequently cited carotid measures of fluid responsiveness were corrected flow time and peak velocity or change in peak velocity with respiration (ΔCDPV). Accordingly, the diagnostic characteristics of corrected flow time in these studies varied widely, with sensitivities from 60% to 73%, specificities from 82% to 92%, and areas under the receiver operating characteristic curves from 0.75 to 0.88. Optimal cutoff values for ΔCDPV ranged from 9.1% to 14%, with areas under the receiver operating characteristic curves from 0.81 to 0.91, sensitivities from 73% to 86%, and specificities from 78% to 86%. Other measures, such as carotid blood flow and carotid diameter, had limited data to support their use. Heterogeneity of the studies prohibited a meta-analysis. Most studies had a moderate risk of bias and high applicability. CONCLUSIONS Preliminary research suggests that carotid ultrasound measures may be useful adjunct measures of fluid status; however, they should not be interpreted as absolute and should be placed in a clinical context. The most well-defined and supported measure currently is ΔCDPV, with cutoffs from 9% to 14%. Corrected flow time shows promise, because of heterogeneity of how this value is measured, an optimal cutoff has not been established.
Collapse
Affiliation(s)
- Lance Beier
- Department of Emergency Medicine, Kaiser Permanente San Diego, San Diego, California, USA
| | - Joshua Davis
- Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Dasia Esener
- Department of Emergency Medicine, Kaiser Permanente San Diego, San Diego, California, USA
| | - Charles Grant
- Department of Emergency Medicine, Kaiser Permanente San Diego, San Diego, California, USA
| | - J Matthew Fields
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| |
Collapse
|
42
|
Meriño M, Martín SS, Sandaña P, Herlitz K, Aguayo C, Godoy A, Torres-Vergara P, Gonzalez M, Troncoso F, Acurio J, Escudero C. Deletion of the adenosine A 2A receptor increases the survival rate in a mice model of polymicrobial sepsis. Purinergic Signal 2020; 16:427-437. [PMID: 32808144 DOI: 10.1007/s11302-020-09719-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/28/2020] [Indexed: 02/07/2023] Open
Abstract
We aim to investigate the role of A2A receptor in peritonitis-related sepsis by injection of a fecal solution (FS) as a model of polymicrobial infection. C57/black J6 wild-type (WT) and A2A-deficient mice (A2AKO) were exposed to sepsis induced by intraperitoneal injection of a FS (FS-induced peritonitis) or instead was injected with saline buffer (Sham). Survival rate and sepsis score were measured up to 48 h. The presence of bacteria in tissue homogenates was analyzed. Telemetry and speckle laser Doppler were used for systemic blood pressure and peripheral blood perfusion analysis, respectively. Histological analysis and identification of active caspase 3 were performed in selected organs, including the liver. The survival rate of A2AKO mice exposed to FS-induced peritonitis was significantly higher, and the sepsis score was lower than their respective WT counterpart. Injection of FS increases (50 to 150 folds) the number of colonies forming units in the liver, kidney, blood, and lung in WT mice, while these effects were significantly attenuated in A2AKO mice exposed to FS-induced peritonitis. A significant reduction in both systolic and diastolic blood pressure, as well as in the peripheral perfusion was observed in WT and A2AKO mice exposed to FS-induced peritonitis. Although, these last effects were significantly attenuated in A2AKO mice. Histological analysis showed a large perivascular infiltration of polymorphonuclear in the liver of WT and A2AKO mice exposed to FS-induced peritonitis, but again, this effect was attenuated in A2AKO mice. Finally, high expression of active caspase 3 was found only in the liver of WT mice exposed to FS-induced peritonitis. The absence of the A2A receptor increases the survival rate in mice exposed to polymicrobial sepsis. This outcome was associated with both hemodynamic compensation and enhanced anti-bacterial response.
Collapse
Affiliation(s)
- Miguel Meriño
- Vascular Physiology Laboratory, Group of Investigation in Tumor Angiogenesis (GIANT), Department of Basic Sciences, Faculty of Sciences, University of Bío-Bío, 3780000, Chillán, Chile
- Facultad de Ciencias de la Salud, Universidad Adventista de Chile, Chillan, Chile
| | - Sebastián San Martín
- Biomedical Research Centre, School of Medicine, Universidad de Valparaíso, Valparaíso, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health), Chillán, Chile
| | - Pedro Sandaña
- Anatomo-pathology Service, Clinical Hospital Herminda Martín, Chillán, Chile
- Universidad Católica de la Santísima Concepción, Concepción, Chile
| | - Kurt Herlitz
- Vascular Physiology Laboratory, Group of Investigation in Tumor Angiogenesis (GIANT), Department of Basic Sciences, Faculty of Sciences, University of Bío-Bío, 3780000, Chillán, Chile
| | - Claudio Aguayo
- Group of Research and Innovation in Vascular Health (GRIVAS Health), Chillán, Chile
- Department of Clinical Biochemistry and Immunology, Faculty of Pharmacy, University of Concepción, Concepción, Chile
| | - Alejandro Godoy
- Group of Research and Innovation in Vascular Health (GRIVAS Health), Chillán, Chile
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14263, USA
- Centro de Biología Celular y Biomedicina (CEBICEM), Universidad San Sebastián, Santiago, Chile
| | - Pablo Torres-Vergara
- Group of Research and Innovation in Vascular Health (GRIVAS Health), Chillán, Chile
- Departamento de Farmacia, Facultad de Farmacia, Universidad de Concepción, Concepción, Chile
| | - Marcelo Gonzalez
- Group of Research and Innovation in Vascular Health (GRIVAS Health), Chillán, Chile
- Laboratorio de Investigación Materno-Fetal (LIMaf), Department of Obstetrics and Gynecology, Faculty of Medicine, University of Concepción, Concepción, Chile
| | - Felipe Troncoso
- Vascular Physiology Laboratory, Group of Investigation in Tumor Angiogenesis (GIANT), Department of Basic Sciences, Faculty of Sciences, University of Bío-Bío, 3780000, Chillán, Chile
| | - Jesenia Acurio
- Vascular Physiology Laboratory, Group of Investigation in Tumor Angiogenesis (GIANT), Department of Basic Sciences, Faculty of Sciences, University of Bío-Bío, 3780000, Chillán, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health), Chillán, Chile
| | - Carlos Escudero
- Vascular Physiology Laboratory, Group of Investigation in Tumor Angiogenesis (GIANT), Department of Basic Sciences, Faculty of Sciences, University of Bío-Bío, 3780000, Chillán, Chile.
- Group of Research and Innovation in Vascular Health (GRIVAS Health), Chillán, Chile.
| |
Collapse
|
43
|
Li Y, Li H, Zhang D. Timing of norepinephrine initiation in patients with septic shock: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:488. [PMID: 32762765 PMCID: PMC7409707 DOI: 10.1186/s13054-020-03204-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 07/26/2020] [Indexed: 12/13/2022]
Abstract
Background The effect of the timing of norepinephrine initiation on clinical outcomes in patients with septic shock is uncertain. A systematic review and meta-analysis was performed to evaluate the impact of early and late start of norepinephrine support on clinical outcomes in patients with septic shock. Methods We searched the PubMed, Cochrane, and Embase databases for randomized controlled trials (RCTs) and cohort studies from inception to the 1st of March 2020. We included studies involving adult patients (> 18 years) with septic shock. All authors reported our primary outcome of short-term mortality and clearly comparing early versus late norepinephrine initiation with clinically relevant secondary outcomes (ICU length of stay, time to achieved target mean arterial pressure (≥ 65 mmHg), and volume of intravenous fluids within 6 h). Results were expressed as odds ratio (OR) and mean difference (MD) with accompanying 95% confidence interval (CI). Results Five studies including 929 patients were included. The primary outcome of this meta-analysis showed that the short-term mortality of the early group was lower than that of the late group (odds ratio [OR] = 0.45; 95% CI, 0.34 to 0.61; P < 0.00001; χ2 = 3.74; I2 = 0%). Secondary outcomes demonstrated that the time to achieved target MAP of the early group was shorter than that of the late group (mean difference = − 1.39; 95% CI, − 1.81 to − 0.96; P < 0.00001; χ2 = 1.03; I2 = 0%). The volume of intravenous fluids within 6 h of the early group was less than that of the late group (mean difference = − 0.50; 95% CI, − 0.68 to − 0.32; P < 0.00001; χ2 = 33.76; I2 = 94%). There was no statistically significant difference in the ICU length of stay between the two groups (mean difference = − 0.11; 95% CI, − 1.27 to 1.05; P = 0.86; χ2 = 0.85; I2 = 0%). Conclusions Early initiation of norepinephrine in patients with septic shock was associated with decreased short-term mortality, shorter time to achieved target MAP, and less volume of intravenous fluids within 6 h. There was no significant difference in ICU length of stay between early and late groups. Further large-scale RCTs are still required to confirm these results.
Collapse
Affiliation(s)
- Yuting Li
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, 130021, Jilin, China
| | - Hongxiang Li
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, 130021, Jilin, China
| | - Dong Zhang
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, 130021, Jilin, China.
| |
Collapse
|
44
|
Li Y, Li H, Zhang D. Timing of norepinephrine initiation in patients with septic shock: a systematic review and meta-analysis. CRITICAL CARE (LONDON, ENGLAND) 2020. [PMID: 32762765 DOI: 10.1186/s13054-020-03204-x.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The effect of the timing of norepinephrine initiation on clinical outcomes in patients with septic shock is uncertain. A systematic review and meta-analysis was performed to evaluate the impact of early and late start of norepinephrine support on clinical outcomes in patients with septic shock. METHODS We searched the PubMed, Cochrane, and Embase databases for randomized controlled trials (RCTs) and cohort studies from inception to the 1st of March 2020. We included studies involving adult patients (> 18 years) with septic shock. All authors reported our primary outcome of short-term mortality and clearly comparing early versus late norepinephrine initiation with clinically relevant secondary outcomes (ICU length of stay, time to achieved target mean arterial pressure (≥ 65 mmHg), and volume of intravenous fluids within 6 h). Results were expressed as odds ratio (OR) and mean difference (MD) with accompanying 95% confidence interval (CI). RESULTS Five studies including 929 patients were included. The primary outcome of this meta-analysis showed that the short-term mortality of the early group was lower than that of the late group (odds ratio [OR] = 0.45; 95% CI, 0.34 to 0.61; P < 0.00001; χ2 = 3.74; I2 = 0%). Secondary outcomes demonstrated that the time to achieved target MAP of the early group was shorter than that of the late group (mean difference = - 1.39; 95% CI, - 1.81 to - 0.96; P < 0.00001; χ2 = 1.03; I2 = 0%). The volume of intravenous fluids within 6 h of the early group was less than that of the late group (mean difference = - 0.50; 95% CI, - 0.68 to - 0.32; P < 0.00001; χ2 = 33.76; I2 = 94%). There was no statistically significant difference in the ICU length of stay between the two groups (mean difference = - 0.11; 95% CI, - 1.27 to 1.05; P = 0.86; χ2 = 0.85; I2 = 0%). CONCLUSIONS Early initiation of norepinephrine in patients with septic shock was associated with decreased short-term mortality, shorter time to achieved target MAP, and less volume of intravenous fluids within 6 h. There was no significant difference in ICU length of stay between early and late groups. Further large-scale RCTs are still required to confirm these results.
Collapse
Affiliation(s)
- Yuting Li
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, 130021, Jilin, China
| | - Hongxiang Li
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, 130021, Jilin, China
| | - Dong Zhang
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, 130021, Jilin, China.
| |
Collapse
|
45
|
Manipulating the Microcirculation in Sepsis - the Impact of Vasoactive Medications on Microcirculatory Blood Flow: A Systematic Review. Shock 2020; 52:5-12. [PMID: 30102639 DOI: 10.1097/shk.0000000000001239] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Sepsis is life-threatening organ dysfunction because of a dysregulated host response to infection. Disturbed microvascular blood flow is associated with excess mortality and is a potential future target for interventions. This review addresses the evidence for pharmacological manipulation of the microcirculation in sepsis assessed by techniques that evaluate the sublingual microvasculature. METHODS Systematic review using a published protocol. Eligibility criteria were studies of septic patients published from January 2000 to February 2018. Interventions were drugs aimed at improving perfusion. Outcome was improvement in microvascular flow using orthogonal polarization spectral, sidestream dark field, or incident dark field imaging (Grades of Recommendation, Assessment, Development, and Evaluation criteria used). RESULTS Two thousand six hundred and six articles were screened and 22 included. (6 randomized controlled trials, 12 interventional, 3 observational, and 1 pilot, n = 572 participants). Multiple measurement techniques were described, including: automated analyses, subjective, and composite scoring systems. Norepinephrine was not found to improve microvascular flow (low-grade evidence, n = 6 studies); except in chronic hypertension (low, n = 1 study). Addition of arginine vasopressin or terlipressin to norepinephrine maintained flow while decreasing norepinephrine requirements (high, n = 2 studies). Neither dobutamine nor glyceryl trinitrate consistently improved flow (low, n = 6 studies). A single study (n = 40 participants) demonstrated improved flow with levosimendan (high). In a risk of bias assessment 16/16 interventional, pilot and observational studies were found to be high risk. CONCLUSIONS There is no robust evidence to date that any one agent can reproducibly lead to improved microvascular flow. Furthermore, no study demonstrated outcome benefit of one therapeutic agent over another. Updated consensus guidelines could improve comparable reporting of measurements and reduce bias, to enable meaningful comparisons around the effects of individual pharmacological agents.
Collapse
|
46
|
Shi R, Hamzaoui O, De Vita N, Monnet X, Teboul JL. Vasopressors in septic shock: which, when, and how much? ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:794. [PMID: 32647719 PMCID: PMC7333107 DOI: 10.21037/atm.2020.04.24] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In addition to fluid resuscitation, the vasopressor therapy is a fundamental treatment of septic shock-induced hypotension as it aims at correcting the vascular tone depression and then at improving organ perfusion pressure. Experts’ recommendations currently position norepinephrine (NE) as the first-line vasopressor in septic shock. Vasopressin and its analogues are only second-line vasopressors as strong recent evidence suggests no benefit of their early administration in spite of promising preliminary data. Early administration of NE may allow achieving the initial mean arterial pressure (MAP) target faster and reducing the risk of fluid overload. The diastolic arterial pressure (DAP) as a marker of vascular tone, helps identifying the patients who need NE urgently. Available data suggest a MAP of 65 mmHg as the initial target but a more individualized approach is often required depending on several factors such as history of chronic hypertension or value of central venous pressure (CVP). In cases of refractory hypotension, increasing NE up to doses ≥1 µg/kg/min could be an option. However, current experts’ guidelines suggest to combine NE with other vasopressors such as vasopressin, with the intent to rising the MAP to target or to decrease the NE dosage.
Collapse
Affiliation(s)
- Rui Shi
- Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S999 LabEx - LERMIT, Hôpital Marie-Lannelongue, Le Plessis Robinson, France
| | - Olfa Hamzaoui
- Service de réanimation polyvalente, Hôpital Antoine Béclère, AP-HP, Université Paris-Saclay 92141, Clamart, France
| | - Nello De Vita
- Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S999 LabEx - LERMIT, Hôpital Marie-Lannelongue, Le Plessis Robinson, France
| | - Xavier Monnet
- Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S999 LabEx - LERMIT, Hôpital Marie-Lannelongue, Le Plessis Robinson, France
| | - Jean-Louis Teboul
- Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S999 LabEx - LERMIT, Hôpital Marie-Lannelongue, Le Plessis Robinson, France
| |
Collapse
|
47
|
Busse LW, Ostermann M. Vasopressor Therapy and Blood Pressure Management in the Setting of Acute Kidney Injury. Semin Nephrol 2020; 39:462-472. [PMID: 31514910 DOI: 10.1016/j.semnephrol.2019.06.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Acute kidney injury (AKI) is common in the setting of shock. Hemodynamic instability is a risk factor for the development of AKI, and pathophysiological mechanisms include loss of renal perfusion pressure and impaired microcirculation. Although restoration of mean arterial pressure (MAP) may mitigate the risk of AKI to some extent, evidence on this is conflicting. Also debatable is the optimal blood pressure needed to minimize the risk of kidney injury. A MAP of 65 mm Hg traditionally has been considered adequate to maintain renal perfusion pressure, and studies have failed to consistently show improved outcomes at higher levels of MAP. Therapeutic options to support renal perfusion consist of catecholamines, vasopressin, and angiotensin II. Although catecholamines are the most studied, they are associated with adverse events at higher doses, including AKI. Vasopressin and angiotensin II are noncatecholamine options to support blood pressure and may improve microcirculatory hemodynamics through unique mechanisms, including differential vasoconstriction of efferent and afferent arterioles within the nephron. Future areas of study include methods by which clinicians can measure renal blood flow in a macrocirculatory and microcirculatory way, a personalized approach to blood pressure management in septic shock using patient-specific measures of perfusion adequacy, and novel agents that may improve the microcirculation within the kidneys without causing adverse microcirculatory effects in other organs.
Collapse
Affiliation(s)
- Laurence W Busse
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA.
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' National Health Service Foundation Hospital, London, United Kingdom
| |
Collapse
|
48
|
Cardinali M, Magnin M, Bonnet-Garin JM, Paquet C, Ayoub JY, Allaouchiche B, Junot S. A new photoplethysmographic device for continuous assessment of urethral mucosa perfusion: evaluation in a porcine model. J Clin Monit Comput 2020; 35:585-598. [PMID: 32361961 DOI: 10.1007/s10877-020-00515-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 04/27/2020] [Indexed: 01/25/2023]
Abstract
This study proposes to evaluate an innovative device consisting of an indwelling urinary catheter equipped with a photoplethysmography (PPG) sensor in contact with the urethral mucosa that provides a continuous index called urethral perfusion index (uPI). The goal of this study was to determine if the uPI could bring out tissue perfusion modifications induced by hypotension and vasopressors in a porcine model. Twelve piglets were equipped for heart rate, MAP, cardiac index, stroke volume index, systemic vascular resistance index and uPI monitoring. The animals were exposed to different levels of mean arterial pressure (MAP), ranging from low to high values. Friedman tests with a posteriori multiple comparison were performed and a generalized linear mixed model (GLMM) was used to assess the relationship between uPI and MAP. Urethral Perfusion Index and other haemodynamic parameters varied significantly at the different time-points of interest. There was a positive correlation between MAP and uPI below a specific MAP value, called dissociation threshold (DT). Above this threshold, uPI and MAP were negatively correlated. This relationship, assessed with the GLMM, yielded a significant positive fixed effect coefficient (+ 0.2, P < 0.00001) below the DT and a significant negative fixed effect (- 0.14, P < 0.00001) above DT. In an experimental setting, the PPG device and its index uPI permitted the detection of urethral mucosa perfusion alterations associated with hypotension or excessive doses of vasopressors. Further studies are needed to evaluate this device in a clinical context.
Collapse
Affiliation(s)
- Martina Cardinali
- VetAgro Sup, Université de Lyon, Unité APCSe, Campus Vétérinaire de Lyon, 1 Avenue Bourgelat, 69280, Marcy l'Etoile, France
| | - Mathieu Magnin
- VetAgro Sup, Université de Lyon, Unité APCSe, Campus Vétérinaire de Lyon, 1 Avenue Bourgelat, 69280, Marcy l'Etoile, France
| | - Jeanne-Marie Bonnet-Garin
- VetAgro Sup, Université de Lyon, Unité APCSe, Campus Vétérinaire de Lyon, 1 Avenue Bourgelat, 69280, Marcy l'Etoile, France
| | - Christian Paquet
- VetAgro Sup, Université de Lyon, Unité APCSe, Campus Vétérinaire de Lyon, 1 Avenue Bourgelat, 69280, Marcy l'Etoile, France
| | - Jean-Yves Ayoub
- VetAgro Sup, Université de Lyon, Unité APCSe, Campus Vétérinaire de Lyon, 1 Avenue Bourgelat, 69280, Marcy l'Etoile, France
| | - Bernard Allaouchiche
- Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Réanimation Médicale, Université Claude Bernard Lyon 1, Unité APCSe, 5 place d'Arsonval, 69437, Lyon, Cedex 03, France
| | - Stephane Junot
- VetAgro Sup, Université de Lyon, Unité APCSe, Campus Vétérinaire de Lyon, 1 Avenue Bourgelat, 69280, Marcy l'Etoile, France.
| |
Collapse
|
49
|
Pruitt LG. Lymphatic flow modulation as adjunct therapy for septic shock. Med Hypotheses 2020; 142:109748. [PMID: 32339860 DOI: 10.1016/j.mehy.2020.109748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 04/19/2020] [Indexed: 11/16/2022]
Abstract
The lymphatic system is an important component of human health and is critical in maintaining microcirculatory flow and immune system homeostasis. During septic shock, increased capillary permeability results in excess filtration of intravascular fluid and solutes producing interstitial edema with subsequent hydrostatic and oncotic gradient breakdown. The accumulation of interstitial fluid results in impaired solute exchange, leukocyte signaling, and aberrancy in capillary flow. Modulation of lymphatic flow during times of interstitial volume overload such as septic shock may decrease interstitial volume resulting in improved perfusion, decreased end-organ damage, and contribute to disease resolution. Multiple studies in both humans and animals have shown nitric oxide to be a potent modulator of lymphatic function. The present study suggests a hypothetical adjunct therapy for patients with septic shock through the use of phosphodiesterase inhibitors, which may improve microcirculatory flow by decreasing interstitial fluid volume via increased lymphatic fluid drainage.
Collapse
Affiliation(s)
- Louis Gordon Pruitt
- Saint Anthony Hospital, Department of Emergency Medicine, 11567 Canterwood Boulevard Northwest, Gig Harbor, WA 98332, United States.
| |
Collapse
|
50
|
Effect of Increasing Blood Pressure With Noradrenaline on the Microcirculation of Patients With Septic Shock and Previous Arterial Hypertension. Crit Care Med 2020; 47:1033-1040. [PMID: 31094744 DOI: 10.1097/ccm.0000000000003795] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To assess whether an increase in mean arterial pressure in patients with septic shock and previous systemic arterial hypertension changes microcirculatory and systemic hemodynamic variables compared with patients without arterial hypertension (control). DESIGN Prospective, nonblinded, interventional study. SETTING Three ICUs in two teaching hospitals. PATIENTS After informed consent, we included patients older than 18 years with septic shock for at least 6 hours, sedated, and under mechanical ventilation. We paired patients with and without arterial hypertension by age. INTERVENTIONS After obtaining systemic and microcirculation baseline hemodynamic variables (time 0), we increased noradrenaline dose to elevate mean arterial pressure up to 85-90 mm Hg before collecting a new set of measurements (time 1). MEASUREMENTS AND MAIN RESULTS We included 40 patients (20 in each group). There was no significant difference in age between the groups. After the rise in mean arterial pressure, there was a significant increase in cardiac index and a slight but significant reduction in lactate in both groups. We observed a significant improvement in the proportion of perfused vessels (control: 57.2 ± 14% to 66 ± 14.8%; arterial hypertension: 61.4 ± 12.3% to 70.8 ± 7.1%; groups: p = 0.29; T0 and T1: p < 0.001; group and time interaction: p = 0.85); perfused vessels density (control: 15.6 ± 4 mm/mm to 18.6 ± 4.5 mm/mm; arterial hypertension: 16.4 ± 3.5 mm/mm to 19.1 ± 3 mm/mm; groups: p = 0.51; T0 and T1: p < 0.001; group and time interaction: p = 0.70), and microcirculatory flow index (control: 2.1 ± 0.6 to 2.4 ± 0.6; arterial hypertension: 2.1 ± 0.5 to 2.6 ± 0.2; groups: p = 0.71; T0 and T1: p = 0.002; group and time interaction: p = 0.45) in both groups. CONCLUSIONS Increasing mean arterial pressure with noradrenaline in septic shock patients improves density and flow in small vessels of sublingual microcirculation. However, this improvement occurs both in patients with previous arterial hypertension and in those without arterial hypertension.
Collapse
|