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Hibshman M, Anderson ML. Clinical progress note: Steroids in severe community-acquired pneumonia. J Hosp Med 2024. [PMID: 39075644 DOI: 10.1002/jhm.13473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 07/13/2024] [Accepted: 07/19/2024] [Indexed: 07/31/2024]
Affiliation(s)
- Madison Hibshman
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Hospital Medicine Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
| | - Mel L Anderson
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Hospital Medicine Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
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Martel-Duguech L, Poirier J, Bourdeau I, Lacroix A. Diagnosis and management of secondary adrenal crisis. Rev Endocr Metab Disord 2024; 25:619-637. [PMID: 38411891 DOI: 10.1007/s11154-024-09877-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2024] [Indexed: 02/28/2024]
Abstract
Adrenal crisis (AC) is a life threatening acute adrenal insufficiency (AI) episode which can occur in patients with primary AI but also secondary AI (SAI), tertiary AI (TAI) and iatrogenic AI (IAI). In SAI, TAI and IAI, AC may develop when the HPA axis is unable to mount an adequate glucocorticoid response to severe stress due to pituitary or hypothalamic disruption. It manifests as an acute deterioration in multi-organ homeostasis that, if untreated, leads to shock and death. Despite the availability of effective preventive strategies, its prevalence is increasing in patients with SAI, TAI and IAI due to more frequent exogenous steroid administration, pituitary immune-related effects of immune checkpoint inhibitors and opioid use in pain management. The delayed diagnosis of acute AI which remains infrequently suspected increases the risk of AC. Its main precipitating factors are infections, emotional distress, surgery, cessation or reduction in GC doses, pituitary infarction or surgical cure of endogenous Cushing's syndrome. In patients not known previously to have SAI/TAI/IAI, recognition of its symptoms, signs, and biochemical abnormalities can be challenging and cause delay in proper diagnosis and therapy. Effective therapy of AC is rapid intravenous administration of hydrocortisone (initial bolus of 100 mg followed by 200 mg/24 h as continuous infusion or bolus of 50 mg every 6 h) and 0.9% saline. In diagnosed patients, preventive education in sick-day rules adjustment of glucocorticoid replacement and hydrocortisone parenteral self-administration must be performed repeatedly by trained health care providers. Strategies to improve the adequate preventive education in patients at risk for secondary AI should be promoted in collaboration with various medical specialist societies and patients support associations.
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Affiliation(s)
- Luciana Martel-Duguech
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), 900 Saint-Denis Street, Montréal, QC H2X 0A9, Québec, Canada
| | - Jonathan Poirier
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), 900 Saint-Denis Street, Montréal, QC H2X 0A9, Québec, Canada
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), 900 Saint-Denis Street, Montréal, QC H2X 0A9, Québec, Canada
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), 900 Saint-Denis Street, Montréal, QC H2X 0A9, Québec, Canada.
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Chaudhuri D, Nei AM, Rochwerg B, Balk RA, Asehnoune K, Cadena R, Carcillo JA, Correa R, Drover K, Esper AM, Gershengorn HB, Hammond NE, Jayaprakash N, Menon K, Nazer L, Pitre T, Qasim ZA, Russell JA, Santos AP, Sarwal A, Spencer-Segal J, Tilouche N, Annane D, Pastores SM. 2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia. Crit Care Med 2024; 52:e219-e233. [PMID: 38240492 DOI: 10.1097/ccm.0000000000006172] [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: 04/16/2024]
Abstract
RATIONALE New evidence is available examining the use of corticosteroids in sepsis, acute respiratory distress syndrome (ARDS) and community-acquired pneumonia (CAP), warranting a focused update of the 2017 guideline on critical illness-related corticosteroid insufficiency. OBJECTIVES To develop evidence-based recommendations for use of corticosteroids in hospitalized adults and children with sepsis, ARDS, and CAP. PANEL DESIGN The 22-member panel included diverse representation from medicine, including adult and pediatric intensivists, pulmonologists, endocrinologists, nurses, pharmacists, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines. We followed Society of Critical Care Medicine conflict of interest policies in all phases of the guideline development, including task force selection and voting. METHODS After development of five focused Population, Intervention, Control, and Outcomes (PICO) questions, we conducted systematic reviews to identify the best available evidence addressing each question. We evaluated the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach and formulated recommendations using the evidence-to-decision framework. RESULTS In response to the five PICOs, the panel issued four recommendations addressing the use of corticosteroids in patients with sepsis, ARDS, and CAP. These included a conditional recommendation to administer corticosteroids for patients with septic shock and critically ill patients with ARDS and a strong recommendation for use in hospitalized patients with severe CAP. The panel also recommended against high dose/short duration administration of corticosteroids for septic shock. In response to the final PICO regarding type of corticosteroid molecule in ARDS, the panel was unable to provide specific recommendations addressing corticosteroid molecule, dose, and duration of therapy, based on currently available evidence. CONCLUSIONS The panel provided updated recommendations based on current evidence to inform clinicians, patients, and other stakeholders on the use of corticosteroids for sepsis, ARDS, and CAP.
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Affiliation(s)
- Dipayan Chaudhuri
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Andrea M Nei
- Department of Pharmacy, Mayo Clinic Hospital-Rochester, Rochester, MN
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Robert A Balk
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL
| | - Karim Asehnoune
- Department of Anesthesiology, CHU Nantes, Université de Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, France
| | - Rhonda Cadena
- Department of Internal Medicine, Wake Forest School of Medicine, Atrium Health, Carolinas Medical Center, Charlotte, NC
| | - Joseph A Carcillo
- Department of Critical Care Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, PA
| | - Ricardo Correa
- Department of Endocrinology, Diabetes and Metabolism, Endocrine and Metabolism Institute, Cleveland Clinic, Cleveland, OH
| | | | - Annette M Esper
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine; Miami, FL
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Naomi E Hammond
- Malcolm Fisher Department of Intensive Care Medicine, Critical Care Program, The George Institute for Global Health, UNSW Sydney, Newtown, NSW, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Namita Jayaprakash
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI
- Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI
| | - Kusum Menon
- Division of Pediatric Critical Care, University of Ottawa and Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Department of Pediatrics, University of Ottawa and Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Lama Nazer
- King Hussein Cancer Center Department of Pharmacy, Amman, Jordan
| | - Tyler Pitre
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Zaffer A Qasim
- Department of Emergency Medicine and Critical Care Medicine, University of Pennsylvania Health System, Philadelphia, PA
| | - James A Russell
- Division of Critical Care, Department of Medicine, Centre for Heart Lung Innovation St. Paul's Hospital University of British Columbia, Vancouver, BC, Canada
| | - Ariel P Santos
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Aarti Sarwal
- Department of Neurology [Neurocritical Care], Atrium Wake Forest School of Medicine, Winston Salem, NC
| | - Joanna Spencer-Segal
- Department of Internal Medicine and Michigan Neuroscience Institute, University of Michigan, Ann Arbor, MI
| | - Nejla Tilouche
- Intensive Care Unit, Service de Réanimation Polyvalente, Hôpital de Gonesse, Gonesse, France
| | - Djillali Annane
- Department of Intensive Care, Raymond Poincaré Hospital, Assistance Publique-Hôpitaux de Paris, Garches, France
- School of Medicine Simone Veil, University of Versailles Saint Quentin, University Paris-Saclay, Versaillles, France
- IHU Prometheus Fédération Hospitalo-Universitaire SEPSIS, University Paris-Saclay, INSERM, Garches, France
| | - Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Critical Care Center, Memorial Sloan Kettering Cancer Center, New York, NY
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Chaudhuri D, Nei AM, Rochwerg B, Balk RA, Asehnoune K, Cadena RS, Carcillo JA, Correa R, Drover K, Esper AM, Gershengorn HB, Hammond NE, Jayaprakash N, Menon K, Nazer L, Pitre T, Qasim ZA, Russell JA, Santos AP, Sarwal A, Spencer-Segal J, Tilouche N, Annane D, Pastores SM. Executive Summary: Guidelines on Use of Corticosteroids in Critically Ill Patients With Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia Focused Update 2024. Crit Care Med 2024; 52:833-836. [PMID: 38240490 DOI: 10.1097/ccm.0000000000006171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Affiliation(s)
- Dipayan Chaudhuri
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Andrea M Nei
- Department of Pharmacy, Mayo Clinic Hospital-Rochester, Rochester, MN
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Robert A Balk
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL
| | - Karim Asehnoune
- Department of Anesthesiology, CHU Nantes, Université de Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, France
| | - Rhonda S Cadena
- Department of Internal Medicine, Wake Forest School of Medicine, Atrium Health, Carolinas Medical Center, Charlotte, NC
| | - Joseph A Carcillo
- Department of Critical Care Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, PA
| | - Ricardo Correa
- Department of Endocrinology, Diabetes and Metabolism, Endocrine and Metabolism Institute, Cleveland Clinic, Cleveland, OH
| | | | - Annette M Esper
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Naomi E Hammond
- Malcolm Fisher Department of Intensive Care Medicine, Critical Care Program, The George Institute for Global Health, UNSW Sydney, Newtown, NSW, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Namita Jayaprakash
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI
- Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI
| | - Kusum Menon
- Division of Pediatric Critical Care, Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Lama Nazer
- King Hussein Cancer Center Department of Pharmacy, Amman, Jordan
| | - Tyler Pitre
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Zaffer A Qasim
- Department of Emergency Medicine and Critical Care Medicine, University of Pennsylvania Health System, Philadelphia, PA
| | - James A Russell
- Division of Critical Care, Department of Medicine, Centre for Heart Lung Innovation St. Paul's Hospital University of British Columbia, Vancouver, BC, Canada
| | - Ariel P Santos
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Aarti Sarwal
- Department of Neurology [Neurocritical Care], Atrium Wake Forest School of Medicine, Winston Salem, NC
| | - Joanna Spencer-Segal
- Department of Internal Medicine, Michigan Neuroscience Institute, University of Michigan, Ann Arbor, MI
| | - Nejla Tilouche
- Intensive Care Unit, Service de Réanimation Polyvalente, Hôpital de Gonesse, Grenoble, France
| | - Djillali Annane
- Department of Intensive Care, Raymond Poincaré Hospital, Assistance Publique-Hôpitaux de Paris, Garches, France
- School of Medicine Simone Veil, University of Versailles Saint Quentin, University Paris-Saclay, Versaillles, France
- IHU Prometheus Fédération Hospitalo-Universitaire SEPSIS, University Paris-Saclay, INSERM, Garches, France
| | - Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Critical Care Center, Memorial Sloan Kettering Cancer Center, New York, NY
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Chaudhuri D, Israelian L, Putowski Z, Prakash J, Pitre T, Nei AM, Spencer-Segal JL, Gershengorn HB, Annane D, Pastores SM, Rochwerg B. Adverse Effects Related to Corticosteroid Use in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia: A Systematic Review and Meta-Analysis. Crit Care Explor 2024; 6:e1071. [PMID: 38567382 PMCID: PMC10986917 DOI: 10.1097/cce.0000000000001071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVES We postulate that corticosteroid-related side effects in critically ill patients are similar across sepsis, acute respiratory distress syndrome (ARDS), and community-acquired pneumonia (CAP). By pooling data across all trials that have examined corticosteroids in these three acute conditions, we aim to examine the side effects of corticosteroid use in critical illness. DATA SOURCES We performed a comprehensive search of MEDLINE, Embase, Centers for Disease Control and Prevention library of COVID research, CINAHL, and Cochrane center for trials. STUDY SELECTION We included randomized controlled trials (RCTs) that compared corticosteroids to no corticosteroids or placebo in patients with sepsis, ARDS, and CAP. DATA EXTRACTION We summarized data addressing the most described side effects of corticosteroid use in critical care: gastrointestinal bleeding, hyperglycemia, hypernatremia, superinfections/secondary infections, neuropsychiatric effects, and neuromuscular weakness. DATA SYNTHESIS We included 47 RCTs (n = 13,893 patients). Corticosteroids probably have no effect on gastrointestinal bleeding (relative risk [RR], 1.08; 95% CI, 0.87-1.34; absolute risk increase [ARI], 0.3%; moderate certainty) or secondary infections (RR, 0.97; 95% CI, 0.89-1.05; absolute risk reduction, 0.5%; moderate certainty) and may have no effect on neuromuscular weakness (RR, 1.22; 95% CI, 1.03-1.45; ARI, 1.4%; low certainty) or neuropsychiatric events (RR, 1.19; 95% CI, 0.82-1.74; ARI, 0.5%; low certainty). Conversely, they increase the risk of hyperglycemia (RR, 1.21; 95% CI, 1.11-1.31; ARI, 5.4%; high certainty) and probably increase the risk of hypernatremia (RR, 1.59; 95% CI, 1.29-1.96; ARI, 2.3%; moderate certainty). CONCLUSIONS In ARDS, sepsis, and CAP, corticosteroids are associated with hyperglycemia and probably with hypernatremia but likely have no effect on gastrointestinal bleeding or secondary infections. More data examining effects of corticosteroids, particularly on neuropsychiatric outcomes and neuromuscular weakness, would clarify the safety of this class of drugs in critical illness.
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Affiliation(s)
| | - Lori Israelian
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Zbigniew Putowski
- Centre for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Jay Prakash
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Tyler Pitre
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Andrea M Nei
- Department of Pharmacy, Mayo Clinic Hospital, Rochester, MN
| | - Joanna L Spencer-Segal
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI
- Michigan Neuroscience Institute, University of Michigan, Ann Arbor, MI
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Djillali Annane
- Department of Intensive Care, Hôpital Raymond Poincaré, FHU SEPSIS, AP-HP, Garches, France
- Paris Saclay University, UVSQ, INSERM, Lab of Inflammation & Infection 2I (U1173), Montigny-le-Bretonneux, France
| | - Stephen M Pastores
- Critical Care Center, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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6
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Hardy E, Fernandez-Patron C. Could Endogenous Glucocorticoids Influence SARS-CoV-2 Infectivity? Cells 2022; 11:cells11192955. [PMID: 36230917 PMCID: PMC9562004 DOI: 10.3390/cells11192955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/10/2022] [Accepted: 09/20/2022] [Indexed: 12/15/2022] Open
Abstract
Endogenous glucocorticoids and their synthetic analogues, such as dexamethasone, stimulate receptor-mediated signal transduction mechanisms on target cells. Some of these mechanisms result in beneficial outcomes whereas others are deleterious in the settings of pathogen infections and immunological disorders. Here, we review recent studies by several groups, including our group, showing that glucocorticoids can directly interact with protein components on SARS-CoV-2, the causative agent of COVID-19. We postulate an antiviral defence mechanism by which endogenous glucocorticoids (e.g., cortisol produced in response to SARS-CoV-2 infection) can bind to multiple sites on SARS-CoV-2 surface protein, Spike, inducing conformational alterations in Spike subunit 1 (S1) that inhibit SARS-CoV-2 interaction with the host SARS-CoV-2 receptor, ACE2. We suggest that glucocorticoids-mediated inhibition of S1 interaction with ACE2 may, consequently, affect SARS-CoV-2 infectivity. Further, glucocorticoids interactions with Spike could protect against a broad spectrum of coronaviruses and their variants that utilize Spike for infection of the host. These notions may be useful for the design of new antivirals for coronavirus diseases.
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Affiliation(s)
- Eugenio Hardy
- Center of Molecular Immunology, P.O. Box 16040, Havana 11600, Cuba
- Correspondence: (E.H.); (C.F.-P.)
| | - Carlos Fernandez-Patron
- Department of Biochemistry, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, AB T6G 2H7, Canada
- Correspondence: (E.H.); (C.F.-P.)
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7
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Zochios V, Brodie D, Shekar K, Schultz MJ, Parhar KKS. Invasive mechanical ventilation in patients with acute respiratory distress syndrome receiving extracorporeal support: a narrative review of strategies to mitigate lung injury. Anaesthesia 2022; 77:1137-1151. [PMID: 35864561 DOI: 10.1111/anae.15806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 11/28/2022]
Abstract
Veno-venous extracorporeal membrane oxygenation is indicated in patients with acute respiratory distress syndrome and severely impaired gas exchange despite evidence-based lung protective ventilation, prone positioning and other parts of the standard algorithm for treating such patients. Extracorporeal support can facilitate ultra-lung-protective ventilation, meaning even lower volumes and pressures than standard lung-protective ventilation, by directly removing carbon dioxide in patients needing injurious ventilator settings to maintain sufficient gas exchange. Injurious ventilation results in ventilator-induced lung injury, which is one of the main determinants of mortality in acute respiratory distress syndrome. Marked reductions in the intensity of ventilation to the lowest tolerable levels under extracorporeal support may be achieved and could thereby potentially mitigate ventilator-induced lung injury and theoretically patient self-inflicted lung injury in spontaneously breathing patients with high respiratory drive. However, the benefits of this strategy may be counterbalanced by the use of continuous deep sedation and even neuromuscular blocking drugs, which may impair physical rehabilitation and impact long-term outcomes. There are currently a lack of large-scale prospective data to inform optimal invasive ventilation practices and how to best apply a holistic approach to patients receiving veno-venous extracorporeal membrane oxygenation, while minimising ventilator-induced and patient self-inflicted lung injury. We aimed to review the literature relating to invasive ventilation strategies in patients with acute respiratory distress syndrome receiving extracorporeal support and discuss personalised ventilation approaches and the potential role of adjunctive therapies in facilitating lung protection.
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Affiliation(s)
- V Zochios
- Department of Cardiothoracic Critical Care Medicine and ECMO, Glenfield Hospital, University Hospitals of Leicester National Health Service Trust, Leicester, UK.,Department of Cardiovascular Sciences, University of Leicester, UK
| | - D Brodie
- Columbia University College of Physicians and Surgeons, New York, NY, USA.,Centre for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - K Shekar
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane and Bond University, Goldcoast, QLD, Australia
| | - M J Schultz
- Department of Intensive Care, Amsterdam University Medical Centres, Amsterdam, the Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, Oxford University, Oxford, UK.,Department of Medical Affairs, Hamilton Medical AG, Bonaduz, Switzerland
| | - K K S Parhar
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
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Chertok Shacham E, Ishay A. New insights on Effects of Glucocorticoids in SARS-CoV-2 infection. Endocr Pract 2022; 28:1100-1106. [PMID: 35870803 PMCID: PMC9300587 DOI: 10.1016/j.eprac.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/20/2022] [Accepted: 07/14/2022] [Indexed: 01/08/2023]
Abstract
Objective Since January 2020, the highly contagious novel coronavirus SARS-CoV-2 has caused a global pandemic. Severe COVID-19 leads to a massive release of proinflammatory mediators, leading to diffuse damage to the lung parenchyma, and the development of acute respiratory distress syndrome. Treatment with the highly potent glucocorticoid (GC) dexamethasone was found to be effective in reducing mortality in severely affected patients. Methods To review the effects of glucocorticoids in the context of COVID-19 we performed a literature search in the PubMed database using the terms COVID-19 and glucocorticoid treatment. We identified 1429 article publications related to COVID-19 and glucocorticoid published from 1.1.2020 to the present including 238 review articles and 36 Randomized Controlled Trials. From these studies, we retrieved 13 Randomized Controlled Trials and 86 review articles that were relevant to our review topics. We focused on the recent literature dealing with glucocorticoid metabolism in critically ill patients and investigating the effects of glucocorticoid therapy on the immune system in COVID-19 patients with severe lung injury. Results In our review, we have discussed the regulation of the hypothalamic-pituitary-adrenal axis in patients with critical illness, selection of a specific GC for critical illness-related GC insufficiency, and recent studies that investigated hypothalamic-pituitary-adrenal dysfunction in patients with COVID-19. We have also addressed the specific activation of the immune system with chronic endogenous glucocorticoid excess, as seen in patients with Cushing syndrome, and, finally, we have discussed immune activation due to coronavirus infection and the possible mechanisms leading to improved outcomes in patients with COVID-19 treated with GCs. Conclusion For clinical endocrinologists prescribing GCs for their patients, a precise understanding of both the molecular- and cellular-level mechanisms of endogenous and exogenous GCs is imperative, including timing of administration, dosage, duration of treatment, and specific formulations of GCs.
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Affiliation(s)
| | - Avraham Ishay
- Endocrinology Unit, HaEmek Medical Center, Afula, Israel; Faculty of medicine, Technion - Israel Institute of Technology, Haifa, Israel
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9
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Endocrine and Electrolyte Disorders. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00040-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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10
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Ceccato A, Russo A, Barbeta E, Oscanoa P, Tiseo G, Gabarrus A, Di Giannatale P, Nogas S, Cilloniz C, Menichetti F, Ferrer M, Niederman M, Falcone M, Torres A. Real-world corticosteroid use in severe pneumonia: a propensity-score-matched study. Crit Care 2021; 25:432. [PMID: 34915895 PMCID: PMC8674860 DOI: 10.1186/s13054-021-03840-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 11/24/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide despite correct antibiotic use. Corticosteroids have long been evaluated as a treatment option, but heterogeneous effects on survival have precluded their widespread implementation. We aimed to evaluate whether corticosteroids might improve clinical outcomes in patients with severe CAP and high inflammatory responses. STUDY DESIGN AND METHODS We analyzed two prospective observational cohorts of patients with CAP in Barcelona and Rome who were admitted to intensive care with a high inflammatory response. Propensity score (PS) matching was used to obtain balance among the baseline variables in both groups, and we excluded patients with viral pneumonia or who received hydrocortisone. RESULTS Of the 610 patients admitted with severe CAP, 198 (32%) received corticosteroids and 387 had major criteria for severe CAP. All patients had a baseline serum C-reactive protein above 15 mg/dL. Patients who received corticosteroids were more commonly male, had more comorbidities (e.g., cancer or chronic obstructive pulmonary disease), and presented with significantly higher sequential organ failure assessment scores. Eighty-nine patients met major severity criteria (invasive mechanical ventilation and/or septic shock) and were matched per group. Twenty-eight-day mortality was lower among patients receiving corticosteroids (16 patients, 18%) than among those not receiving them (28 patients, 31%; p = 0.037). After PS matching, corticosteroid therapy reduced the 28-day mortality risk in patients who met major severity criteria (hazard ratio (HR) 0.53, 95% confidence interval (CI) 0.29-0.98) (p = 0.043). In patients who did not meet major severity criteria, no benefits were observed with corticosteroid use (HR 0.88 (95%CI 0.32-2.36). CONCLUSIONS Corticosteroid treatment may be of benefit for patients with CAP who have septic shock and/or a high inflammatory response and requirement for invasive mechanical ventilation. Corticosteroids appear to have no impact on mortality when these features are not present.
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Affiliation(s)
- A Ceccato
- Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
| | - A Russo
- Department of Public Health and Infectious Diseases, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - E Barbeta
- Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - P Oscanoa
- Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - G Tiseo
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - A Gabarrus
- Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - P Di Giannatale
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia Analgesia, Perioperative and Intensive Care, SS. Annunziata Hospital, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - S Nogas
- Dipartimento Scienze Chirurgiche E Diagnostiche Integrate (DISC), Università Degli Studi Di Genova, Genova, Italy
| | - C Cilloniz
- Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - F Menichetti
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - M Ferrer
- Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - M Niederman
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York Presbyterian/Weill Cornell Medical Center, New York, NY, USA
| | - M Falcone
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - A Torres
- Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB), Barcelona, Spain.
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona, Villarroel 170, 08036, Barcelona, Spain.
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11
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Zhao Q, Shen Y, Li R, Wu J, Lyu J, Jiang M, Lu L, Zhu M, Wang W, Wang Z, Liu Q, Hoffmann U, Karhausen J, Sheng H, Zhang W, Yang W. Cardiac arrest and resuscitation activates the hypothalamic-pituitary-adrenal axis and results in severe immunosuppression. J Cereb Blood Flow Metab 2021; 41:1091-1102. [PMID: 32787543 PMCID: PMC8054717 DOI: 10.1177/0271678x20948612] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In patients who are successfully resuscitated after initial cardiac arrest (CA), mortality and morbidity rates are high, due to ischemia/reperfusion injury to the whole body including the nervous and immune systems. How the interactions between these two critical systems contribute to post-CA outcome remains largely unknown. Using a mouse model of CA and cardiopulmonary resuscitation (CA/CPR), we demonstrate that CA/CPR induced neuroinflammation in the brain, in particular, a marked increase in pro-inflammatory cytokines, which subsequently activated the hypothalamic-pituitary-adrenal (HPA) axis. Importantly, this activation was associated with a severe immunosuppression phenotype after CA. The phenotype was characterized by a striking reduction in size of lymphoid organs accompanied by a massive loss of immune cells and reduced immune function of splenic lymphocytes. The mechanistic link between post-CA immunosuppression and the HPA axis was substantiated, as we discovered that glucocorticoid treatment, which mimics effects of the activated HPA axis, exacerbated post-CA immunosuppression, while RU486 treatment, which suppresses its effects, significantly mitigated lymphopenia and lymphoid organ atrophy and improved CA outcome. Taken together, targeting the HPA axis could be a viable immunomodulatory therapeutic to preserve immune homeostasis after CA/CPR and thus improve prognosis of post-resuscitation CA patients.
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Affiliation(s)
- Qiang Zhao
- Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Yuntian Shen
- Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, China
| | - Ran Li
- Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Jiangbo Wu
- Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Jingjun Lyu
- Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Department of Emergency Medicine, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Maorong Jiang
- Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, China
| | - Liping Lu
- Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Minghua Zhu
- Department of Immunology, Duke University Medical Center, Durham, NC, USA
| | - Wei Wang
- Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Zhuoran Wang
- Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Qiang Liu
- Department of Neurobiology, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Ulrike Hoffmann
- Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Jörn Karhausen
- Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Huaxin Sheng
- Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Weiguo Zhang
- Department of Immunology, Duke University Medical Center, Durham, NC, USA
| | - Wei Yang
- Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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12
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Garmes HM, Boguszewski CL, Miranda PAC, Martins MRA, da Silva SRC, Abucham JZ, de Castro Musolino NR, Vilar L, Portari LHC, Gadelha MR, Kasuki L, Naves LA, Czepielewski MA, de Almeida TS, Duarte FHG, Glezer A, Bronstein MD. Management of hypopituitarism: a perspective from the Brazilian Society of Endocrinology and Metabolism. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 65:212-230. [PMID: 33905631 PMCID: PMC10065316 DOI: 10.20945/2359-3997000000335] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Hypopituitarism is a disorder characterized by insufficient secretion of one or more pituitary hormones. New etiologies of hypopituitarism have been recently described, including head trauma, cerebral hemorrhage, and drug-induced hypophysitis. The investigation of patients with these new disorders, in addition to advances in diagnosis and treatment of hypopituitarism, has increased the prevalence of this condition. Pituitary hormone deficiencies can induce significant clinical changes with consequent increased morbidity and mortality rates, while hormone replacement based on current guidelines protects these patients. In this review, we will first discuss the different etiologies of hypopituitarism and then address one by one the clinical aspects, diagnostic evaluation, and therapeutic options for deficiencies of TSH, ACTH, gonadotropin, and GH. Finally, we will detail the hormonal interactions that occur during replacement of pituitary hormones.
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Affiliation(s)
- Heraldo Mendes Garmes
- Unidade de Neuroendocrinologia, Divisão de Endocrinologia e Metabologia, Departamento de Clínica Médica, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil,
| | - César Luiz Boguszewski
- Serviço de Endocrinologia e Metabologia, Departamento de Clínica Médica, Universidade Federal do Paraná (SEMPR), Curitiba, PR, Brasil,
| | | | | | - Silvia Regina Correa da Silva
- Unidade de Neuroendocrinologia, Divisão de Endocrinologia e Metabolismo, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brasil
| | - Julio Zaki Abucham
- Unidade de Neuroendocrinologia, Divisão de Endocrinologia e Metabolismo, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brasil
| | - Nina Rosa de Castro Musolino
- Unidade de Neuroendocrinologia, Divisão de Neurocirurgia Funcional, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, DP, Brasil
| | - Lucio Vilar
- Serviço de Endocrinologia, Hospital das Clínicas da Universidade Federal de Pernambuco, Recife, PE, Brasil
| | - Luiz Henrique Corrêa Portari
- Unidade de Neuroendocrinologia, Divisão de Endocrinologia e Metabolismo, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brasil
| | - Mônica Roberto Gadelha
- Unidade de Neuroendocrinologia, Instituto Estadual do Cérebro Paulo Niemeyer, Centro de Pesquisa de Neuroendocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Leandro Kasuki
- Unidade de Neuroendocrinologia, Instituto Estadual do Cérebro Paulo Niemeyer, Centro de Pesquisa de Neuroendocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Luciana Ansaneli Naves
- Serviço de Endocrinologia, Faculdade de Medicina da Universidade de Brasília, Brasília, DF, Brasil
| | - Mauro Antônio Czepielewski
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre; Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - Tobias Skrebsky de Almeida
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre; Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | | | - Andrea Glezer
- Unidade de Neuroendocrinologia, Laboratório de Endocrinologia Celular e Molecular LIM-25, Divisão de Endocrinologia e Metabolismo, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| | - Marcello Delano Bronstein
- Unidade de Neuroendocrinologia, Laboratório de Endocrinologia Celular e Molecular LIM-25, Divisão de Endocrinologia e Metabolismo, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
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13
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Erstad BL, Barletta JF. Drug dosing in the critically ill obese patient: a focus on medications for hemodynamic support and prophylaxis. Crit Care 2021; 25:77. [PMID: 33622380 PMCID: PMC7901103 DOI: 10.1186/s13054-021-03495-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/08/2021] [Indexed: 12/29/2022] Open
Abstract
Medications used for supportive care or prophylaxis constitute a significant portion of drug utilization in the intensive care unit. Evidence-based guidelines are available for many aspects of supportive care but drug doses listed are typically for patients with normal body habitus and not morbid obesity. Failure to account for the pharmacokinetic changes that occur with obesity can lead to an incorrect dose and treatment failure or toxicity. This paper is intended to help clinicians design initial dosing regimens in critically ill obese patients for medications commonly used for hemodynamic support or prophylaxis. A detailed literature search of medications used for supportive care or prophylaxis listed in practice guidelines was conducted with an emphasis on obesity, pharmacokinetics and dosing. Relevant manuscripts were reviewed and strategies for dosing are provided. For medications used for hemodynamic support, a similar strategy can be used as in non-obese patients. Similarly, medications for stress ulcer prophylaxis do not need to be adjusted. Anticoagulants for venous thromboembolism prophylaxis, on the other hand, require an individualized approach where higher doses are necessary.
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Affiliation(s)
- Brian L Erstad
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, 1295 N Martin Ave, PO Box 210202, Tucson, AZ, 85721, USA
| | - Jeffrey F Barletta
- Department of Pharmacy Practice, College of Pharmacy, Midwestern University, 19555 N 59th Ave, Glendale, AZ, 85308, USA.
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14
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Odeyemi YE, Herasevich S, Chalmers SJ, Barreto EF, Frank RD, Gajic OO, Yadav H. Biomarker-Concordant Steroid Use in Critically Ill Patients with Pneumonia. Mayo Clin Proc Innov Qual Outcomes 2020; 4:649-656. [PMID: 33367210 PMCID: PMC7749267 DOI: 10.1016/j.mayocpiqo.2020.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Objectives To evaluate the frequency and consequences of prescribing corticosteroids for pneumonia in a biomarker-concordant manner. Patients and Methods This was a single-center retrospective cohort study of adults with pneumonia admitted to the medical intensive care unit (ICU) at Mayo Clinic in Rochester, Minnesota, between January 1, 2009, and June 30, 2014. Steroid use was “biomarker concordant” if given when C-reactive protein (CRP) was ≥150 mg/L or withheld when CRP was <150 mg/L, and vice versa for biomarker discordant. Results Of 3481 ICU admissions with community-acquired pneumonia, 169 (4.9%) had CRPs measured within 48 hours of admission to the ICU. Steroid use in the ICU was biomarker concordant in 88 (52%) patients and biomarker discordant in 81 (48%) patients. Biomarker-concordant steroid use was associated with faster resolution of lung injury: median fraction of inspired oxygen on day 3 (0.4 [0.3, 0.5] vs 0.3 [0.21, 0.4], P=.005), day 4 (0.35 [0.3, 0.5] vs 0.28 [0.21, 0.38], P=<.001), and day 5 (0.30 [0.24, 0.45] vs 0.28 [0.21, 0.40], P=.03), and increased ICU (3.5; 95% CI, 0.5 to 6.4, P=.02), and hospital-free days (3.6; 95% CI, 0.4 to 6.8, P=.03) on multivariate analysis. Conclusions In critically ill patients with community-acquired pneumonia, steroid use is rarely biomarker informed and often discordant with inflammatory biomarker levels. Biomarker-concordant steroid use was associated with a faster recovery of hypoxemia and increased ICU- and hospital-free days. Future well-designed prospective studies are justified to test the potential value of biomarker-concordant steroid therapy.
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Affiliation(s)
- Yewande E. Odeyemi
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
- Correspondence: Address to Yewande Odeyemi, MBBS, MS, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.
| | - Svetlana Herasevich
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Sarah J. Chalmers
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Erin F. Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Ryan D. Frank
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Ognjen O. Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Hemang Yadav
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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15
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Bhattacharya S, Krishnamurthy A, Gopalakrishnan M, Kalra S, Kantroo V, Aggarwal S, Surana V. Endocrine and Metabolic Manifestations of Snakebite Envenoming. Am J Trop Med Hyg 2020; 103:1388-1396. [PMID: 32602439 DOI: 10.4269/ajtmh.20-0161] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Snakebite envenoming is a neglected, public health problem in tropical and subtropical regions. Local tissue necrosis, neurotoxic, and hemo-vasculotoxic effects are well-recognized features, whereas the endocrine and metabolic derangements are not as well known. In addition to contributing to morbidity, some of these manifestations can be potentially life-threatening if not recognized early. The most prominent endocrine manifestation is hypopituitarism (HP), which can manifest acutely or remain asymptomatic and present years later. Unexplained recurrent hypoglycemia and refractory hypotension are early clinical clues to suspect corticotroph axis involvement in acute settings. Chronic pituitary failure may present, like Sheehan's syndrome, several years after the bite. The occurrence of acute kidney injury, capillary leak syndrome, and disseminated intravascular coagulation are predictors of HP. Adrenal hemorrhages are documented in autopsy series; however, primary adrenal insufficiency is very rare and confounded by the presence of HP. Hyponatremia, hypokalemia or hyperkalemia, and dysglycemia can occur, but the mechanisms involved are only partially understood. Awareness, a high index of suspicion, correct interpretation of hormonal parameters, and timely treatment of these abnormalities can be lifesaving.
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Affiliation(s)
| | | | - Maya Gopalakrishnan
- Department of General Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, India
| | - Viny Kantroo
- Department of Respiratory Critical Care and Sleep Medicine, Apollo Hospitals, New Delhi, India
| | - Sameer Aggarwal
- Department of Endocrinology, Apex Plus Superspeciality Hospital, Rohtak, India
| | - Vineet Surana
- Department of Endocrinology, Manipal Hospital, New Delhi, India
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16
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Fernández-Cruz A, Ruiz-Antorán B, Muñoz-Gómez A, Sancho-López A, Mills-Sánchez P, Centeno-Soto GA, Blanco-Alonso S, Javaloyes-Garachana L, Galán-Gómez A, Valencia-Alijo Á, Gómez-Irusta J, Payares-Herrera C, Morrás-Torre I, Sánchez-Chica E, Delgado-Téllez-de-Cepeda L, Callejas-Díaz A, Ramos-Martínez A, Múñez-Rubio E, Avendaño-Solá C. A Retrospective Controlled Cohort Study of the Impact of Glucocorticoid Treatment in SARS-CoV-2 Infection Mortality. Antimicrob Agents Chemother 2020; 64:e01168-20. [PMID: 32571831 PMCID: PMC7449182 DOI: 10.1128/aac.01168-20] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 06/19/2020] [Indexed: 12/21/2022] Open
Abstract
Evidence to support the use of steroids in coronavirus disease 2019 (COVID-19) pneumonia is lacking. We aim to determine the impact of steroid use for COVID-19 pneumonia on hospital mortality. We performed a single-center retrospective cohort study in a university hospital in Madrid, Spain, during March of 2020. To determine the role of steroids in in-hospital mortality, patients admitted with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia and treated with steroids were compared to patients not treated with steroids, and we adjusted with a propensity score for patients on steroid treatment. Survival times were compared using the log rank test. Different steroid regimens were compared and adjusted with a second propensity score. During the study period, 463 out of 848 hospitalized patients with COVID-19 pneumonia fulfilled inclusion criteria. Among them, 396 (46.7%) patients were treated with steroids and 67 patients were not. Global mortality was 15.1%. The median time to steroid treatment from symptom onset was 10 days (interquartile range [IQR], 8 to 13 days). In-hospital mortality was lower in patients treated with steroids than in controls (13.9% [55/396] versus 23.9% [16/67]; hazard ratio [HR], 0.51 [95% confidence interval, 0.27 to 0.96]; P = 0.044). Steroid treatment reduced mortality by 41.8% relative to the mortality with no steroid treatment (relative risk reduction, 0.42 [95% confidence interval, 0.048 to 0.65]). Initial treatment with 1 mg/kg of body weight/day of methylprednisolone versus steroid pulses was not associated with in-hospital mortality (13.5% [42/310] versus 15.1% [13/86]; odds ratio [OR], 0.880 [95% confidence interval, 0.449 to 1.726]; P = 0.710). Our results show that the survival of patients with SARS-CoV-2 pneumonia is higher in patients treated with glucocorticoids than in those not treated. Rates of in-hospital mortality were not different between initial regimens of 1 mg/kg/day of methylprednisolone and glucocorticoid pulses.
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Affiliation(s)
- Ana Fernández-Cruz
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Belén Ruiz-Antorán
- Clinical Pharmacology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Ana Muñoz-Gómez
- Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Aránzazu Sancho-López
- Clinical Pharmacology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Patricia Mills-Sánchez
- Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Gustavo Adolfo Centeno-Soto
- Clinical Pharmacology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Silvia Blanco-Alonso
- Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Laura Javaloyes-Garachana
- Clinical Pharmacology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Amy Galán-Gómez
- Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Ángela Valencia-Alijo
- Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Javier Gómez-Irusta
- Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Concepción Payares-Herrera
- Clinical Pharmacology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Ignacio Morrás-Torre
- Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Enrique Sánchez-Chica
- Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Laura Delgado-Téllez-de-Cepeda
- Pharmacy Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Alejandro Callejas-Díaz
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Antonio Ramos-Martínez
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
- Pharmacy Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Elena Múñez-Rubio
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Cristina Avendaño-Solá
- Clinical Pharmacology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
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17
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Matera MG, Rogliani P, Calzetta L, Cazzola M. Pharmacological management of COVID-19 patients with ARDS (CARDS): A narrative review. Respir Med 2020; 171:106114. [PMID: 32795902 PMCID: PMC7402220 DOI: 10.1016/j.rmed.2020.106114] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/30/2020] [Accepted: 08/01/2020] [Indexed: 12/15/2022]
Abstract
Coronavirus disease 2019 (COVID-19) is highly infectious. It has been highlighted that if not expertly and individually managed with consideration of the vasocentric features, a COVID-19 patient with an acute respiratory distress syndrome (CARDS) may eventually develop multiorgan failure. Unfortunately, there is still no definite drug for CARDS that is capable of reducing either short-term or long-term mortality and no specific treatments for COVID-19 exist right now. In this narrative review, based on a selective literature search in EMBASE, MEDLINE, Scopus, The Cochrane Library, Web of Science, and Google Scholar and ClinicalTrials.gov, we have examined the emerging evidence on the possible treatment of CARDS. Although numerous pharmacologic therapies to improve clinical outcomes in CARDS have been studied also in clinical trials, none have shown efficacy and there is great uncertainty about their effectiveness. There is still no recommendation for the therapeutic use of any specific agent to treat CARDS because no drugs are validated to have significant efficacy in clinical treatment of COVID-19 patients in large-scale trials. However, there exist a number of drugs that may be useful at least in some patients. The real challenge now is to link the right patient to the right treatment.
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Affiliation(s)
- Maria Gabriella Matera
- Unit of Pharmacology, Dept. Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Dept. Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Unit of Respiratory Disease and Lung Function Dept. Medicine and Surgery, University of Parma, Parma, Italy
| | - Mario Cazzola
- Unit of Respiratory Medicine, Dept. Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy.
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McDonnell E, Collins R, Hernandez M, Brown ART. Effect of hydrocortisone versus methylprednisolone on clinical outcomes in oncology patients with septic shock. J Oncol Pharm Pract 2020; 27:54-62. [PMID: 32686618 DOI: 10.1177/1078155220910788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Corticosteroids are used as adjunctive treatment of critical illness-related corticosteroid insufficiency in patients with septic shock. This study aims to compare the impact of hydrocortisone versus methylprednisolone on duration of septic shock in critically ill oncology patients. METHODS Single-center, retrospective cohort study of adult patients receiving hydrocortisone ≥200 mg/day or methylprednisolone ≥40 mg/day with septic shock. The primary outcome was time to shock reversal defined as time to systolic blood pressure ≥90 mmHg without vasopressors for ≥24 h. RESULTS Eighty-eight patients were included, 49 patients received hydrocortisone and 39 patients received methylprednisolone. Solid tumor malignancy was more common in the hydrocortisone group, while hematological malignancy was more common in the methylprednisolone group (p = 0.009). Time to shock reversal was similar between hydrocortisone and methylprednisolone groups (72.4 versus 70.4 h; p = 0.825). Intensive care unit mortality occurred in 51.02% versus 53.85% of patients in hydrocortisone versus methylprednisolone, respectively (p = 0.792). Patients who received methylprednisolone had higher rates of mechanical ventilation (89.74% versus 55.1%, p < 0.001) and longer intensive care unit and hospital lengths of stay (4.2 versus 11.4 days and 14.3 versus 25.7 days; p < 0.001) compared to hydrocortisone. No differences were seen in incidence of steroid-related adverse effects between groups. CONCLUSIONS In oncology patients with septic shock, the use of hydrocortisone versus methylprednisolone does not appear to affect time to shock reversal.
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Affiliation(s)
- Emily McDonnell
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, USA
| | - Reagan Collins
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, USA
| | - Mike Hernandez
- Division of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, USA
| | - Anne Rain T Brown
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, USA
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The Efficacy, Safety, and Optimal Regimen of Corticosteroids in Sepsis: A Bayesian Network Meta-Analysis. Crit Care Explor 2020; 2:e0094. [PMID: 32426736 PMCID: PMC7188436 DOI: 10.1097/cce.0000000000000094] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Supplemental Digital Content is available in the text. Conventional systematic reviews have indicated that corticosteroids might result in a slight reduction in mortality in sepsis. However, the efficacy, safety, and optimal regimen of different corticosteroids partly remain unknown. In this study, we conducted a Bayesian network meta-analysis for a head-to-head comparison of the therapeutic efficacy and safety of currently used corticosteroids in sepsis.
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Tabatabai A, Menaker J, Stene E, Kufera JA, Rabinowitz RP, Kon Z, Herr DL, Scalea TM. Methylprednisolone may be associated with improved lung compliance in acute respiratory distress syndrome patients on veno-venous extracorporeal membrane oxygenation. Perfusion 2020; 35:515-520. [PMID: 32072859 DOI: 10.1177/0267659120906044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Methylprednisolone has been used for acute respiratory distress syndrome with variable results. Veno-venous extracorporeal membrane oxygenation use in acute respiratory distress syndrome has increased. Occasionally, both are used. We hypothesized that methylprednisolone could improve lung compliance and ease weaning from extracorporeal membrane oxygenation in acute respiratory distress syndrome patients. METHODS We retrospectively reviewed all patients in our veno-venous extracorporeal membrane oxygenation unit treated with methylprednisolone over a 20 month period. Methylprednisolone was initiated for inability to wean off veno-venous extracorporeal membrane oxygenation. Dynamic compliance (Cdyn) was calculated at cannulation, methylprednisolone initiation, and decannulation. Demographics, extracorporeal membrane oxygenation-specific data, and ventilator data were collected. Wilcoxon rank-sum test was used to test for differences in dynamic compliance. RESULTS A total of 12 veno-venous extracorporeal membrane oxygenation patients received methylprednisolone. Mean age was 50 (±15) years. Seven had influenza. Methylprednisolone was started on median Day 16 (interquartile range: 11-22) of veno-venous extracorporeal membrane oxygenation. In total, 10 patients had veno-venous extracorporeal membrane oxygenation decannulation on median Day 12 (7-22) after methylprednisolone initiation. Two patients died before decannulation. The 10 decannulated patients had initial median dynamic compliance (mL × cm H2O-1) of 12 (7-23), then 16 (10-24) at methylprednisolone initiation, and then 44 (34-60) at decannulation. Dynamic compliance was higher at decannulation than methylprednisolone initiation (p = 0.002), and unchanged from cannulation to methylprednisolone initiation for all patients (p = 0.97). A total of 10 patients had significant infections. None had significant gastrointestinal bleed or wound healing issues. CONCLUSION Methylprednisolone may be associated with improved compliance in acute respiratory distress syndrome allowing for decannulation from veno-venous extracorporeal membrane oxygenation. High rates of infection are associated with methylprednisolone use in veno-venous extracorporeal membrane oxygenation. Further studies are required to identify appropriate patient selection for methylprednisolone use in patients on veno-venous extracorporeal membrane oxygenation.
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Affiliation(s)
- Ali Tabatabai
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jay Menaker
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Edward Stene
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joseph A Kufera
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ronald P Rabinowitz
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Zachary Kon
- NYU Langone Medical Center, New York, NY, USA
| | - Daniel L Herr
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
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Livesay S, Fried H, Gagnon D, Karanja N, Lele A, Moheet A, Olm-Shipman C, Taccone F, Tirschwell D, Wright W, Claude Hemphill Iii J. Clinical Performance Measures for Neurocritical Care: A Statement for Healthcare Professionals from the Neurocritical Care Society. Neurocrit Care 2020; 32:5-79. [PMID: 31758427 DOI: 10.1007/s12028-019-00846-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Performance measures are tools to measure the quality of clinical care. To date, there is no organized set of performance measures for neurocritical care. METHODS The Neurocritical Care Society convened a multidisciplinary writing committee to develop performance measures relevant to neurocritical care delivery in the inpatient setting. A formal methodology was used that included systematic review of the medical literature for 13 major neurocritical care conditions, extraction of high-level recommendations from clinical practice guidelines, and development of a measurement specification form. RESULTS A total of 50,257 citations were reviewed of which 150 contained strong recommendations deemed suitable for consideration as neurocritical care performance measures. Twenty-one measures were developed across nine different conditions and two neurocritical care processes of care. CONCLUSIONS This is the first organized Neurocritical Care Performance Measure Set. Next steps should focus on field testing to refine measure criteria and assess implementation.
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Affiliation(s)
- Sarah Livesay
- College of Nursing, Rush University, Chicago, IL, USA.
| | | | - David Gagnon
- Maine Medical Center Department of Pharmacy, Portland, ME, USA
| | - Navaz Karanja
- Departments of Neurosciences and Anesthesiology, University of California-San Diego, San Diego, CA, USA
| | - Abhijit Lele
- Department of Anesthesiology and Pain Medicine, Neurocritical Care Service, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Asma Moheet
- OhioHealth Riverside Methodist Hospital, Columbus, OH, USA
| | - Casey Olm-Shipman
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | - Fabio Taccone
- Department of Intensive Care of Hospital Erasme, Brussels, Belgium
| | - David Tirschwell
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Wendy Wright
- Departments of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
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22
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Azoulay E, Russell L, Van de Louw A, Metaxa V, Bauer P, Povoa P, Montero JG, Loeches IM, Mehta S, Puxty K, Schellongowski P, Rello J, Mokart D, Lemiale V, Mirouse A. Diagnosis of severe respiratory infections in immunocompromised patients. Intensive Care Med 2020; 46:298-314. [PMID: 32034433 PMCID: PMC7080052 DOI: 10.1007/s00134-019-05906-5] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 12/19/2019] [Indexed: 12/23/2022]
Abstract
An increasing number of critically ill patients are immunocompromised. Acute hypoxemic respiratory failure (ARF), chiefly due to pulmonary infection, is the leading reason for ICU admission. Identifying the cause of ARF increases the chances of survival, but may be extremely challenging, as the underlying disease, treatments, and infection combine to create complex clinical pictures. In addition, there may be more than one infectious agent, and the pulmonary manifestations may be related to both infectious and non-infectious insults. Clinically or microbiologically documented bacterial pneumonia accounts for one-third of cases of ARF in immunocompromised patients. Early antibiotic therapy is recommended but decreases the chances of identifying the causative organism(s) to about 50%. Viruses are the second most common cause of severe respiratory infections. Positive tests for a virus in respiratory samples do not necessarily indicate a role for the virus in the current acute illness. Invasive fungal infections (Aspergillus, Mucorales, and Pneumocystis jirovecii) account for about 15% of severe respiratory infections, whereas parasites rarely cause severe acute infections in immunocompromised patients. This review focuses on the diagnosis of severe respiratory infections in immunocompromised patients. Special attention is given to newly validated diagnostic tests designed to be used on non-invasive samples or bronchoalveolar lavage fluid and capable of increasing the likelihood of an early etiological diagnosis.
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Affiliation(s)
- Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France.
- Université de Paris, Paris, France.
| | - Lene Russell
- Department of Intensive Care, Rigshospitalet and Copenhagen Academy for Medical Simulation and Education, University of Copenhagen, Copenhagen, Denmark
| | - Andry Van de Louw
- Division of Pulmonary and Critical Care, Penn State University College of Medicine, Hershey, PA, USA
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Philippe Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Pedro Povoa
- Polyvalent Intensive Care Unit, Hospital de São Francisco Xavier, NOVA Medical School, New University of Lisbon, Lisbon, Portugal
| | - José Garnacho Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Ignacio Martin Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, St James Street, Dublin 8, Ireland
| | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Kathryn Puxty
- Department of Intensive Care, Glasgow Royal Infirmary, Glasgow, UK
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit 13i2, Comprehensive Cancer Center, Center of Excellence in Medical Intensive Care (CEMIC), Medical University of Vienna, Vienna, Austria
| | - Jordi Rello
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto Salud Carlos III, Madrid, Spain
- CRIPS Department, Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain
| | - Djamel Mokart
- Critical Care Department, Institut Paoli Calmettes, Marseille, France
| | - Virginie Lemiale
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France
| | - Adrien Mirouse
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France
- Université de Paris, Paris, France
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23
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Lemieux SM, Levine AR. Low-dose corticosteroids in septic shock: Has the pendulum shifted? Am J Health Syst Pharm 2020; 76:493-500. [PMID: 30851043 DOI: 10.1093/ajhp/zxz017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE The utility of low-dose corticosteroids in septic shock is reviewed. SUMMARY Low-dose corticosteroids are suggested as treatment for septic shock patients who remain hemodynamically unstable despite adequate fluid resuscitation and vasopressor therapy. However, the risks and benefits of corticosteroids are unclear in this patient population. Previous multicenter trials have yielded conflicting results on the survival benefits of corticosteroids. The recently published Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock (ADRENAL) and Activated Protein C and Corticosteroids for Human Septic Shock (APROCCHSS) trials provide valuable but opposing insight into this ongoing debate. Discordant findings related to mortality in these trials are likely related to differences in study design, corticosteroid regimen, and baseline characteristics among enrolled patients. The utility of adding fludrocortisone to hydrocortisone compared with using hydrocortisone alone is unclear. There does not appear to be an advantage to administering corticosteroids as a continuous infusion to reduce the rate of hyperglycemia or providing a taper to prevent rebound hypotension. CONCLUSION The mortality benefit of corticosteroids appears to be greatest in septic shock patients with high vasopressor requirements, evidence of multiorgan failure, and primary lung infections. Corticosteroids consistently lead to a faster reversal of shock and may shorten the duration of mechanical ventilation. Corticosteroids do not seem to increase the risk of superinfection at low doses but frequently lead to a higher frequency of hyperglycemia. We recommend the administration of corticosteroids to septic shock patients with escalating doses of vasopressors and evidence of multiorgan dysfunction.
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Affiliation(s)
- Steven M Lemieux
- University of Saint Joseph School of Pharmacy and Physician Assistant Studies, Hartford, CT.,Department of Pharmacy Services, Yale New Haven Hospital, New Haven, CT
| | - Alexander R Levine
- University of Saint Joseph School of Pharmacy and Physician Assistant Studies, Hartford, CT.,Department of Pharmacy, Saint Francis Hospital and Medical Center, Hartford, CT
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Chen X, Chai Y, Wang SB, Wang JC, Yue SY, Jiang RC, Zhang JN. Risk factors for corticosteroid insufficiency during the sub-acute phase of acute traumatic brain injury. Neural Regen Res 2020; 15:1259-1265. [PMID: 31960811 PMCID: PMC7047797 DOI: 10.4103/1673-5374.272611] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Hypothalamic-pituitary-adrenal axis dysfunction may lead to the occurrence of critical illness-related corticosteroid insufficiency. Critical illness-related corticosteroid insufficiency can easily occur after traumatic brain injury, but few studies have examined this occurrence. A multicenter, prospective, cohort study was performed to evaluate the function of the hypothalamic-pituitary-adrenal axis and the incidence of critical illness-related corticosteroid insufficiency during the sub-acute phase of traumatic brain injury. One hundred and forty patients with acute traumatic brain injury were enrolled from the neurosurgical departments of three tertiary-level hospitals in China, and the critical illness-related corticosteroid insufficiency incidence, critical-illness-related corticosteroid insufficiency-related risk factors, complications, and 28-day mortality among these patients was recorded. Critical illness-related corticosteroid insufficiency was diagnosed in patients with plasma total cortisol levels less than 10 μg/dL (275.9 nM) on post-injury day 4 or when serum cortisol was insufficiently suppressed (less than 50%) during a dexamethasone suppression test on post-injury day 5. The results demonstrated that critical illness-related corticosteroid insufficiency occurred during the sub-acute phase of traumatic brain injury in 5.6% of patients with mild injury, 22.5% of patients with moderate injury, and 52.2% of patients with severe injury. Traumatic brain injury-induced critical illness-related corticosteroid insufficiency was strongly correlated to injury severity during the sub-acute stage of traumatic brain injury. Traumatic brain injury patients with critical illness-related corticosteroid insufficiency frequently presented with hemorrhagic cerebral contusions, diffuse axonal injury, brain herniation, and hypotension. Differences in the incidence of hospital-acquired pneumonia, gastrointestinal bleeding, and 28-day mortality were observed between patients with and without critical illness-related corticosteroid insufficiency during the sub-acute phase of traumatic brain injury. Hypotension, brain-injury severity, and the types of traumatic brain injury were independent risk factors for traumatic brain injury-induced critical illness-related corticosteroid insufficiency. These findings indicate that critical illness-related corticosteroid insufficiency is common during the sub-acute phase of traumatic brain injury and is strongly associated with poor prognosis. The dexamethasone suppression test is a practical assay for the evaluation of hypothalamic-pituitary-adrenal axis function and for the diagnosis of critical illness-related corticosteroid insufficiency in patients with traumatic brain injury, especially those with hypotension, hemorrhagic cerebral contusions, diffuse axonal injury, and brain herniation. Sub-acute infection of acute traumatic brain injury may be an important factor associated with the occurrence and development of critical illness-related corticosteroid insufficiency. This study protocol was approved by the Ethics Committee of General Hospital of Tianjin Medical University, China in December 2011 (approval No. 201189).
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Affiliation(s)
- Xin Chen
- Department of Neurosurgery, General Hospital of Tianjin Medical University, Tianjin, China
| | - Yan Chai
- Tianjin Neurological Institute; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China
| | - Shao-Bo Wang
- Department of Neurosurgery, Ordos Central Hospital, Ordos, Inner Mongolia Autonomous Region, China
| | - Jia-Chong Wang
- Department of Neurosurgery, Affiliated Haikou Hospital of Xiangya Medical College, Central South University, Changsha, Hunan Province, China
| | - Shu-Yuan Yue
- Department of Neurosurgery, General Hospital of Tianjin Medical University, Tianjin, China
| | - Rong-Cai Jiang
- Department of Neurosurgery, General Hospital of Tianjin Medical University, Tianjin, China
| | - Jian-Ning Zhang
- Tianjin Neurological Institute; Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education; Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, China
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25
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Gavrilovic S, Andrijevic A, Mujakovic A, Odeyemi Y, Paralija B, Gajic O. Adjunct corticosteroid treatment in patients with pneumonia: A precision medicine approach. Bosn J Basic Med Sci 2019; 19:315-320. [PMID: 30640592 PMCID: PMC6868487 DOI: 10.17305/bjbms.2019.3977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 12/18/2018] [Indexed: 01/29/2023] Open
Abstract
Pneumonia is the leading infectious cause of death worldwide. While inflammation is critically important in host response to microbial invasion, exaggerated inflammation can damage the lungs, contributing to respiratory failure and mortality. Corticosteroids are effective in reducing inflammation and can also cause immune suppression. Presently, clinicians are unable to reliably distinguish between exaggerated and appropriate immune response and thus cannot rapidly identify patients most likely to benefit from adjunctive corticosteroids. In this review, we propose a biomarker-guided, precision medicine approach to corticosteroid treatment, aimed to give these medications at appropriate dose and time and only to patients who have exaggerated inflammation.
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Affiliation(s)
- Srdjan Gavrilovic
- Intensive Care Unit, Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.
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Chalmers S, Khawaja A, Wieruszewski PM, Gajic O, Odeyemi Y. Diagnosis and treatment of acute pulmonary inflammation in critically ill patients: The role of inflammatory biomarkers. World J Crit Care Med 2019. [DOI: 10.5492/wjccm.v8.i5.74] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Chalmers S, Khawaja A, Wieruszewski PM, Gajic O, Odeyemi Y. Diagnosis and treatment of acute pulmonary inflammation in critically ill patients: The role of inflammatory biomarkers. World J Crit Care Med 2019; 8:59-71. [PMID: 31559145 PMCID: PMC6753396 DOI: 10.5492/wjccm.v8.i5.59] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/02/2019] [Accepted: 08/06/2019] [Indexed: 02/06/2023] Open
Abstract
Pneumonia and acute respiratory distress syndrome are common and important causes of respiratory failure in the intensive care unit with a significant impact on morbidity, mortality and health care utilization despite early antimicrobial therapy and lung protective mechanical ventilation. Both clinical entities are characterized by acute pulmonary inflammation in response to direct or indirect lung injury. Adjunct anti-inflammatory treatment with corticosteroids is increasingly used, although the evidence for benefit is limited. The treatment decisions are based on radiographic, clinical and physiological variables without regards to inflammatory state. Current evidence suggests a role of biomarkers for the assessment of severity, and distinguishing sub-phenotypes (hyper-inflammatory versus hypo-inflammatory) with important prognostic and therapeutic implications. Although many inflammatory biomarkers have been studied the most common and of interest are C-reactive protein, procalcitonin, and pro-inflammatory cytokines including interleukin 6. While extensively studied as prognostic tools (prognostic enrichment), limited data are available for the role of biomarkers in determining appropriate initiation, timing and dosing of adjunct anti-inflammatory treatment (predictive enrichment).
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Affiliation(s)
- Sarah Chalmers
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Ali Khawaja
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Patrick M Wieruszewski
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, United States
| | - Ognjen Gajic
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Yewande Odeyemi
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
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Topjian AA, de Caen A, Wainwright MS, Abella BS, Abend NS, Atkins DL, Bembea MM, Fink EL, Guerguerian AM, Haskell SE, Kilgannon JH, Lasa JJ, Hazinski MF. Pediatric Post–Cardiac Arrest Care: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e194-e233. [DOI: 10.1161/cir.0000000000000697] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Successful resuscitation from cardiac arrest results in a post–cardiac arrest syndrome, which can evolve in the days to weeks after return of sustained circulation. The components of post–cardiac arrest syndrome are brain injury, myocardial dysfunction, systemic ischemia/reperfusion response, and persistent precipitating pathophysiology. Pediatric post–cardiac arrest care focuses on anticipating, identifying, and treating this complex physiology to improve survival and neurological outcomes. This scientific statement on post–cardiac arrest care is the result of a consensus process that included pediatric and adult emergency medicine, critical care, cardiac critical care, cardiology, neurology, and nursing specialists who analyzed the past 20 years of pediatric cardiac arrest, adult cardiac arrest, and pediatric critical illness peer-reviewed published literature. The statement summarizes the epidemiology, pathophysiology, management, and prognostication after return of sustained circulation after cardiac arrest, and it provides consensus on the current evidence supporting elements of pediatric post–cardiac arrest care.
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29
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Major publications in critical care pharmacotherapy literature in 2018. J Crit Care 2019; 52:200-207. [DOI: 10.1016/j.jcrc.2019.04.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/22/2019] [Accepted: 04/27/2019] [Indexed: 01/21/2023]
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30
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Coiffard B, Diallo AB, Culver A, Mezouar S, Hammad E, Vigne C, Nicolino-Brunet C, Dignat-George F, Baumstarck K, Boucekine M, Leone M, Mege JL. Circadian Rhythm Disruption and Sepsis in Severe Trauma Patients. Shock 2019; 52:29-36. [PMID: 30074979 DOI: 10.1097/shk.0000000000001241] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Circadian rhythms are important regulators of immune functions. Admission to an intensive care unit may impact molecular clock activity and host response. Our objective was to assess and compare the immune circadian rhythms in trauma patients who develop and in those who do not develop sepsis. METHODS Blood samples were collected from severe trauma patients within 4 days after admission, with collections taking place every 4 h over a 24-h period. Cortisol and cytokines were measured with immunoassays. Whole-blood expression of 3 clock genes (Bmal1, Per2, and Per3) was studied by reverse transcription quantitative polymerase chain reaction. Neutrophils, monocytes, and lymphocytes were analyzed by flow cytometry. Patients with and without sepsis were compared with the cosinor mixed model to estimate mesors, amplitudes, and acrophases. RESULTS Thirty-eight patients were enrolled in the study, and 13 developed at least 1 septic episode. The septic patients had higher levels of cortisol than the nonseptic patients (mesor at 489 nmol/L vs. 405 nmol/L, P < 0.05) and delayed acrophases (22 h vs. 15 h, P < 0.05). They also had lower lymphocyte counts (mesor at 785 vs. 1,012 cells/μL, P < 0.05), higher neutrophil counts (mesor at 7,648 vs. 7,001 cells/μL, P < 0.05), and monocyte counts (mesor at 579 vs. 473 cells/μL, P < 0.05) than the nonseptic patients. Although no amplitude difference was identified, the acrophases were significantly different between the 2 groups for lymphocytes, interleukin 10 and tumor necrosis factor. CONCLUSION We demonstrated that all trauma patients had impaired circadian rhythms of cortisol, cytokines, leukocytes, and clock genes. Early circadian disruption was associated with the occurrence of sepsis and might be a marker of sepsis severity.
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Affiliation(s)
- Benjamin Coiffard
- IRD, AP-HM, MEPHI, IHU-Méditerranée Infection, Aix Marseille Université, Marseille, France
| | - Aissatou B Diallo
- IRD, AP-HM, MEPHI, IHU-Méditerranée Infection, Aix Marseille Université, Marseille, France
| | - Aurélien Culver
- Service d'Anesthésie et de Réanimation, APHM, CHU Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Soraya Mezouar
- IRD, AP-HM, MEPHI, IHU-Méditerranée Infection, Aix Marseille Université, Marseille, France
| | - Emmanuelle Hammad
- Service d'Anesthésie et de Réanimation, APHM, CHU Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Coralie Vigne
- Service d'Anesthésie et de Réanimation, APHM, CHU Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Corine Nicolino-Brunet
- Service d'Hématologie, APHM, CHU La Conception, Aix-Marseille Université, Marseille, France
| | - Françoise Dignat-George
- Service d'Hématologie, APHM, CHU La Conception, Aix-Marseille Université, Marseille, France
- INSERM, VRCM, Aix-Marseille Université, Marseille, France
| | | | | | - Marc Leone
- IRD, AP-HM, MEPHI, IHU-Méditerranée Infection, Aix Marseille Université, Marseille, France
- Service d'Anesthésie et de Réanimation, APHM, CHU Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Jean-Louis Mege
- IRD, AP-HM, MEPHI, IHU-Méditerranée Infection, Aix Marseille Université, Marseille, France
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Ceccato A, Ferrer M, Barbeta E, Torres A. Adjunctive Therapies for Community-Acquired Pneumonia. Clin Chest Med 2018; 39:753-764. [DOI: 10.1016/j.ccm.2018.07.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Lamontagne F, Rochwerg B, Lytvyn L, Guyatt GH, Møller MH, Annane D, Kho ME, Adhikari NKJ, Machado F, Vandvik PO, Dodek P, Leboeuf R, Briel M, Hashmi M, Camsooksai J, Shankar-Hari M, Baraki MK, Fugate K, Chua S, Marti C, Cohen D, Botton E, Agoritsas T, Siemieniuk RAC. Corticosteroid therapy for sepsis: a clinical practice guideline. BMJ 2018; 362:k3284. [PMID: 30097460 PMCID: PMC6083439 DOI: 10.1136/bmj.k3284] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Francois Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Canada
- Centre de recherche du CHU de Sherbrooke, Centre intégré universitaire de santé et de services sociaux - Estrie, Sherbrooke, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Lyubov Lytvyn
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Djillali Annane
- Service de Médecine Intensive et Réanimation, Hôpital Raymond Poincaré, Garches, France
| | - Michelle E Kho
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | - Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Flavia Machado
- Federal University of Sao Paulo, Sao Paulo, Brazil
- Latin America Sepsis Institute, Sao Paulo, Brazil
| | - Per O Vandvik
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
| | - Peter Dodek
- Center for Health Evaluation and Outcome Sciences and Division of Critical Care Medicine, St Paul's Hospital and University of British Columbia, Vancouver, Canada
| | - Rebecca Leboeuf
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Matthias Briel
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Madiha Hashmi
- Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan
| | | | - Manu Shankar-Hari
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- NIHR Clinician Scientist, School of Immunology & Microbial Sciences, Kings College London, United Kingdom
| | | | | | | | - Christophe Marti
- Division of General Internal Medicine, Rehabilitation and Geriatrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Dian Cohen
- Centre de santé de la vallée Massawippi, Ayer's Cliff, Canada
| | - Edouard Botton
- Comité stratégique patient-partenaire, Centre de recherche du CHU de Sherbrooke, Centre intégré universitaire de santé et de services sociaux - Estrie, Sherbrooke, Canada
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Reed A C Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Mongardon N, Savary G, Geri G, El Bejjani MR, Silvera S, Dumas F, Charpentier J, Pène F, Mira JP, Cariou A. Prognostic value of adrenal gland volume after cardiac arrest: Association of CT-scan evaluation with shock and mortality. Resuscitation 2018; 129:135-140. [PMID: 29852197 DOI: 10.1016/j.resuscitation.2018.05.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/18/2018] [Accepted: 05/26/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Adrenal gland volume is associated with survival in septic shock. As sepsis and post-cardiac arrest syndrome share many pathophysiological features, we assessed the association between adrenal gland volume measured by computerized tomography (CT)-scan and post-cardiac arrest shock and intensive care unit (ICU) mortality, in a large cohort of out-of-hospital cardiac arrest (OHCA) patients. We also investigated the association between adrenal hormonal function and both adrenal gland volume and outcomes. PATIENTS AND METHODS Prospective analysis of CT-scan performed at hospital admission in patients admitted after OHCA (2007-2012). A pair of blinded radiologist calculated manually adrenal gland volume. In a subgroup of patients, plasma cortisol was measured at admission and 60 min after a cosyntropin test. Factors associated with post-cardiac arrest shock and ICU mortality were identified using multivariate logistic regression. RESULTS Among 775 patients admitted during this period after OHCA, 138 patients were included: 72 patients (52.2%) developed a post-cardiac arrest shock, and 98 patients (71.1%) died. In univariate analysis, adrenal gland volume was not different between patients with and without post-cardiac arrest shock: 10.6 and 11.3 cm3, respectively (p = 0.9) and between patients discharged alive or dead: 10.2 and 11.8 cm3, respectively (p = 0.4). Multivariate analysis confirmed that total adrenal gland volume was associated neither with post-cardiac arrest shock nor mortality. Neither baseline cortisol level nor delta between baseline and after cosyntropin test cortisol levels were associated with adrenal volume, post-cardiac arrest shock onset or mortality. CONCLUSION After OHCA, adrenal gland volume is not associated with post-cardiac arrest shock onset or ICU mortality. Adrenal gland volume does not predict adrenal gland hormonal response.
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Affiliation(s)
- Nicolas Mongardon
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Guillaume Savary
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Guillaume Geri
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 56 rue Leblanc, 75015 Paris, France
| | - Marie-Rose El Bejjani
- Radiology Department, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Stéphane Silvera
- Radiology Department, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Florence Dumas
- Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 56 rue Leblanc, 75015 Paris, France; Emergency Department, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Julien Charpentier
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Frédéric Pène
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Jean-Paul Mira
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Alain Cariou
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 56 rue Leblanc, 75015 Paris, France.
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