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van Lier D, Picod A, Marx G, Laterre PF, Hartmann O, Knothe C, Azibani F, Struck J, Santos K, Zimmerman J, Bergmann A, Mebazaa A, Pickkers P. Effects of enrichment strategies on outcome of adrecizumab treatment in septic shock: Post-hoc analyses of the phase II adrenomedullin and outcome in septic shock 2 trial. Front Med (Lausanne) 2022; 9:1058235. [PMID: 36530868 PMCID: PMC9751049 DOI: 10.3389/fmed.2022.1058235] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/07/2022] [Indexed: 08/19/2023] Open
Abstract
PURPOSE Adrecizumab, a non-neutralizing antibody of adrenomedullin (ADM) was recently investigated regarding its potential to restore endothelial barrier function in septic shock patients with high plasma ADM levels. Circulating dipeptidyl peptidase 3 (cDPP3), a protease involved in the degradation of several cardiovascular mediators, represents another biological pathway strongly associated with outcome in septic shock, although unrelated to ADM. Therefore, the prognosis of patients with elevated cDPP3 may not be influenced by Adrecizumab. Also, time until initiation of treatment may influence efficacy. OBJECTIVE To evaluate effects of cDPP3-based enrichment on treatment efficacy of Adrecizumab. MATERIALS AND METHODS Post-hoc analysis of AdrenOSS-2, a phase-II, double-blind, randomized, placebo-controlled biomarker-guided trial of Adrecizumab. RESULTS Compared to the total study cohort [HR for 28-day mortality of 0.84 (95% CI 0.53;1.31), p = 0.439], therapeutic benefit of Adrecizumab tended to be more pronounced in the subgroup of 249 patients with low cDPP3 (<50 ng/mL); [HR of 0.61 (95% CI 0.34;1.08), p = 0.085]. Median duration to study drug infusion was 8.5 h. In the subgroup of 129 patients with cDPP3 <50 ng/mL and an early start of treatment (<8.5 h after septic shock diagnosis) HR for 28-day mortality vs. placebo was 0.49 (95% CI 0.21-1.18), p = 0.105. In multivariate interaction analyses corrected for baseline disease severity, both cDPP3, as well as the cDPP3 * treatment interaction term were associated with a reduced HR for 28-day mortality in the Adrecizumab treated group; p = 0.015 for cDPP3 in univariate analysis, p = 0.025 for the interaction term between cDPP3 and treatment group. In contrast, treatment timing was not significantly associated with 28-day mortality in multivariate interaction analyses. DISCUSSION In septic shock patients with high ADM levels, a further post-hoc enrichment strategy based on cDPP3 may indicate (with all the caveats to be considered for post-hoc subgroup analyses) that therapeutic efficacy is most pronounced in patients with lower cDPP3 levels.
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Affiliation(s)
- Dirk van Lier
- Department of Intensive Care Medicine and Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, Netherlands
| | - Adrien Picod
- Anesthésie-Réanimation, Hôpital Lariboisière, AP–HP, Paris, France
| | - Gernot Marx
- Klinik fur Operative Intensivmedizin und Intermediate Care, Universitätsklinikum Aachen, Aachen, Germany
| | - Pierre-François Laterre
- Unité de Soins Intensifs, Cliniques Universitaires Saint-Luc (UCL Bruxelles), Brussels, Belgium
| | | | | | - Feriel Azibani
- Anesthésie-Réanimation, Hôpital Lariboisière, AP–HP, Paris, France
| | | | | | | | - Andreas Bergmann
- Sphingotec GmbH, Hennigsdorf, Germany
- Adrenomed AG, Hennigsdorf, Germany
| | - Alexandre Mebazaa
- Anesthésie-Réanimation, Hôpital Lariboisière, AP–HP, Paris, France
- Université de Paris, U942 Inserm, MASCOT, APHP, Fédération Hospitalo-Universitaire PROMICE, Hôpitaux Universitaires Saint-Louis-Lariboisière, Paris, France
| | - Peter Pickkers
- Department of Intensive Care Medicine and Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, Netherlands
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Di Somma S, Crisanti L. Can Acute Care Biomarkers Change Patient’s Management in Sepsis? EURASIAN JOURNAL OF EMERGENCY MEDICINE 2022. [DOI: 10.4274/eajem.galenos.2022.21.2.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Lundberg OHM, Rosenqvist M, Bronton K, Schulte J, Friberg H, Melander O. Bioactive adrenomedullin in sepsis patients in the emergency department is associated with mortality, organ failure and admission to intensive care. PLoS One 2022; 17:e0267497. [PMID: 35482727 PMCID: PMC9049572 DOI: 10.1371/journal.pone.0267497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 04/08/2022] [Indexed: 11/29/2022] Open
Abstract
Background Adrenomedullin is a vasoactive hormone with potentially prognostic and therapeutic value, which mainly has been investigated in intensive care unit (ICU) settings. The triaging in the emergency department (ED) of patients to the right level of care is crucial for patient outcome. Objectives The primary aim of this study was to investigate the association of bioactive adrenomedullin (bio-ADM) with mortality among sepsis patients in the ED. Secondary aims were to investigate the association of bio-ADM with multiple organ failure (MOF), ICU admission and ED discharge. Methods In this prospective observational cohort study, adult sepsis patients in the ED (2013–2015) had blood samples collected for later batch analysis of bio-ADM. Odds ratios (OR) with 95% confidence interval (CI) for bio-ADM were calculated. Results Bio-ADM in 594 sepsis patients was analyzed of whom 51 died within 28 days (8.6%), 34 developed severe MOF, 27 were ICU admitted and 67 were discharged from the ED. The median (interquartile range) bio-ADM was 36 (26–56) and 63 (42–132) pg/mL among survivors and non-survivors, respectively, 81 (56–156) pg/mL for patients with severe MOF and 77 (42–133) pg/mL for ICU admitted patients. Each log-2 increment of bio-ADM conferred an OR of 2.30 (95% CI 1.74–3.04) for mortality, the adjusted OR was 2.39 (95% CI 1.69–3.39). The area under the receiver operating characteristic curve of a prognostic mortality model based on demographics and biomarkers increased from 0.80 to 0.86 (p = 0.02) when bio-ADM was added. Increasing bio-ADM was associated with severe MOF, ICU admission and ED discharge with adjusted ORs of 3.30 (95% CI 2.13–5.11), 1.75 (95% CI 1.11–2.77) and 0.46 (95% CI 0.32–0.68), respectively. Conclusion Bio-ADM in sepsis patients in the ED is associated with mortality, severe MOF, ICU admission and ED discharge, and may be of clinical importance for triage of sepsis patients in the ED.
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Affiliation(s)
- Oscar H. M. Lundberg
- Department of Clinical Sciences, Anaesthesiology and Intensive Care, Medical Faculty, Lund University, Lund, Sweden
- Department of Intensive and Perioperative Care, Skåne University Hospital, Malmö, Sweden
- * E-mail:
| | - Mari Rosenqvist
- Department of Clinical Sciences, Medical Faculty, Lund University, Malmö, Sweden
- Department of Infectious Diseases, Skåne University Hospital, Malmö, Sweden
| | - Kevin Bronton
- Department of Clinical Sciences, Medical Faculty, Lund University, Malmö, Sweden
- Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | | | - Hans Friberg
- Department of Clinical Sciences, Anaesthesiology and Intensive Care, Medical Faculty, Lund University, Lund, Sweden
- Department of Intensive and Perioperative Care, Skåne University Hospital, Malmö, Sweden
| | - Olle Melander
- Department of Clinical Sciences, Medical Faculty, Lund University, Malmö, Sweden
- Department of Infectious Diseases, Skåne University Hospital, Malmö, Sweden
- Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
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Soussi S, Sharma D, Jüni P, Lebovic G, Brochard L, Marshall JC, Lawler PR, Herridge M, Ferguson N, Del Sorbo L, Feliot E, Mebazaa A, Acton E, Kennedy JN, Xu W, Gayat E, Dos Santos CC. Identifying clinical subtypes in sepsis-survivors with different one-year outcomes: a secondary latent class analysis of the FROG-ICU cohort. Crit Care 2022; 26:114. [PMID: 35449071 PMCID: PMC9022336 DOI: 10.1186/s13054-022-03972-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Late mortality risk in sepsis-survivors persists for years with high readmission rates and low quality of life. The present study seeks to link the clinical sepsis-survivors heterogeneity with distinct biological profiles at ICU discharge and late adverse events using an unsupervised analysis. METHODS In the original FROG-ICU prospective, observational, multicenter study, intensive care unit (ICU) patients with sepsis on admission (Sepsis-3) were identified (N = 655). Among them, 467 were discharged alive from the ICU and included in the current study. Latent class analysis was applied to identify distinct sepsis-survivors clinical classes using readily available data at ICU discharge. The primary endpoint was one-year mortality after ICU discharge. RESULTS At ICU discharge, two distinct subtypes were identified (A and B) using 15 readily available clinical and biological variables. Patients assigned to subtype B (48% of the studied population) had more impaired cardiovascular and kidney functions, hematological disorders and inflammation at ICU discharge than subtype A. Sepsis-survivors in subtype B had significantly higher one-year mortality compared to subtype A (respectively, 34% vs 16%, p < 0.001). When adjusted for standard long-term risk factors (e.g., age, comorbidities, severity of illness, renal function and duration of ICU stay), subtype B was independently associated with increased one-year mortality (adjusted hazard ratio (HR) = 1.74 (95% CI 1.16-2.60); p = 0.006). CONCLUSIONS A subtype with sustained organ failure and inflammation at ICU discharge can be identified from routine clinical and laboratory data and is independently associated with poor long-term outcome in sepsis-survivors. Trial registration NCT01367093; https://clinicaltrials.gov/ct2/show/NCT01367093 .
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Affiliation(s)
- Sabri Soussi
- Interdepartmental Division of Critical Care, Faculty of Medicine, St Michael's Hospital, Keenan Research Centre for Biomedical Science and Institute of Medical Sciences, University of Toronto, 209 Victoria St 7th Floor, Toronto, ON, M5B 1T8, Canada.
| | - Divya Sharma
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, M5B 1W8, Canada.,Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Gerald Lebovic
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, M5B 1W8, Canada.,Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care, Faculty of Medicine, St Michael's Hospital, Keenan Research Centre for Biomedical Science and Institute of Medical Sciences, University of Toronto, 209 Victoria St 7th Floor, Toronto, ON, M5B 1T8, Canada
| | - John C Marshall
- Interdepartmental Division of Critical Care, Faculty of Medicine, St Michael's Hospital, Keenan Research Centre for Biomedical Science and Institute of Medical Sciences, University of Toronto, 209 Victoria St 7th Floor, Toronto, ON, M5B 1T8, Canada
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, University Health Network, and Heart and Stroke Richard Lewar Centre of Excellence in Cardiovascular Research, University of Toronto, Toronto, ON, Canada
| | - Margaret Herridge
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, Toronto General Research Institute, Institute of Medical Science, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Niall Ferguson
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, Toronto General Research Institute, Institute of Medical Science, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Lorenzo Del Sorbo
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, Toronto General Research Institute, Institute of Medical Science, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Elodie Feliot
- Department of Anesthesiology, Critical Care, Lariboisière - Saint-Louis Hospitals, DMU Parabol, AP-HP Nord; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France
| | - Alexandre Mebazaa
- Department of Anesthesiology, Critical Care, Lariboisière - Saint-Louis Hospitals, DMU Parabol, AP-HP Nord; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France
| | - Erica Acton
- Interdepartmental Division of Critical Care, Faculty of Medicine, St Michael's Hospital, Keenan Research Centre for Biomedical Science and Institute of Medical Sciences, University of Toronto, 209 Victoria St 7th Floor, Toronto, ON, M5B 1T8, Canada
| | - Jason N Kennedy
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Etienne Gayat
- Department of Anesthesiology, Critical Care, Lariboisière - Saint-Louis Hospitals, DMU Parabol, AP-HP Nord; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France
| | - Claudia C Dos Santos
- Interdepartmental Division of Critical Care, Faculty of Medicine, St Michael's Hospital, Keenan Research Centre for Biomedical Science and Institute of Medical Sciences, University of Toronto, 209 Victoria St 7th Floor, Toronto, ON, M5B 1T8, Canada
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Takagi K, Levy B, Kimmoun A, Miró Ò, Duarte K, Asakage A, Blet A, Deniau B, Schulte J, Hartmann O, Cotter G, Davison BA, Gayat E, Mebazaa A. Elevated Plasma Bioactive Adrenomedullin and Mortality in Cardiogenic Shock: Results from the OptimaCC Trial. J Clin Med 2021; 10:4512. [PMID: 34640526 PMCID: PMC8509471 DOI: 10.3390/jcm10194512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/26/2021] [Accepted: 09/28/2021] [Indexed: 12/25/2022] Open
Abstract
AIMS Bioactive adrenomedullin (bio-ADM) was recently shown to be a prognostic marker in patients with acute circulatory failure. We investigate the association of bio-ADM with organ injury, functional impairment, and survival in cardiogenic shock (CS). METHODS OptimaCC was a multicenter and randomized trial in 57 patients with CS. In this post-hoc analysis, the primary endpoint was to assess the association between bio-ADM and 30-day all-cause mortality. Secondary endpoints included adverse events and parameters of organ injury or functional impairment. RESULTS Bio-ADM values were higher in 30-day non-survivors than 30-day survivors at inclusion (median (interquartile range) 67.0 (54.6-142.9) pg/mL vs. 38.7 (23.8-63.6) pg/mL, p = 0.010), at 24 h (p = 0.012), and up to 48 h (p = 0.027). Using a bio-ADM cutoff of 53.8 pg/mL, patients with increased bio-ADM had a HR of 3.90 (95% confidence interval 1.43-10.68, p = 0.008) for 30-day all-cause mortality, and similar results were observed even after adjustment for severity scores. Patients with the occurrence of refractory CS had higher bio-ADM value at inclusion (90.7 (59.9-147.7) pg/mL vs. 40.7 (23.0-64.7) pg/mL p = 0.005). Bio-ADM values at inclusion were correlated with pulmonary vascular resistance index, estimated glomerular filtration rate, and N-terminal pro-B-type natriuretic peptide (r = 0.49, r = -0.47, and r = 0.64, respectively; p < 0.001). CONCLUSIONS In CS patients, the values of bio-ADM are associated with some parameters of organ injury and functional impairment and are prognostic for the occurrence of refractory CS and 30-day mortality.
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Affiliation(s)
- Koji Takagi
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, 75010 Paris, France; (K.T.); (A.K.); (A.B.); (B.D.); (G.C.); (B.A.D.); (E.G.)
- Momentum Research, Inc., Chapel Hill, NC 27517, USA
| | - Bruno Levy
- Service de Médecine Intensive et Réanimation Brabois, CHRU de Nancy, 54511 Vandœuvre-lès-Nancy, France;
- U1116, Défaillance Circulatoire Aigue et Chronique, Faculté de Médecine de Nancy, 54500 Vandœuvre-lès-Nancy, France;
- Université de Lorraine, CS25233, CEDEX, 54052 Nancy, France
| | - Antoine Kimmoun
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, 75010 Paris, France; (K.T.); (A.K.); (A.B.); (B.D.); (G.C.); (B.A.D.); (E.G.)
- Service de Médecine Intensive et Réanimation Brabois, CHRU de Nancy, 54511 Vandœuvre-lès-Nancy, France;
- U1116, Défaillance Circulatoire Aigue et Chronique, Faculté de Médecine de Nancy, 54500 Vandœuvre-lès-Nancy, France;
- Université de Lorraine, CS25233, CEDEX, 54052 Nancy, France
| | - Òscar Miró
- Emergency Department, Hospital Clínic, 08036 Barcelona, Catalonia, Spain;
- IDIBAPS (Institut d’Investigacions Biomèdiques August Pi i Sunyer), 08036 Barcelona, Catalonia, Spain
- Medical School, University of Barcelona, 08036 Barcelona, Catalonia, Spain
| | - Kévin Duarte
- U1116, Défaillance Circulatoire Aigue et Chronique, Faculté de Médecine de Nancy, 54500 Vandœuvre-lès-Nancy, France;
- Université de Lorraine, CS25233, CEDEX, 54052 Nancy, France
- INSERM, Centre d’Investigations Cliniques Plurithématique 1433, Institut Lorrain du Cœur et des Vaisseaux, 54500 Vandœuvre-lès-Nancy, France
| | - Ayu Asakage
- Department of Emergency and Critical Care Medicine, Yokohama City Minato Red Cross Hospital, Yokohama 2318682, Japan;
| | - Alice Blet
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, 75010 Paris, France; (K.T.); (A.K.); (A.B.); (B.D.); (G.C.); (B.A.D.); (E.G.)
- Department of Anesthesiology, Critical Care and Burn Center, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, 75010 Paris, France
| | - Benjamin Deniau
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, 75010 Paris, France; (K.T.); (A.K.); (A.B.); (B.D.); (G.C.); (B.A.D.); (E.G.)
- Department of Anesthesiology, Critical Care and Burn Center, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, 75010 Paris, France
| | - Janin Schulte
- SphingoTec, Neuendorfstraße 15A, 16761 Hennigsdorf, Germany; (J.S.); (O.H.)
| | - Oliver Hartmann
- SphingoTec, Neuendorfstraße 15A, 16761 Hennigsdorf, Germany; (J.S.); (O.H.)
| | - Gad Cotter
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, 75010 Paris, France; (K.T.); (A.K.); (A.B.); (B.D.); (G.C.); (B.A.D.); (E.G.)
- Momentum Research, Inc., Chapel Hill, NC 27517, USA
| | - Beth A Davison
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, 75010 Paris, France; (K.T.); (A.K.); (A.B.); (B.D.); (G.C.); (B.A.D.); (E.G.)
- Momentum Research, Inc., Chapel Hill, NC 27517, USA
| | - Etienne Gayat
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, 75010 Paris, France; (K.T.); (A.K.); (A.B.); (B.D.); (G.C.); (B.A.D.); (E.G.)
- Department of Anesthesiology, Critical Care and Burn Center, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, 75010 Paris, France
| | - Alexandre Mebazaa
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, 75010 Paris, France; (K.T.); (A.K.); (A.B.); (B.D.); (G.C.); (B.A.D.); (E.G.)
- Department of Anesthesiology, Critical Care and Burn Center, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, 75010 Paris, France
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Zhao Y, Pu M, Zhang J, Wang Y, Yan X, Yu L, He Z. Recent advancements of nanomaterial-based therapeutic strategies toward sepsis: bacterial eradication, anti-inflammation, and immunomodulation. NANOSCALE 2021; 13:10726-10747. [PMID: 34165483 DOI: 10.1039/d1nr02706a] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Sepsis is a life threatening disease that is caused by a dysregulated host immune response to infection, resulting in tissue damage and organ dysfunction, which account for a high in-hospital mortality (approximately 20%). However, there are still no effective and specific therapeutics for clinical sepsis management. Nanomaterial-based strategies have emerged as promising tools for improving the therapeutic efficacy of sepsis by combating lethal bacterial infection, modulating systemic inflammatory response, preventing multiple organ failure, etc. This review has comprehensively summarized the recent advancements in nanomaterial-based strategies for the management of sepsis and severe complications, in which those nanosystems act either as inherent therapeutics or as nanocarriers for the precise delivery of agents. These formulations mechanically possess antibacterial, anti-inflammatory, immunomodulatory, and anti-oxidative effects, achieving multifunctional synergistic treatment efficacy against sepsis. Furthermore, several cell membrane-derived biomimetic nanoplatforms have been used as decoys to trap and neutralize the pathogenic toxins. The critical role of other adjuvant therapies in sepsis management, including the combination of nanotechnology and stem cell therapy, is also highlighted. Overall, this review provides insights into innovative nanotechnology-based strategies applied in sepsis treatment.
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Affiliation(s)
- Yi Zhao
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, Ocean University of China, China.
| | - Minju Pu
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, Ocean University of China, China.
| | - Jingwen Zhang
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, Ocean University of China, China.
| | - Yanan Wang
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, Ocean University of China, China.
| | - Xuefeng Yan
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, Ocean University of China, China.
| | - Liangmin Yu
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, Ocean University of China, China.
| | - Zhiyu He
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, Ocean University of China, China.
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Mouncey PR, Richards-Belle A, Thomas K, Harrison DA, Sadique MZ, Grieve RD, Camsooksai J, Darnell R, Gordon AC, Henry D, Hudson N, Mason AJ, Saull M, Whitman C, Young JD, Lamontagne F, Rowan KM. Reduced exposure to vasopressors through permissive hypotension to reduce mortality in critically ill people aged 65 and over: the 65 RCT. Health Technol Assess 2021; 25:1-90. [PMID: 33648623 PMCID: PMC7957458 DOI: 10.3310/hta25140] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Vasopressors are administered to critical care patients to avoid hypotension, which is associated with myocardial injury, kidney injury and death. However, they work by causing vasoconstriction, which may reduce blood flow and cause other adverse effects. A mean arterial pressure target typically guides administration. An individual patient data meta-analysis (Lamontagne F, Day AG, Meade MO, Cook DJ, Guyatt GH, Hylands M, et al. Pooled analysis of higher versus lower blood pressure targets for vasopressor therapy septic and vasodilatory shock. Intensive Care Med 2018;44:12-21) suggested that greater exposure, through higher mean arterial pressure targets, may increase risk of death in older patients. OBJECTIVE To estimate the clinical effectiveness and cost-effectiveness of reduced vasopressor exposure through permissive hypotension (i.e. a lower mean arterial pressure target of 60-65 mmHg) in older critically ill patients. DESIGN A pragmatic, randomised clinical trial with integrated economic evaluation. SETTING Sixty-five NHS adult general critical care units. PARTICIPANTS Critically ill patients aged ≥ 65 years receiving vasopressors for vasodilatory hypotension. INTERVENTIONS Intervention - permissive hypotension (i.e. a mean arterial pressure target of 60-65 mmHg). Control (usual care) - a mean arterial pressure target at the treating clinician's discretion. MAIN OUTCOME MEASURES The primary clinical outcome was 90-day all-cause mortality. The primary cost-effectiveness outcome was 90-day incremental net monetary benefit. Secondary outcomes included receipt and duration of advanced respiratory and renal support, mortality at critical care and acute hospital discharge, and questionnaire assessment of cognitive decline and health-related quality of life at 90 days and 1 year. RESULTS Of 2600 patients randomised, 2463 (permissive hypotension, n = 1221; usual care, n = 1242) were analysed for the primary clinical outcome. Permissive hypotension resulted in lower exposure to vasopressors than usual care [mean duration 46.0 vs. 55.9 hours, difference -9.9 hours (95% confidence interval -14.3 to -5.5 hours); total noradrenaline-equivalent dose 31.5 mg vs. 44.3 mg, difference -12.8 mg (95% CI -18.0 mg to -17.6 mg)]. By 90 days, 500 (41.0%) patients in the permissive hypotension group and 544 (43.8%) patients in the usual-care group had died (absolute risk difference -2.85%, 95% confidence interval -6.75% to 1.05%; p = 0.154). Adjustment for prespecified baseline variables resulted in an odds ratio for 90-day mortality of 0.82 (95% confidence interval 0.68 to 0.98) favouring permissive hypotension. There were no significant differences in prespecified secondary outcomes or subgroups; however, patients with chronic hypertension showed a mortality difference favourable to permissive hypotension. At 90 days, permissive hypotension showed similar costs to usual care. However, with higher incremental life-years and quality-adjusted life-years in the permissive hypotension group, the incremental net monetary benefit was positive, but with high statistical uncertainty (£378, 95% confidence interval -£1347 to £2103). LIMITATIONS The intervention was unblinded, with risk of bias minimised through central allocation concealment and a primary outcome not subject to observer bias. The control group event rate was higher than anticipated. CONCLUSIONS In critically ill patients aged ≥ 65 years receiving vasopressors for vasodilatory hypotension, permissive hypotension did not significantly reduce 90-day mortality compared with usual care. The absolute treatment effect on 90-day mortality, based on 95% confidence intervals, was between a 6.8-percentage reduction and a 1.1-percentage increase in mortality. FUTURE WORK Future work should (1) update the individual patient data meta-analysis, (2) explore approaches for evaluating heterogeneity of treatment effect and (3) explore 65 trial conduct, including use of deferred consent, to inform future trials. TRIAL REGISTRATION Current Controlled Trials ISRCTN10580502. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 14. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Alvin Richards-Belle
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Karen Thomas
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - M Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard D Grieve
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Julie Camsooksai
- Critical Care, Research and Innovation, Poole Hospital NHS Foundation Trust, Poole, UK
| | - Robert Darnell
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
- Intensive Care Unit, Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | | | - Nicholas Hudson
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Alexina J Mason
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Michelle Saull
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | | | - J Duncan Young
- Kadoorie Centre for Critical Care Research and Education, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - François Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de Recherche du Centre Hospitalier, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
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8
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Carsetti A, Bignami E, Cortegiani A, Donadello K, Donati A, Foti G, Grasselli G, Romagnoli S, Antonelli M, DE Blasio E, Forfori F, Guarracino F, Scolletta S, Tritapepe L, Scudeller L, Cecconi M, Girardis M. Good clinical practice for the use of vasopressor and inotropic drugs in critically ill patients: state-of-the-art and expert consensus. Minerva Anestesiol 2021; 87:714-732. [PMID: 33432794 DOI: 10.23736/s0375-9393.20.14866-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Vasopressors and inotropic agents are widely used in critical care. However, strong evidence supporting their use in critically ill patients is lacking in many clinical scenarios. Thus, the Italian Society of Anesthesia and Intensive Care (SIAARTI) promoted a project aimed to provide indications for good clinical practice on the use of vasopressors and inotropes, and on the management of critically ill patients with shock. A panel of 16 experts in the field of intensive care medicine and hemodynamics has been established. Systematic review of the available literature was performed based on PICO questions. Basing on available evidence, the panel prepared a summary of evidence and then wrote the clinical questions. A modified semi-quantitative RAND/UCLA appropriateness method has been used to determine the appropriateness of specific clinical scenarios. The panel identified 29 clinical questions for the use of vasopressors and inotropes in patients with septic shock and cardiogenic shock. High level of agreement exists among the panel members about appropriateness of inotropes/vasopressors' use in patients with septic shock and cardiogenic shock.
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Affiliation(s)
- Andrea Carsetti
- Anesthesia and Intensive Care Unit, Ospedali Riuniti University Hospital, Ancona, Italy - .,Department of Biomedical Sciences and Public Health, Polytechnic University of Marche, Ancona, Italy -
| | - Elena Bignami
- Division of Anesthesiology, Critical Care and Pain Medicine, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science, Section of Anesthesia, Analgesia, Intensive Care and Emergency, Paolo Giaccone Polyclinic Hospital, University of Palermo, Palermo, Italy
| | - Katia Donadello
- Anesthesia and Intensive Care B Unit, Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy
| | - Abele Donati
- Anesthesia and Intensive Care Unit, Ospedali Riuniti University Hospital, Ancona, Italy.,Department of Biomedical Sciences and Public Health, Polytechnic University of Marche, Ancona, Italy
| | - Giuseppe Foti
- Department of Anesthesia and Intensive Care, ASST Monza, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Giacomo Grasselli
- Department of Anesthesiology, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Stefano Romagnoli
- Section of Anesthesiology and Intensive Care, Department of Health Science, University of Florence, Careggi University Hospital, Florence, Italy
| | - Massimo Antonelli
- Department of Anesthesiology Emergency and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Francesco Forfori
- Department of Anesthesia and Intensive Care, University of Pisa, Pisa Italy
| | - Fabio Guarracino
- Department of Anesthesia and Critical Care Medicine, Pisana University Hospital, Pisa, Italy
| | - Sabino Scolletta
- Anesthesia and Intensive Care Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Luigi Tritapepe
- Anesthesia and Intensive Care Unit, San Camillo-Forlanini Hospital, Rome, Italy
| | - Luigia Scudeller
- Scientific Direction, IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Units, Humanitas Clinical and Research Hospital, IRCCS, Rozzano, Milan, Italy and Department of Biomedical Science, Humanitas University, Rozzano, Milan, Italy
| | - Massimo Girardis
- Department of Anesthesia and Intensive Care, Modena University Hospital, Modena, Italy
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9
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Castello LM, Gavelli F, Baldrighi M, Salmi L, Mearelli F, Fiotti N, Patrucco F, Bellan M, Sainaghi PP, Ronzoni G, Di Somma S, Lupia E, Muiesan ML, Biolo G, Avanzi GC. Hypernatremia and moderate-to-severe hyponatremia are independent predictors of mortality in septic patients at emergency department presentation: A sub-group analysis of the need-speed trial. Eur J Intern Med 2021; 83:21-27. [PMID: 33160790 DOI: 10.1016/j.ejim.2020.10.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/03/2020] [Accepted: 10/05/2020] [Indexed: 12/15/2022]
Abstract
STUDY OBJECTIVE Early risk stratification of septic patients presenting to the emergency department (ED) is challenging. The aim of the study was to evaluate the prognostic role of plasmatic sodium level (PNa+) derangements at ED presentation in septic patients. METHODS According to PNa+ at ED presentation patients were divided in eunatremic (136-145 mEq/L), hypernatremic (>145 mEq/L) and hyponatremic (<136 mEq/L). Hyponatremic patients were subsequently divided in mild (130-135 mEq/L), moderate (125-129 mEq/L) and severe (<125 mEq/L). 7 and 30-day mortality was evaluated according to PNa+ derangements and the degree of hyponatremia. The same analysis was then performed only in respiratory tract infection-related (RTI-r) sepsis patients. RESULTS 879 septic patients were included in this analysis, 40.3% had hyponatremia, 5.7% hypernatremia. Hypernatremia showed higher mortality rates at both endpoints compared to eunatremia and hyponatremia (p<0.0001 for both). Eunatremia and mild hyponatremia were compared vs. moderate-to-severe hyponatremia showing a significant difference in terms of 7 and 30-day survival (p = 0.004 and p = 0.007, respectively). The Cox proportional model identified as independent predictors of 7 and 30-day mortality moderate-to-severe hyponatremia (HR 4.89[2.38-10.03] and 1.79[1.07-3.01], respectively) and hypernatremia (HR 3.52[1.58-7.82] and 2.14[1.17-3.92], respectively). The same analysis was performed in patients with respiratory tract infection-related sepsis (n = 549), with similar results. CONCLUSION Both hypernatremia and moderate-to-severe hyponatremia at ED presentation independently predict mortality in septic patients, allowing early risk stratification and suggesting more aggressive therapeutic strategies.
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Affiliation(s)
- Luigi Mario Castello
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy; Emergency Medicine Department AOU Maggiore della Carità, Novara, Italy
| | - Francesco Gavelli
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy; Emergency Medicine Department AOU Maggiore della Carità, Novara, Italy.
| | - Marco Baldrighi
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy; Emergency Medicine Department AOU Maggiore della Carità, Novara, Italy
| | - Livia Salmi
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Filippo Mearelli
- Unit of Internal Medicine, Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Nicola Fiotti
- Unit of Internal Medicine, Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Filippo Patrucco
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Mattia Bellan
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Pier Paolo Sainaghi
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Giulia Ronzoni
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Salvatore Di Somma
- Unit of Emergency Medicine, Department of Medical Surgery Sciences and Translational medicine, University "Sapienza" of Rome, Rome, Italy
| | - Enrico Lupia
- Unit of Emergency Medicine, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Maria Lorenza Muiesan
- Unit of Internal Medicine, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Gianni Biolo
- Unit of Internal Medicine, Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Gian Carlo Avanzi
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy; Emergency Medicine Department AOU Maggiore della Carità, Novara, Italy
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10
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Abstract
Adrenomedullin (ADM) is a 52 amino acid containing free circulating vasoactive peptide hormone found to be active in various pathophysiological states including sepsis. High ADM levels at admission have been correlated with vasopressor requirements, organ dysfunction, and mortality in sepsis patients. ADM stimulation results in vasodilation and loss of vascular resistance in humans resulting in hypotension with the potential for negative impact in septic shock. However, in vitro human and animal experiments have shown that ADM decreases hyperpermeability and capillary leak, thus having an endothelial barrier stabilizing effect during septic shock. Adrenomedullin thus appears to be a double-edged weapon. This editorial critically reviews the article by Daga et al. who evaluated serum ADM as a prognostic marker to review the gender-related difference in mortality pattern, and also the correlation of ADM level to APACHE II and SOFA scores. The role of adrenomedullin in sepsis and the potential developments in the future have been discussed concisely. How to cite this article: Ajith Kumar AK. Adrenomedullin in Sepsis: Finally, a Friend or an Enemy? Indian J Crit Care Med 2020;24(12):1151-1153.
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Affiliation(s)
- AK Ajith Kumar
- Department of Critical Care, Manipal Hospitals, Bengaluru, Karnataka, India
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11
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Lundberg OHM, Lengquist M, Spångfors M, Annborn M, Bergmann D, Schulte J, Levin H, Melander O, Frigyesi A, Friberg H. Circulating bioactive adrenomedullin as a marker of sepsis, septic shock and critical illness. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:636. [PMID: 33148300 PMCID: PMC7641835 DOI: 10.1186/s13054-020-03351-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 10/16/2020] [Indexed: 12/13/2022]
Abstract
Background Biomarkers can be of help to understand critical illness and to identify and stratify sepsis. Adrenomedullin is a vasoactive hormone, with reported prognostic and potentially therapeutic value in sepsis. The primary aim of this study was to investigate the association of circulating bioactive adrenomedullin (bio-ADM) levels at intensive care unit (ICU) admission with mortality in sepsis patients and in a general ICU population. Secondary aims included the association of bio-ADM with organ failure and the ability of bio-ADM to identify sepsis. Methods In this retrospective observational study, adult patients admitted to one of four ICUs during 2016 had admission bio-ADM levels analysed. Age-adjusted odds ratios (OR) with 95% CI for log-2 transformed bio-ADM, and Youden’s index derived cut-offs were calculated. The primary outcome was 30-day mortality, and secondary outcomes included the need for organ support and the ability to identify sepsis. Results Bio-ADM in 1867 consecutive patients were analysed; 632 patients fulfilled the sepsis-3 criteria of whom 267 had septic shock. The median bio-ADM in the entire ICU population was 40 pg/mL, 74 pg/mL in sepsis patients, 107 pg/mL in septic shock and 29 pg/mL in non-septic patients. The association of elevated bio-ADM and mortality in sepsis patients and the ICU population resulted in ORs of 1.23 (95% CI 1.07–1.41) and 1.22 (95% CI 1.12–1.32), respectively. The association with mortality remained after additional adjustment for lactate in sepsis patients. Elevated bio-ADM was associated with an increased need for dialysis with ORs of 2.28 (95% CI 2.01–2.59) and 1.97 (95% CI 1.64–2.36) for the ICU population and sepsis patients, respectively, and with increased need of vasopressors, OR 1.33 (95% CI 1.23–1.42) (95% CI 1.17–1.50) for both populations. Sepsis was identified with an OR of 1.78 (95% CI 1.64–1.94) for bio-ADM, after additional adjustment for severity of disease. A bio-ADM cut-off of 70 pg/mL differentiated between survivors and non-survivors in sepsis, but a Youden’s index derived threshold of 108 pg/mL performed better. Conclusions Admission bio-ADM is associated with 30-day mortality and organ failure in sepsis patients as well as in a general ICU population. Bio-ADM may be a morbidity-independent sepsis biomarker.
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Affiliation(s)
- Oscar H M Lundberg
- Department of Clinical Medicine, Anaesthesiology and Intensive Care, Lund University, 22185, Lund, Sweden. .,Department of Intensive and Perioperative Care, Skåne University Hospital, 20502, Malmö, Sweden.
| | - Maria Lengquist
- Department of Clinical Medicine, Anaesthesiology and Intensive Care, Lund University, 22185, Lund, Sweden.,Department of Intensive and Perioperative Care, Skåne University Hospital, 20502, Malmö, Sweden
| | - Martin Spångfors
- Department of Clinical Medicine, Anaesthesiology and Intensive Care, Lund University, 22185, Lund, Sweden.,Department of Anaesthesia and Intensive Care, Kristianstad Hospital, 29133, Kristianstad, Sweden
| | - Martin Annborn
- Department of Clinical Medicine, Anaesthesiology and Intensive Care, Lund University, 22185, Lund, Sweden.,Department of Anaesthesia and Intensive Care, Helsingborg Hospital, 25437, Helsingborg, Sweden
| | | | | | - Helena Levin
- Department of Clinical Medicine, Anaesthesiology and Intensive Care, Lund University, 22185, Lund, Sweden
| | - Olle Melander
- Department of Infectious diseases, Skåne University Hospital, 20502, Malmö, Sweden.,Department of Internal medicine, Skåne University Hospital, 20502, Malmö, Sweden
| | - Attila Frigyesi
- Department of Clinical Medicine, Anaesthesiology and Intensive Care, Lund University, 22185, Lund, Sweden.,Department of Intensive and Perioperative Care, Skåne University Hospital, 20502, Malmö, Sweden
| | - Hans Friberg
- Department of Clinical Medicine, Anaesthesiology and Intensive Care, Lund University, 22185, Lund, Sweden.,Department of Intensive and Perioperative Care, Skåne University Hospital, 20502, Malmö, Sweden
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12
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Lamontagne F, Richards-Belle A, Thomas K, Harrison DA, Sadique MZ, Grieve RD, Camsooksai J, Darnell R, Gordon AC, Henry D, Hudson N, Mason AJ, Saull M, Whitman C, Young JD, Rowan KM, Mouncey PR. Effect of Reduced Exposure to Vasopressors on 90-Day Mortality in Older Critically Ill Patients With Vasodilatory Hypotension: A Randomized Clinical Trial. JAMA 2020; 323:938-949. [PMID: 32049269 PMCID: PMC7064880 DOI: 10.1001/jama.2020.0930] [Citation(s) in RCA: 160] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 01/23/2020] [Indexed: 12/19/2022]
Abstract
Importance Vasopressors are commonly administered to intensive care unit (ICU) patients to raise blood pressure. Balancing risks and benefits of vasopressors is a challenge, particularly in older patients. Objective To determine whether reducing exposure to vasopressors through permissive hypotension (mean arterial pressure [MAP] target, 60-65 mm Hg) reduces mortality at 90 days in ICU patients aged 65 years or older with vasodilatory hypotension. Design, Setting, and Participants A multicenter, pragmatic, randomized clinical trial was conducted in 65 ICUs in the United Kingdom and included 2600 randomized patients aged 65 years or older with vasodilatory hypotension (assessed by treating clinician). The study was conducted from July 2017 to March 2019, and follow-up was completed in August 2019. Interventions Patients were randomized 1:1 to vasopressors guided either by MAP target (60-65 mm Hg, permissive hypotension) (n = 1291) or according to usual care (at the discretion of treating clinicians) (n = 1307). Main Outcome and Measures The primary clinical outcome was all-cause mortality at 90 days. Results Of 2600 randomized patients, after removal of those who declined or had withdrawn consent, 2463 (95%) were included in the analysis of the primary outcome (mean [SD] age 75 years [7 years]; 1387 [57%] men). Patients randomized to the permissive hypotension group had lower exposure to vasopressors compared with those in the usual care group (median duration 33 hours vs 38 hours; difference in medians, -5.0; 95% CI, -7.8 to -2.2 hours; total dose in norepinephrine equivalents median, 17.7 mg vs 26.4 mg; difference in medians, -8.7 mg; 95% CI, -12.8 to -4.6 mg). At 90 days, 500 of 1221 (41.0%) in the permissive hypotension compared with 544 of 1242 (43.8%) in the usual care group had died (absolute risk difference, -2.85%; 95% CI, -6.75 to 1.05; P = .15) (unadjusted relative risk, 0.93; 95% CI, 0.85-1.03). When adjusted for prespecified baseline variables, the odds ratio for 90-day mortality was 0.82 (95% CI, 0.68 to 0.98). Serious adverse events were reported for 79 patients (6.2%) in the permissive care group and 75 patients (5.8%) in the usual care group. The most common serious adverse events were acute renal failure (41 [3.2%] vs 33 [2.5%]) and supraventricular cardiac arrhythmia (12 [0.9%] vs 13 [1.0%]). Conclusions and Relevance Among patients 65 years or older receiving vasopressors for vasodilatory hypotension, permissive hypotension compared with usual care did not result in a statistically significant reduction in mortality at 90 days. However, the confidence interval around the point estimate for the primary outcome should be considered when interpreting the clinical importance of the study. Trial Registration isrctn.org Identifier: ISRCTN10580502.
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Affiliation(s)
- François Lamontagne
- Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Alvin Richards-Belle
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Karen Thomas
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - David A. Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - M. Zia Sadique
- London School of Hygiene and Tropical Medicine, Department of Health Services Research and Policy, London, United Kingdom
| | - Richard D. Grieve
- London School of Hygiene and Tropical Medicine, Department of Health Services Research and Policy, London, United Kingdom
| | - Julie Camsooksai
- Critical Care, Poole Hospital NHS Foundation Trust, Poole, Dorset, United Kingdom
| | - Robert Darnell
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Anthony C. Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, United Kingdom
- Intensive Care Unit, Imperial College Healthcare NHS Trust, St Mary’s Hospital, Paddington, London, United Kingdom
| | | | - Nicholas Hudson
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Alexina J. Mason
- London School of Hygiene and Tropical Medicine, Department of Health Services Research and Policy, London, United Kingdom
| | - Michelle Saull
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | | | - J. Duncan Young
- Kadoorie Centre for Critical Care Research and Education, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Kathryn M. Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Paul R. Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
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