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Orso D, Federici N, Lio C, Mearelli F, Bove T. Hemodynamic goals in sepsis and septic shock resuscitation: An umbrella review of systematic reviews and meta-analyses with trial sequential analysis. Aust Crit Care 2024; 37:818-826. [PMID: 38609748 DOI: 10.1016/j.aucc.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 03/03/2024] [Accepted: 03/18/2024] [Indexed: 04/14/2024] Open
Abstract
OBJECTIVE The objective of this study was to verify whether any parameter among those used as the target for haemodynamic optimisation (e.g., mean arterial pressure, central venous oxygen saturation, systolic or diastolic dysfunction, CO2 gap, lactates, right ventricular dysfunction, and PvaCO2/CavO2 ratio) is correlated with mortality in an undifferentiated population with sepsis or septic shock. METHODS An umbrella review, searching MEDLINE, the Cochrane Database of Systematic Reviews, Health Technology Assessment Database, and the JBI Database of Systematic Reviews and Implementation Reports, was performed. We included systematic reviews and meta-analyses enrolling a population of unselected patients with sepsis or septic shock. The main outcome was mortality. Two authors conducted data extraction and risk-of-bias assessments independently. We used a random-effects model to pool binary and continuous data and summarised estimates of effect using equivalent odds ratios (eORs). We used the ROBIS tool to assess risk of bias and the assessment of multiple systematic reviews 2 score to assess global quality. DATA SYNTHESIS 17 systematic reviews and meta-analyses (15 828 patients) were included in the quantitative analysis. Diastolic dysfunction (eOR: 1.42; 95% confidence interval [CI]: 1.14-1.76), PvaCO2/CavO2 ratio (eOR: 2.15; 95% CI: 1.37-3.37), and CO2 gap (eOR: 1.86; 95% CI: 1.07-3.25) showed a significant correlation with mortality. Lactates were the parameter with highest inconsistency (I2 = 92%). Central venous oxygen saturation and right ventricle dysfunction showed significant statistical excess test of significance (p-value = 0.009 and 0.005, respectively). None of the considered parameters showed statistically significant publication bias. CONCLUSIONS According to this umbrella review, diastolic dysfunction is the haemodynamic variable that is most closely linked to the prognosis of septic patients. The PvaCO2/CavO2 ratio and the CO2gap are significantly related to the mortality of septic patients, but the poor quality of evidence or the low number of cases, studied so far, limit their clinical applicability. CLINICAL TRIAL REGISTRATION PROSPERO: International prospective register of systematic reviews, 2023, CRD42023432813 (Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023432813).
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Affiliation(s)
- Daniele Orso
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy.
| | - Nicola Federici
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | - Cristina Lio
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy; Department of Medical Sciences (DAME), University of Udine, Udine, Italy
| | - Filippo Mearelli
- Department of Internal Medicine, ASUGI University Hospital of Trieste, Trieste, Italy
| | - Tiziana Bove
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy; Department of Medical Sciences (DAME), University of Udine, Udine, Italy
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Dari MA, Fayaz A, Sharif S, Hernandez Galaviz S, Hernandez Galaviz E, Bataineh SM, Wei CR, Allahwala D. Comparison of High-Normal Versus Low-Normal Mean Arterial Pressure at Target on Outcomes in Sepsis or Shock Patients: A Meta-Analysis of Randomized Control Trials. Cureus 2024; 16:e52258. [PMID: 38352092 PMCID: PMC10863627 DOI: 10.7759/cureus.52258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2024] [Indexed: 02/16/2024] Open
Abstract
The objective of this meta-analysis was to compare the impact of a high-normal and a low-normal mean arterial pressure (MAP) target on outcomes in patients with sepsis or shock. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, two investigators conducted a thorough literature search across online databases, including PubMed, Cochrane Library, Web of Science, and EMBASE, spanning from inception to December 10, 2023. The assessed outcomes encompassed all-cause mortality, the need for renal replacement therapy, and the length of intensive care unit (ICU) stay. A total of four randomized controlled trials (RCTs) were included, involving 3507 participants with individual study participant counts ranging from 118 to 2463. The pooled analysis revealed no statistically significant difference in the risk of all-cause mortality between the two groups (Risk Ratio (RR): 0.94, 95% Confidence Interval (CI): 0.87 to 1.01). Furthermore, there was no disparity in the rates of renal replacement therapy and the duration of ICU stay between the high-normal and low-normal MAP groups. Our findings indicate no significant distinctions in mortality, rates of renal replacement therapy, or ICU stay duration between the two groups. However, future trials with larger sample sizes are warranted to comprehensively understand the nuanced effects of different MAP settings on outcomes in patients with sepsis and shock.
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Affiliation(s)
- Mohammedsefa A Dari
- Otolaryngology - Head and Neck Surgery, Addis Ababa University, Addis Ababa, ETH
| | - Azrung Fayaz
- Internal Medicine, College of Physicians and Surgeons, Peshawar, PAK
- Internal Medicine, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Shazia Sharif
- Gastroenterology, Lahore General Hospital, Lahore, PAK
| | | | | | | | - Calvin R Wei
- Research and Development, Shing Huei Group, Taipei, TWN
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Hunter S, Manias E, Considine J. Nurse management of noradrenaline infusions in intensive care units: An observational study. Aust Crit Care 2024; 37:58-66. [PMID: 37940445 DOI: 10.1016/j.aucc.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 08/01/2023] [Accepted: 09/12/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Intensive care nurse management of noradrenaline (norepinephrine) infusions is a common and essential clinical competency for patient haemodynamic support. Nurses titrate and wean noradrenaline infusions to a target blood pressure in a dynamic, high-risk, and unpredictable environment. Titration and weaning are complex interventions, and blood pressure goals are often variable. OBJECTIVES The aim was to examine how nurses used blood pressure targets when escalating, weaning, and titrating noradrenaline in intensive care patients admitted for haemodynamic management and explore patient blood pressure responses to changes in noradrenaline doses. METHODS In this naturalistic observational study, noradrenaline dose changes were classified as escalation, weaning, and titration changes and analysed to explore nursing practice. The study was undertaken in two adult medical/surgical intensive care units in Melbourne, Australia. Participants included intensive care nurses and patients who received noradrenaline infusions for haemodynamic support. RESULTS Observations of 14 nurse-patient dyads provided 25 h of blood pressure and noradrenaline dose data. Patient participants received weight-adjusted maximum noradrenaline doses of between 0.06 mcg/kg/min and 0.87 mcg/kg/minute, with those in the escalation group receiving dose increases of up to 5 mcg to achieve blood pressure goals. During weaning, patients maintained or increased their blood pressure as noradrenaline doses were decreased. Nurses consistently maintained blood pressures at higher than target goals, and despite constant fluctuations, they only documented blood pressure readings hourly. CONCLUSIONS Intensive care nurses managed noradrenaline to achieve mean arterial pressure targets that were variable and not evidence based. The disconnection between observed blood pressure fluctuations and nurse documentation of patient blood pressures was reflected in titration practices. Discrepancies between documented and actual blood pressures raised issues about data used by nurses and doctors to inform clinical practice on noradrenaline management.
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Affiliation(s)
- Stephanie Hunter
- Deakin University, School of Nursing and Midwifery, Centre for Quality and Patient Safety Research in the Institute for Health Transformation, 1 Gheringhap Street, Geelong 3220, Australia; Eastern Health Centre for Quality and Patient Safety Research - Eastern Health Partnership, 5 Arnold Street, Box Hill 3128, Victoria, Australia.
| | - Elizabeth Manias
- Deakin University, School of Nursing and Midwifery, Centre for Quality and Patient Safety Research in the Institute for Health Transformation, 1 Gheringhap Street, Geelong 3220, Australia
| | - Julie Considine
- Deakin University, School of Nursing and Midwifery, Centre for Quality and Patient Safety Research in the Institute for Health Transformation, 1 Gheringhap Street, Geelong 3220, Australia; Eastern Health Centre for Quality and Patient Safety Research - Eastern Health Partnership, 5 Arnold Street, Box Hill 3128, Victoria, Australia
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Rikhraj KJK, Ronsley C, Sekhon MS, Mitra AR, Griesdale DEG. High-normal versus low-normal mean arterial pressure thresholds in critically ill patients: a systematic review and meta-analysis of randomized trials. Can J Anaesth 2023; 70:1244-1254. [PMID: 37268800 DOI: 10.1007/s12630-023-02494-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 06/04/2023] Open
Abstract
PURPOSE Targeted blood pressure thresholds remain unclear in critically ill patients. Two prior systematic reviews have not shown differences in mortality with a high mean arterial pressure (MAP) threshold, but there have been new studies published since. Thus, we conducted an updated systematic review and meta-analysis of randomized controlled trials (RCTs) that compared the effect of a high-normal vs low-normal MAP on mortality, favourable neurologic outcome, need for renal replacement therapy, and adverse vasopressor-induced events in critically ill patients. SOURCE We searched six databases from inception until 1 October 2022 for RCTs of critically ill patients targeted to either a high-normal vs a low-normal MAP threshold for at least 24 hr. We assessed study quality using the revised Cochrane risk-of-bias 2 tool and the risk ratio (RR) was used as the summary measure of association. We used the Grading of Recommendations Assessment, Development, and Evaluation framework to assess the certainty of evidence. PRINCIPAL FINDINGS We included eight RCTs with 4,561 patients. Four trials were conducted in patients following out-of-hospital cardiac arrest, two in patients with distributive shock requiring vasopressors, one in patients with septic shock, and one in patients with hepatorenal syndrome. The pooled RRs for mortality (eight RCTs; 4,439 patients) and favourable neurologic outcome (four RCTs; 1,065 patients) were 1.06 (95% confidence interval [CI], 0.99 to 1.14; moderate certainty) and 0.99 (95% CI, 0.90 to 1.08; moderate certainty), respectively. The RR for the need for renal replacement therapy (four RCTs; 4,071 patients) was 0.97 (95% CI, 0.87 to 1.08; moderate certainty). There was no statistical between-study heterogeneity across all outcomes. CONCLUSION This updated systematic review and meta-analysis of RCTs found no differences in mortality, favourable neurologic outcome, or the need for renal replacement therapy between critically ill patients assigned to a high-normal vs low-normal MAP target. STUDY REGISTRATION PROSPERO (CRD42022307601); registered 28 February 2022.
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Affiliation(s)
- Kiran J K Rikhraj
- Department of Emergency Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada.
- Department of Emergency Medicine, Vancouver General Hospital, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.
| | - Claire Ronsley
- Department of Emergency Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Anish R Mitra
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Donald E G Griesdale
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
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Carayannopoulos KL, Pidutti A, Upadhyaya Y, Alshamsi F, Basmaji J, Granholm A, Alhazzani W, Lewis K. Mean Arterial Pressure Targets and Patient-Important Outcomes in Critically Ill Adults: A Systematic Review and Meta-Analysis of Randomized Trials. Crit Care Med 2023; 51:241-253. [PMID: 36661452 DOI: 10.1097/ccm.0000000000005726] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To conduct a systematic review and meta-analysis to determine whether targeting a higher mean arterial pressure (MAP) compared with a lower MAP in adults with shock results in differences in patient important outcomes. DATA SOURCES We searched MEDLINE, EMBASE, the Cochrane Library, and ClinicalTrials.gov through May 2021. STUDY SELECTION Titles and abstracts were screened independently and in duplicate to identify potentially eligible studies, then full text for final eligibility. We included parallel-group randomized controlled trials in adult patients with a diagnosis of shock requiring vasoactive medications. The higher MAP group was required to receive vasoactive medications to target a higher MAP as established by study authors, whereas the lower MAP group received vasoactive medications to target lower MAP. DATA EXTRACTION In triplicate, reviewers independently extracted data using a prepiloted abstraction form. Statistical analyses were conducted using the RevMan software Version 5.3. DATA SYNTHESIS Six randomized controlled trials (n = 3,690) met eligibility criteria. Targeting a higher MAP (75-85 mm Hg) compared with lower MAP of 65 mm Hg resulted in no difference in mortality (relative risk [RR], 1.06; 95% CI, 0.98-1.15; I2 = 0%; p = 0.12; moderate certainty. Targeting a higher MAP resulted in no difference in the risk of undergoing renal replacement therapy (RR, 0.96; 95% CI, 0.83-1.11; I2 = 24%; p = 0.57; moderate certainty); however, a subgroup analysis comparing patients with and without chronic hypertension demonstrated that a higher MAP may reduce the risk of undergoing renal replacement therapy (RR, 0.83; 95% CI, 0.71-0.98; I2 = 0%; p = 0.02). CONCLUSIONS In conclusion, our systematic review and meta-analysis demonstrated with moderate certainty that there is no difference in mortality when a higher MAP is targeted in critically ill adult patients with shock. Further studies are needed to determine the impact of mean arterial pressure on need for renal replacement therapy in this population.
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Affiliation(s)
| | - Andrew Pidutti
- Department of Medicine, Virginia Commonwealth University, Richmond, VA
| | | | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - John Basmaji
- Department of Medicine & Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Impact and Evidence, McMaster University, Hamilton, ON, Canada
| | - Kimberley Lewis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Impact and Evidence, McMaster University, Hamilton, ON, Canada
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Yoshimoto H, Fukui S, Higashio K, Endo A, Takasu A, Yamakawa K. Optimal target blood pressure in critically ill adult patients with vasodilatory shock: A systematic review and meta-analysis. Front Physiol 2022; 13:962670. [PMID: 36051909 PMCID: PMC9424848 DOI: 10.3389/fphys.2022.962670] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
While the Surviving Sepsis Campaign guidelines recommend an initial target value of 65 mmHg as the mean arterial pressure (MAP) in patients with septic shock, the optimal MAP target for improving outcomes remains controversial. We performed a meta-analysis to evaluate the optimal MAP for patients with vasodilatory shock, which included three randomized controlled trials that recruited 3,357 patients. Between the lower (60–70 mmHg) and higher (>70 mmHg) MAP target groups, there was no significant difference in all-cause mortality (risk ratio [RR], 1.06; 95% confidence intervals [CI], 0.98–1.16) which was similar in patients with chronic hypertension (RR, 1.10; 95% CI, 0.98–1.24) and patients aged ≥65 years (RR, 1.10; 95% CI, 0.99–1.21). No significant difference in adverse events was observed between the different MAP groups (RR, 1.04; 95% CI, 0.87–1.24); however, supraventricular arrhythmia was significantly higher in the higher MAP group (RR, 1.73; 95% CI, 1.15–2.60). Renal replacement therapy was reduced in the higher MAP group of patients with chronic hypertension (RR, 0.83; 95% CI, 0.71–0.98). Though the higher MAP control did not improve the mortality rate, it may be beneficial in reducing renal replacement therapy in patients with chronic hypertension. Systematic review registration: UMIN Clinical Trials Registry, identifier UMIN000042624
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Affiliation(s)
- Hidero Yoshimoto
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
- Department of Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Satoshi Fukui
- Faculty of Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Koki Higashio
- Faculty of Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Akira Endo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital, Bunkyo-ku, Tokyo, Japan
| | - Akira Takasu
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Kazuma Yamakawa
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
- *Correspondence: Kazuma Yamakawa,
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Intensive care patients receiving vasoactive medications: A retrospective cohort study. Aust Crit Care 2021; 35:499-505. [PMID: 34503915 DOI: 10.1016/j.aucc.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/21/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Vasoactive medications are high-risk drugs commonly used in intensive care units (ICUs), which have wide variations in clinical management. OBJECTIVES The aim of this study was to describe the patient population, treatment, and clinical characteristics of patients who did and did not receive vasoactive medications while in the ICU and to develop a predictive tool to identify patients needing vasoactive medications. METHODS A retrospective cohort study of patients admitted to a level three tertiary referral ICU over a 12-month period from October 2018 to September 2019 was undertaken. Data from electronic medical records were analysed to describe patient characteristics in an adult ICU. Chi square and Mann-Whitney U tests were used to analyse data relating to patients who did and did not receive vasoactive medications. Univariate analysis and Pearson's r2 were used to determine inclusion in multivariable logistic regression. RESULTS Of 1276 patients in the cohort, 40% (512/1276) received a vasoactive medication for haemodynamic support, with 84% (428/512) receiving noradrenaline. Older patients (odds ratio [OR] = 1.02; 95% confidence interval [CI] = 1.01-1.02; p < 0.001) with higher Acute Physiology and Chronic Health Evaluation (APACHE) III scores (OR = 1.04; 95% CI = 1.03-1.04; p < 0.001) were more likely to receive vasoactive medications than those not treated with vasoactive medications during an intensive care admission. A model developed using multivariable analysis predicted that patients admitted with sepsis (OR = 2.43; 95% CI = 1.43-4.12; p = 0.001) or shock (OR = 4.05; 95% CI = 2.68-6.10; p < 0.001) and managed on mechanical ventilation (OR = 3.76; 95% CI = 2.81-5.02; p < 0.001) were more likely to receive vasoactive medications. CONCLUSIONS Mechanically ventilated patients admitted to intensive care for sepsis and shock with higher APACHE III scores were more likely to receive vasoactive medications. Predictors identified in the multivariable model can be used to direct resources to patients most at risk of receiving vasoactive medications.
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Fukui S, Higashio K, Murao S, Endo A, Akira T, Yamakawa K. Optimal target blood pressure in critically ill adult patients with vasodilatory shock: a protocol for a systematic review and meta-analysis. BMJ Open 2021; 11:e048512. [PMID: 33741676 PMCID: PMC7986773 DOI: 10.1136/bmjopen-2020-048512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION The optimal target of mean arterial pressure (MAP) for better outcomes in patients with vasodilatory shock remains a matter of debate. Although catecholamines are generally used to maintain target blood pressure in hypotensive patients with vasodilatory shock, the adverse effects of catecholamines must also be considered. We will perform a systematic review and meta-analysis of randomised controlled trials (RCTs) to assess the certainty of evidence determining the optimal target of MAP control for patients with vasodilatory shock in critically ill settings. METHODS AND ANALYSIS This study protocol was registered in the University Hospital Medical Information Network Clinical Trials Registry. We will include only RCTs that evaluated the two different comparators for target MAP to be maintained for clinical outcomes of all-cause mortality: organ dysfunction and adverse events in critically ill adult patients with vasodilatory shock. We will search the electronic bibliographic databases of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials in November 2020. Two reviewers will independently screen titles and abstracts, perform full article reviews and extract study data. We will report study characteristics and assess methodological quality using the Cochrane Risk-of-Bias 2 tool. If pooling is appropriate, we will calculate relative risks with 95% CIs for all outcome measures. Clinical and methodological subgroup and sensitivity analyses will be performed to explore heterogeneity. Overall certainty of evidence will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION This study will not involve primary data collection, and formal ethics approval will therefore not be required. We aim to publish this systematic review in a peer-reviewed journal. TRIAL REGISTRATION NUMBER UMIN000042624.
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Affiliation(s)
- Satoshi Fukui
- Faculty of Medicine, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Koki Higashio
- Faculty of Medicine, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Shuhei Murao
- Department of Traumatology and Acute Critical Medicine, Osaka University School of Medicine Graduate School of Medicine, Suita, Osaka, Japan
| | - Akira Endo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Takasu Akira
- Department of Emergency Medicne, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Kazuma Yamakawa
- Department of Emergency Medicne, Osaka Medical College, Takatsuki, Osaka, Japan
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Adjusting mean arterial pressure alarms improves the time spent within blood pressure targets in patients with septic shock: A quasi-experimental study. Aust Crit Care 2020; 34:358-362. [PMID: 33246865 DOI: 10.1016/j.aucc.2020.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/20/2020] [Accepted: 10/10/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Norepinephrine is the first-line vasoactive drug in septic shock. As underdosages or overdosages can be harmful for patients, it seems useful to maintain the mean arterial pressure (MAP) within preset bounds. OBJECTIVES We sought to assess whether adjusted MAP alarms could improve MAP control in patients with septic shock. METHODS We conducted a quasi-experimental before-and-after study. During two consecutive periods, data on MAP control were obtained from patients with septic shock (n = 50/period) treated with norepinephrine over more than 24 h. The norepinephrine administration protocol, including prescription of the MAP target range (e.g., 65-75 mmHg), was identical during the two periods. During the first period (control group), the preset alarms of the monitor were used (i.e., low and high systolic blood pressure alarms set at 90 and 160 mmHg, respectively). During the second period, adjusted MAP alarms were implemented, with upper and lower bounds corresponding to the prescribed MAP target range (MAP-Alarm group). The primary end point was the percentage of time outside the desired MAP target range during the first 24 h of norepinephrine infusion. RESULTS Baseline characteristics were not significantly different. The primary end point was significantly lower in the MAP-Alarm group than in the control group (25 ± 13% versus 51 ± 18%, respectively; p < 0.01). MAP was higher than the target 14 ± 11% of the time in the MAP-Alarm group versus 37 ± 17% in the control group (p < 0.01) and lower than the target 11 ± 9% of the time in the MAP-Alarm versus 21 ± 22% in the control group (p < 0.05). There was no significant difference between the two groups with regard to the dose of norepinephrine, duration of norepinephrine administration, and survival. CONCLUSIONS These results suggest that adjusting MAP alarms to the desired MAP target range could dramatically improve the percentage of time spent within MAP targets in patients with septic shock but does not reduce exposure to norepinephrine.
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10
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Incidence, Patient Characteristics, Mode of Drug Delivery, and Outcomes of Septic Shock Patients Treated With Vasopressors in the Arise Trial. Shock 2020; 52:400-407. [PMID: 30379749 DOI: 10.1097/shk.0000000000001281] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION To describe the utilization of vasopressors (VP) in patients enrolled in the Australasian Resuscitation In Sepsis Evaluation (ARISE) trial, and to explore the association between time to VP and 90-day mortality. METHODS The primary exposure variable was VP use after arrival in the emergency department (ED). Vasoactive agents considered as VP included: norepinephrine, epinephrine, metaraminol, or vasopressin. Time-to-event analysis, multivariable logistic regression, and propensity-matched treatment effects modeling were used to assess the association between time to VP and 90-day mortality. RESULTS In total 1,102 of 1,588 patients (69%) in ARISE received VP at any point. The median [interquartile range (IQR)] time from ED presentation to commencing VP was 4.4 [2.7, 7.1] h, and 38% did so prior to central venous access. The median [IQR] volume of intravenous (i.v.) fluid administered prior to commencing VP was 3.1 [2.3, 4.3] L. Increasing age and volume of i.v. fluid therapy were associated with a lower likelihood of commencing VP early (within 4 h of ED presentation), while greater illness severity was associated with a higher likelihood, P < 0.001, respectively. In those who subsequently died within 90 days, the sub-hazard ratio (95% confidence interval) for commencing VP was 1.4 (1.20, 1.68), P < 0.001, adjusted for age, acute physiology and chronic health evaluation II score, study group, inclusion criteria, plasma lactate, i.v. fluid prior to VP, study institution, and site of infection. DISCUSSION 50% of the ARISE cohort commenced VP within 4.4 h of ED presentation, and many did so prior to central venous access. Earlier initiation of VP was associated with greater crude and adjusted 90-day mortality.
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Llópez-Espinós P, Palazón-Bru A, Beneyto-Ripoll C, Martínez-Díaz AM, Gil-Guillén VF, Carbonell-Torregrosa MDLÁ. Quality assessment of meta-analyses evaluating randomized clinical trials to improve the prognosis of septic shock: an overview of systematic reviews. Curr Med Res Opin 2020; 36:929-939. [PMID: 32267785 DOI: 10.1080/03007995.2020.1754188] [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] [Indexed: 10/24/2022]
Abstract
Objective: Clinical guidelines for the treatment of septic shock are based on the studies with the best scientific evidence, which are meta-analyses of clinical trials. However, these meta-analyses may have methodological limitations that prevent their conclusions from being extrapolated to routine clinical practice. Therefore, the objective of this study is to determine the quality of these meta-analyses through a systematic review.Methods: In this systematic review, we searched MEDLINE, Scopus and EMBASE from inception to May 2019. We selected meta-analyses from clinical trials that determined the effectiveness of an intervention in reducing the incidence of mortality in patients with septic shock. All items were extracted from the Overview Quality Assessment Questionnaire (OQAQ), which collects information from both systematic reviews and meta-analyses.Results: A total of 34 studies were included. Most elements of the OQAQ were conducted satisfactorily, although 35.3% of meta-analyses did not use a quality assessment of the studies included in other analyses. In 52.9% of meta-analyses, the quality of the studies was high or very high.Conclusions: The methods used to obtain the results should be taken into account when recommending an intervention to treat septic shock if the evidence comes from a meta-analysis of the analyzed characteristics.
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Affiliation(s)
| | - Antonio Palazón-Bru
- Department of Clinical Medicine, Miguel Hernández University, San Juan de Alicante, Spain
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Korang SK, Safi S, Feinberg J, Gluud C, Perner A, Jakobsen JC. Higher versus lower blood pressure targets in adults with shock. Hippokratia 2019. [DOI: 10.1002/14651858.cd013470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Steven Kwasi Korang
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
| | - Sanam Safi
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
| | - Joshua Feinberg
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Anders Perner
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Holbaek Hospital; Department of Cardiology; Holbaek Denmark 4300
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13
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Untreated Relative Hypotension Measured as Perfusion Pressure Deficit During Management of Shock and New-Onset Acute Kidney Injury-A Literature Review. Shock 2019; 49:497-507. [PMID: 29040214 DOI: 10.1097/shk.0000000000001033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Maintaining an optimal blood pressure (BP) during shock is a fundamental tenet of critical care. Optimal BP targets may be different for different patients. In current practice, too often, uniform BP targets are pursued which may result in inadvertently accepting a degree of untreated relative hypotension, i.e., the deficit between patients' usual premorbid basal BP and the achieved BP, during vasopressor support. Relative hypotension is a common but an under-recognized and an under-treated sign among patients with potential shock state. From a physiological perspective, any relative reduction in the net perfusion pressure across an organ (e.g., renal) vasculature has a potential to overwhelm autoregulatory mechanisms, which are already under stress during shock. Such perfusion pressure deficit may consequently impact organs' ability to function or recover from an injured state. This review discusses such pathophysiologic mechanisms in detail with a particular focus on the risk of new-onset acute kidney injury (AKI). To review current literature, databases of Medline, Embase, and Google scholar were searched to retrieve articles that either adjusted BP targets based on patients' premorbid BP levels or considered relative hypotension as an exposure endpoint and assessed its association with clinical outcomes among acutely ill patients. There were no randomized controlled trials. Only seven studies could be identified and these were reviewed in detail. These studies indicated a significant association between the degree of relative hypotension that was inadvertently accepted in real-world practice and new-onset organ dysfunction or subsequent AKI. However, this is not a high-quality evidence. Therefore, well-designed randomized controlled trials are needed to evaluate whether adoption of individualized BP targets, which are initially guided by patient's premorbid basal BP and then tailored according to clinical response, is superior to conventional BP targets for vasopressor therapy, particularly among patients with vasodilatory shock states.
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14
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Scheeren TWL, Bakker J, De Backer D, Annane D, Asfar P, Boerma EC, Cecconi M, Dubin A, Dünser MW, Duranteau J, Gordon AC, Hamzaoui O, Hernández G, Leone M, Levy B, Martin C, Mebazaa A, Monnet X, Morelli A, Payen D, Pearse R, Pinsky MR, Radermacher P, Reuter D, Saugel B, Sakr Y, Singer M, Squara P, Vieillard-Baron A, Vignon P, Vistisen ST, van der Horst ICC, Vincent JL, Teboul JL. Current use of vasopressors in septic shock. Ann Intensive Care 2019; 9:20. [PMID: 30701448 PMCID: PMC6353977 DOI: 10.1186/s13613-019-0498-7] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 01/22/2019] [Indexed: 12/29/2022] Open
Abstract
Background Vasopressors are commonly applied to restore and maintain blood pressure in patients with sepsis. We aimed to evaluate the current practice and therapeutic goals regarding vasopressor use in septic shock as a basis for future studies and to provide some recommendations on their use. Methods From November 2016 to April 2017, an anonymous web-based survey on the use of vasoactive drugs was accessible to members of the European Society of Intensive Care Medicine (ESICM). A total of 17 questions focused on the profile of respondents, triggering factors, first choice agent, dosing, timing, targets, additional treatments, and effects of vasopressors. We investigated whether the answers complied with current guidelines. In addition, a group of 34 international ESICM experts was asked to formulate recommendations for the use of vasopressors based on 6 questions with sub-questions (total 14). Results A total of 839 physicians from 82 countries (65% main specialty/activity intensive care) responded. The main trigger for vasopressor use was an insufficient mean arterial pressure (MAP) response to initial fluid resuscitation (83%). The first-line vasopressor was norepinephrine (97%), targeting predominantly a MAP > 60–65 mmHg (70%), with higher targets in patients with chronic arterial hypertension (79%). The experts agreed on 10 recommendations, 9 of which were based on unanimous or strong (≥ 80%) agreement. They recommended not to delay vasopressor treatment until fluid resuscitation is completed but rather to start with norepinephrine early to achieve a target MAP of ≥ 65 mmHg. Conclusion Reported vasopressor use in septic shock is compliant with contemporary guidelines. Future studies should focus on individualized treatment targets including earlier use of vasopressors.
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Affiliation(s)
- Thomas W L Scheeren
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700RB, Groningen, The Netherlands.
| | - Jan Bakker
- New York University Medical Center, New York, USA.,Columbia University Medical Center, New York, USA.,Erasmus MC University Medical Center, Rotterdam, Netherlands.,Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Djillali Annane
- Department of Intensive Care Medicine, School of Medicine Simone Veil, Raymond Poincaré Hospital (APHP), University of Versailles-University Paris Saclay, 104 boulevard Raymond Poincaré, 92380, Garches, France
| | - Pierre Asfar
- Département de Médecine Intensive-Réanimation et de Médecine Hyperbare, Centre Hospitalier Universitaire Angers, Institut MITOVASC, CNRS, UMR 6214, INSERM U1083, Angers University, Angers, France
| | - E Christiaan Boerma
- Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Maurizio Cecconi
- Department of Anaesthesia and Intensive Care Units, Humanitas Research Hospital and Humanitas University, Milan, Italy
| | - Arnaldo Dubin
- Cátedra de Farmacología Aplicada, Facultad de Ciencias Médicas, Universidad Nacional de La Plata y Servicio de Terapia Intensiva, Sanatorio Otamendi, Buenos Aires, Argentina
| | - Martin W Dünser
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University Linz, Linz, Austria
| | - Jacques Duranteau
- Assistance Publique des Hopitaux de Paris, Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
| | - Anthony C Gordon
- Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Olfa Hamzaoui
- Assistance Publique-Hôpitaux de Paris Paris-Sud University Hospitals, Intensive Care Unit, Antoine Béclère Hospital, Clamart, France
| | - Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Marc Leone
- Assistance Publique Hôpitaux de Marseille, Service d'Anesthésie et de Réanimation CHU Nord, Aix Marseille Université, Marseille, France
| | - Bruno Levy
- Service de Réanimation Médicale Brabois et pôle cardio-médico-chirurgical, CHRU, INSERM U1116, Université de Lorraine, Brabois, 54500, Vandoeuvre les Nancy, France
| | - Claude Martin
- Assistance Publique Hôpitaux de Marseille, Service d'Anesthésie et de Réanimation CHU Nord, Aix Marseille Université, Marseille, France
| | - Alexandre Mebazaa
- Department of Anesthesia, Burn and Critical Care, APHP Hôpitaux Universitaires Saint Louis Lariboisière, U942 Inserm, Université Paris Diderot, Paris, France
| | - Xavier Monnet
- Assistance Publique-Hôpitaux de Paris, Paris-Sud University Hospitals, Medical Intensive Care Unit, Bicêtre Hospital, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Paris-Saclay University, Le Plessis-Robinson, France
| | - Andrea Morelli
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, University of Rome "La Sapienza", Rome, Italy
| | - Didier Payen
- INSERM 1160 and Hôpital Lariboisière, APHP, University Paris 7 Denis Diderot, Paris, France
| | | | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Ulm, Germany
| | - Daniel Reuter
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Centre, Rostock, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care, Uniklinikum Jena, Jena, Germany
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Pierre Squara
- ICU Department, Réanimation CERIC, Clinique Ambroise Paré, Neuilly, France
| | - Antoine Vieillard-Baron
- Assistance Publique-Hôpitaux de Paris, Intensive Care Unit, University Hospital Ambroise Paré, Boulogne-Billancourt, France.,INSERM U-1018, CESP, Team 5, University of Versailles Saint-Quentin en Yvelines, Villejuif, France
| | - Philippe Vignon
- Medical-Surgical Intensive Care Unit, INSERM CIC-1435, Teaching Hospital of Limoges, University of Limoges, Limoges, France
| | - Simon T Vistisen
- Institute of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Iwan C C van der Horst
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Louis Teboul
- Service de Réanimation Médicale, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicêtre, France
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15
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Abstract
Far from traditional "vital signs," the field of hemodynamic monitoring (HM) is rapidly developing. However, it is also easy to misunderstand hemodynamic therapy as merely HM and some concrete bundles or guidelines for circulation support. Here, we describe the concept of "critical hemodynamic therapy" and clarify the concepts of the "therapeutic target" and "therapeutic endpoint" in clinical practice. Three main targets (oxygen delivery, blood flow, perfusion pressure) for resuscitation are reviewed in critically ill patients according to the sepsis guidelines and hemodynamic consensus. ScvO2 at least 70% has not been recommended as a directed target for initial resuscitation, and the directed target of mean arterial pressure (MAP) still is 65 mmHg. Moreover, the individual MAP target is underlined, and using flow-dependent monitoring to guide fluid infusion is recommended. The flow-directed target for fluid infusion might be a priority, but it remains controversial in resuscitation. The interpretation of these targets is necessary for adequate resuscitation and the correction of tissue hypoxia. The incoherence phenomenon of resuscitation (macrocirculation and microcirculation, tissue perfusion, and cellular oxygen utilization) is gaining increased attention, and early identification of these incoherences might be helpful to reduce the risk of over-resuscitation.
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16
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Abstract
PURPOSE OF REVIEW Rapid restoration of tissue perfusion and oxygenation are the main goals in the resuscitation of a patient with circulatory collapse. This review will focus on providing an evidence based framework of the technological and conceptual advances in the evaluation and management of the patient with cardiovascular collapse. RECENT FINDINGS The initial approach to the patient in cardiovascular collapse continues to be based on the Ventilate-Infuse-Pump rule. Point of care ultrasound is the preferred modality for the initial evaluation of undifferentiated shock, providing information to narrow the differential diagnosis, to assess fluid responsiveness and to evaluate the response to therapy. After the initial phase of resuscitative fluid administration, which focuses on re-establishing a mean arterial pressure to 65 mmHg, the use of dynamic parameters to assess preload responsiveness such as the passive leg raise test, stroke volume variation, pulse pressure variation and collapsibility of the inferior vena cava in mechanically ventilated patients is recommended. SUMMARY The crashing patient remains a clinical challenge. Using an integrated approach with bedside ultrasound, dynamic parameters for the evaluation of fluid responsiveness and surrogates of evaluation of tissue perfusion have made the assessment of the patient in shock faster, safer and more physiologic.
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Affiliation(s)
- Hitesh Gidwani
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hernando Gómez
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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17
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Wu M, Ghassemi M, Feng M, Celi LA, Szolovits P, Doshi-Velez F. Understanding vasopressor intervention and weaning: risk prediction in a public heterogeneous clinical time series database. J Am Med Inform Assoc 2017; 24:488-495. [PMID: 27707820 DOI: 10.1093/jamia/ocw138] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 08/23/2016] [Indexed: 12/25/2022] Open
Abstract
Background The widespread adoption of electronic health records allows us to ask evidence-based questions about the need for and benefits of specific clinical interventions in critical-care settings across large populations. Objective We investigated the prediction of vasopressor administration and weaning in the intensive care unit. Vasopressors are commonly used to control hypotension, and changes in timing and dosage can have a large impact on patient outcomes. Materials and Methods We considered a cohort of 15 695 intensive care unit patients without orders for reduced care who were alive 30 days post-discharge. A switching-state autoregressive model (SSAM) was trained to predict the multidimensional physiological time series of patients before, during, and after vasopressor administration. The latent states from the SSAM were used as predictors of vasopressor administration and weaning. Results The unsupervised SSAM features were able to predict patient vasopressor administration and successful patient weaning. Features derived from the SSAM achieved areas under the receiver operating curve of 0.92, 0.88, and 0.71 for predicting ungapped vasopressor administration, gapped vasopressor administration, and vasopressor weaning, respectively. We also demonstrated many cases where our model predicted weaning well in advance of a successful wean. Conclusion Models that used SSAM features increased performance on both predictive tasks. These improvements may reflect an underlying, and ultimately predictive, latent state detectable from the physiological time series.
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Affiliation(s)
- Mike Wu
- Department of Computer Science, Yale University, New Haven, CT, USA
| | - Marzyeh Ghassemi
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Mengling Feng
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Leo A Celi
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Peter Szolovits
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Finale Doshi-Velez
- Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
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18
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Song Y, Soh S, Shim JK, Park KU, Kwak YL. Skin perfusion pressure as an indicator of tissue perfusion in valvular heart surgery: Preliminary results from a prospective, observational study. PLoS One 2017; 12:e0184555. [PMID: 28926643 PMCID: PMC5604958 DOI: 10.1371/journal.pone.0184555] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 08/25/2017] [Indexed: 12/11/2022] Open
Abstract
Hemodynamic management aims to provide adequate tissue perfusion, which is often altered during cardiac surgery with cardiopulmonary bypass (CPB). We evaluated whether skin perfusion pressure (SPP) can be used for monitoring of adequacy of tissue perfusion in patients undergoing valvular heart surgery. Seventy-two patients undergoing valve replacement were enrolled. SPP and serum lactate level were assessed after anaesthesia induction (baseline), during CPB, after CPB-off, end of surgery, arrival at intensive care unit, and postoperative 6 h. Lactate was further measured until postoperative 48 h. Association of SPP with lactate and 30-day morbidity comprising myocardial infarction, acute kidney injury, stroke, prolonged intubation, sternal infection, reoperation, and mortality was assessed. Among the lactate levels, postoperative 6 h peak value was most closely linked to composite of 30-day morbidity. The SPP value during CPB and its % change from the baseline value were significantly associated with the postoperative 6 h peak lactate (r = -0.26, P = 0.030 and r = 0.47, P = 0.001, respectively). Optimal cut-off of % decrease in SPP during CPB from baseline value for the postoperative 6 h hyperlactatemia was 48% (area under curve, 0.808; 95% confidence interval (CI), 0.652-0.963; P = 0.001). Decrease in SPP >48% during CPB from baseline value was associated with a 12.8-fold increased risk of composite endpoint of 30-day morbidity (95% CI, 1.48-111.42; P = 0.021) on multivariate logistic regression. Large decrease in SPP during CPB predicts postoperative 6 h hyperlactatemia and 30-day morbidity, which implicates a promising role of SPP monitoring in the achievement of optimal perfusion during CPB.
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Affiliation(s)
- Young Song
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - Sarah Soh
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - Kyoung-Un Park
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - Young-Lan Kwak
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
- * E-mail:
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19
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Abstract
Major advances have been made in mechanical circulatory support in recent years. Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) provides both pulmonary and circulatory support for critically ill patients with hemodynamic compromise, serving as a bridge to recovery or definitive therapy in the form of transplant or a durable ventricular assist device. In the past, VA ECMO support was used in cases of cardiogenic shock or failure to wean from cardiopulmonary bypass; however, the technology is now being applied to an ever-expanding list of conditions, including massive pulmonary embolism, cardiac arrest, drug overdose, and hypothermia.
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Affiliation(s)
- Christopher S King
- Department of Medicine, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA.
| | - Aviral Roy
- Department of Critical Care, Cooper University Hospital, 427C Dorrance, 1 Cooper Plaza, Camden, NJ 08103, USA
| | - Liam Ryan
- Department of Cardiothoracic Surgery, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Ramesh Singh
- Department of Cardiothoracic Surgery, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA
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20
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A systematic review of vasopressor blood pressure targets in critically ill adults with hypotension. Can J Anaesth 2017; 64:703-715. [PMID: 28497426 DOI: 10.1007/s12630-017-0877-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 03/13/2017] [Accepted: 04/11/2017] [Indexed: 10/19/2022] Open
Abstract
PURPOSE Clinicians must balance the risks from hypotension with the potential adverse effects of vasopressors. Experts have recommended a mean arterial pressure (MAP) target of at least 65 mmHg, and higher in older patients and in patients with chronic hypertension or atherosclerosis. We conducted a systematic review of randomized-controlled trials comparing higher vs lower blood pressure targets for vasopressor therapy administered to hypotensive critically ill patients. METHODS We searched MEDLINE®, EMBASE™, and the Cochrane Central Register of Controlled Trials for studies of higher vs lower blood pressure targets for vasopressor therapy in critically ill hypotensive adult patients. Two reviewers independently assessed trial eligibility based on titles and abstracts, and they then selected full-text reports. Outcomes, subgroups, and analyses were prespecified. We used GRADE (Grading of Recommendations Assessment, Development and Evaluation) to rate the overall confidence in the estimates of intervention effects. RESULTS Of 8001 citations, we retrieved 57 full-text articles and ultimately included two randomized-controlled trials (894 patients). Higher blood pressure targets were not associated with lower mortality (relative risk [RR], 1.05; 95% confidence interval [CI], 0.90 to 1.23; P = 0.54), and neither age (P = 0.17) nor chronic hypertension (P = 0.32) modified the overall effect. Nevertheless, higher blood pressure targets were associated with a greater risk of new-onset supraventricular cardiac arrhythmia (RR, 2.08; 95% CI, 1.28 to 3.38; P < 0.01). CONCLUSION Current evidence does not support a MAP target > 70 mmHg in hypotensive critically ill adult patients requiring vasopressor therapy.
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21
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Wendon, J, Cordoba J, Dhawan A, Larsen FS, Manns M, Samuel D, Simpson KJ, Yaron I, Bernardi M. EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure. J Hepatol 2017; 66:1047-1081. [PMID: 28417882 DOI: 10.1016/j.jhep.2016.12.003] [Citation(s) in RCA: 528] [Impact Index Per Article: 75.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 12/07/2016] [Indexed: 02/06/2023]
Abstract
The term acute liver failure (ALF) is frequently applied as a generic expression to describe patients presenting with or developing an acute episode of liver dysfunction. In the context of hepatological practice, however, ALF refers to a highly specific and rare syndrome, characterised by an acute abnormality of liver blood tests in an individual without underlying chronic liver disease. The disease process is associated with development of a coagulopathy of liver aetiology, and clinically apparent altered level of consciousness due to hepatic encephalopathy. Several important measures are immediately necessary when the patient presents for medical attention. These, as well as additional clinical procedures will be the subject of these clinical practice guidelines.
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22
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Rajakumar A, Kaliamoorthy I, Rela M, Mandell MS. Small-for-Size Syndrome: Bridging the Gap Between Liver Transplantation and Graft Recovery. Semin Cardiothorac Vasc Anesth 2017; 21:252-261. [DOI: 10.1177/1089253217699888] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In living donor liver transplantation, optimal graft size is estimated from values like graft volume/standard liver volume and graft/recipient body weight ratio but the final functional hepatic mass is influenced by other donor and recipient factors. Grafts with insufficient functional hepatic mass can produce a life-threatening condition with rapidly progressive liver failure called small-for-size syndrome (SFSS). Diagnosis of SFSS requires careful surveillance for signs of inadequate hepatocellular function, residual portal hypertension, and systemic inflammation that suggest rapidly progressive liver failure. Early diagnosis, symptom control, and addressing the cause of SFSS may prevent the need for retransplantation. With increased attention to avoiding donor risk, intensivists will be confronted with more SFSS recipients. In this review, we aim to outline a systematic approach to the medical management of patients with SFSS by providing a concise synopsis of general supportive care—neurological, cardiovascular, and renal support, mechanical ventilation, nutritional support, infection control, and tailored immunosuppression—with an aim to avoid end-organ damage or death and a review of current interventions including liver support devices, portal flow modulating drugs, and other experimental interventions that aim to preserve existing hepatic mass and improve conditions for hepatic regeneration. We examine evidence for SFSS interventions to provide the reader with information that may assist in clinical decision making. Points of controversy in care are purposefully highlighted to identify areas where additional experimental work is still needed. A full understanding of the pathophysiology of SFSS and measures to support liver regeneration will guide effective management.
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23
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Pettilä V, Merz T, Wilkman E, Perner A, Karlsson S, Lange T, Hästbacka J, Hjortrup PB, Kuitunen A, Jakob SM, Takala J. Targeted tissue perfusion versus macrocirculation-guided standard care in patients with septic shock (TARTARE-2S): study protocol and statistical analysis plan for a randomized controlled trial. Trials 2016; 17:384. [PMID: 27484695 PMCID: PMC4971711 DOI: 10.1186/s13063-016-1515-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 07/20/2016] [Indexed: 12/25/2022] Open
Abstract
Background Septic shock has a 90-day mortality risk of up to 50 %. The hemodynamic targets, including mean arterial pressure (MAP) are not based on robust clinical data. Both severe hypotension and high doses of vasopressors may be harmful. Hence, re-evaluation of hemodynamic targets in septic shock is relevant. Methods/design The targeted tissue perfusion versus macrocirculation-guided standard care in patients with septic shock (TARTARE-2S) trial is a prospective, two-parallel-group, randomized, open-label, multicenter trial with assessor-blinded outcome evaluation. We will randomize at least 200 patients with septic shock in four European intensive care units (ICUs) to test whether a tissue perfusion-guided treatment strategy based on capillary refill time, peripheral temperature, arterial lactate concentrations, and accepting lower MAP levels, leads to a faster resolution of shock than macrocirculation target-guided standard care. The primary outcome measure is days alive in 30 days with normal arterial blood lactate (first value of <2 mmol/L) and without any inotropic or vasopressor agent. Secondary outcomes include individual components of the primary outcome, days alive without renal replacement, days alive without mechanical ventilation in 30 days, and new acute kidney injury. The sample size enables detection of a 13.5-h difference in the primary outcome with a type 1 error of 5 % and power of 80 %, assuming 25 % mortality and a mean of 650 h (SD 30) among the 30-day survivors. After 150 included patients the statistician masked for allocation group will recalculate the sample size potentially increasing the sample up to 300. The Data Safety and Monitoring Board (DSMB) will review the safety data after 100 patients. Discussion The TARTARE-2S trial will provide important clinical data on treatment targets in septic shock, evaluating the impact of clinical tissue perfusion-guided hemodynamic treatment on a surrogate outcome combining resolution of shock (hyperlactatemia and vasopressors/inotropes), and 30-day mortality. Trial registration ClinicalTrials.gov: NCT02579525. Registered on 19 October 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1515-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ville Pettilä
- Department of Intensive Care Medicine, Bern University Hospital (Inselspital), University of Bern, Bern, Switzerland. .,Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Tobias Merz
- Department of Intensive Care Medicine, Bern University Hospital (Inselspital), University of Bern, Bern, Switzerland
| | - Erika Wilkman
- Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,CRIC, Center of Research for Intensive Care, Copenhagen, Denmark
| | - Sari Karlsson
- Department of Intensive Care, Tampere University Hospital, Tampere, Finland
| | - Theis Lange
- CRIC, Center of Research for Intensive Care, Copenhagen, Denmark.,Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Johanna Hästbacka
- Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Peter Buhl Hjortrup
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Anne Kuitunen
- Department of Intensive Care, Tampere University Hospital, Tampere, Finland
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Bern University Hospital (Inselspital), University of Bern, Bern, Switzerland
| | - Jukka Takala
- Department of Intensive Care Medicine, Bern University Hospital (Inselspital), University of Bern, Bern, Switzerland
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Dünser M, Hjortrup PB, Pettilä V. Vasopressors in shock: are we meeting our target and do we really understand what we are aiming at? Intensive Care Med 2016; 42:1176-8. [PMID: 26932348 DOI: 10.1007/s00134-016-4269-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 02/09/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Martin Dünser
- Intensive Care Units, Department of Anesthesiology, Perioperative and General Intensive Care Medicine, University Hospital Salzburg and Paracelsus Private Medical University, Salzburg, Austria.
| | - Peter Buhl Hjortrup
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ville Pettilä
- Department of Intensive Care Medicine, Bern University Hospital (Inselspital), University of Bern, Bern, Switzerland
- Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Lamontagne F, Meade MO, Hébert PC, Asfar P, Lauzier F, Seely AJE, Day AG, Mehta S, Muscedere J, Bagshaw SM, Ferguson ND, Cook DJ, Kanji S, Turgeon AF, Herridge MS, Subramanian S, Lacroix J, Adhikari NKJ, Scales DC, Fox-Robichaud A, Skrobik Y, Whitlock RP, Green RS, Koo KKY, Tanguay T, Magder S, Heyland DK. Higher versus lower blood pressure targets for vasopressor therapy in shock: a multicentre pilot randomized controlled trial. Intensive Care Med 2016; 42:542-550. [PMID: 26891677 DOI: 10.1007/s00134-016-4237-3] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 01/20/2016] [Indexed: 12/29/2022]
Abstract
PURPOSE In shock, hypotension may contribute to inadequate oxygen delivery, organ failure and death. We conducted the Optimal Vasopressor Titration (OVATION) pilot trial to inform the design of a larger trial examining the effect of lower versus higher mean arterial pressure (MAP) targets for vasopressor therapy in shock. METHODS We randomly assigned critically ill patients who were presumed to suffer from vasodilatory shock regardless of admission diagnosis to a lower (60-65 mmHg) versus a higher (75-80 mmHg) MAP target. The primary objective was to measure the separation in MAP between groups. We also recorded days with protocol deviations, enrolment rate, cardiac arrhythmias and mortality for prespecified subgroups. RESULTS A total of 118 patients were enrolled from 11 centres (2.3 patients/site/month of screening). The between-group separation in MAP was 9 mmHg (95% CI 7-11). In the lower and higher MAP groups, we observed deviations on 12 versus 8% of all days on vasopressors (p = 0.059). Risks of cardiac arrhythmias (20 versus 36%, p = 0.07) and hospital mortality (30 versus 33%, p = 0.84) were not different between lower and higher MAP arms. Among patients aged 75 years or older, a lower MAP target was associated with reduced hospital mortality (13 versus 60%, p = 0.03) but not in younger patients. CONCLUSIONS This pilot study supports the feasibility of a large trial comparing lower versus higher MAP targets for shock. Further research may help delineate the reasons for vasopressor dosing in excess of prescribed targets and how individual patient characteristics modify the response to vasopressor therapy.
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Affiliation(s)
- François Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada.
- Centre de Recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada.
- Centre Hospitalier Universitaire de Sherbrooke, 3001 12e avenue N., Sherbrooke, QC, J1H 5N4, Canada.
| | - Maureen O Meade
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Paul C Hébert
- Department of Medicine and Research Centre, Université de Montréal, Montreal, QC, Canada
| | - Pierre Asfar
- Department of Medical Intensive Care Medicine, University Hospital Angers, Angers, France
| | - François Lauzier
- Department of Medicine, Université Laval, Quebec, QC, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec, QC, Canada
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Université Laval, Quebec, QC, Canada
| | - Andrew J E Seely
- Thoracic Surgery and Critical Care Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Andrew G Day
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - John Muscedere
- Department of Medicine, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Deborah J Cook
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Salmaan Kanji
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec, QC, Canada
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Université Laval, Quebec, QC, Canada
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Sanjay Subramanian
- Department of Critical Care Medicine, Mercy St John's Medical Center, St Louis, MO, USA
| | - Jacques Lacroix
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Quebec, Canada
| | - Neill K J Adhikari
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | | | - Richard P Whitlock
- Department of Surgery, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Robert S Green
- Department of Critical Care, Dalhousie University, Halifax, NS, Canada
| | - Karen K Y Koo
- Department of Critical Care Medicine, Swedish Medical Center, Seattle, WA, USA
| | - Teddie Tanguay
- Canadian Association of Critical Care Nurses, London, ON, Canada
| | | | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada
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Kato R, Pinsky MR. Personalizing blood pressure management in septic shock. Ann Intensive Care 2015; 5:41. [PMID: 26573630 PMCID: PMC4646890 DOI: 10.1186/s13613-015-0085-5] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 11/02/2015] [Indexed: 12/29/2022] Open
Abstract
This review examines the available evidence for targeting a specific mean arterial pressure (MAP) in sepsis resuscitation. The clinical data suggest that targeting an MAP of 65-70 mmHg in patients with septic shock who do not have chronic hypertension is a reasonable first approximation. Whereas in patients with chronic hypertension, targeting a higher MAP of 80-85 mmHg minimizes renal injury, but it comes with increased risk of arrhythmias. Importantly, MAP alone should not be used as a surrogate of organ perfusion pressure, especially under conditions in which intracranial, intra-abdominal or tissue pressures may be elevated. Organ-specific perfusion pressure targets include 50-70 mmHg for the brain based on trauma brain injury as a surrogate for sepsis, 65 mmHg for renal perfusion and >50 mmHg for hepato-splanchnic flow. Even at the same MAP, organs and regions within organs may have different perfusion pressure and pressure-flow relationships. Thus, once this initial MAP target is achieved, MAP should be titrated up or down based on the measures of organ function and tissue perfusion.
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Affiliation(s)
- Ryotaro Kato
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 606 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 606 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
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Abstract
IMPORTANCE Septic shock is a clinical emergency that occurs in more than 230,000 US patients each year. OBSERVATIONS AND ADVANCES: In the setting of suspected or documented infection, septic shock is typically defined in a clinical setting by low systolic (≤90 mm Hg) or mean arterial blood pressure (≤65 mm Hg) accompanied by signs of hypoperfusion (eg, oliguria, hyperlactemia, poor peripheral perfusion, or altered mental status). Focused ultrasonography is recommended for the prompt recognition of complicating physiology (eg, hypovolemia or cardiogenic shock), while invasive hemodynamic monitoring is recommended only for select patients. In septic shock, 3 randomized clinical trials demonstrate that protocolized care offers little advantage compared with management without a protocol. Hydroxyethyl starch is no longer recommended, and debate continues about the role of various crystalloid solutions and albumin. CONCLUSIONS AND RELEVANCE The prompt diagnosis of septic shock begins with obtainment of medical history and performance of a physical examination for signs and symptoms of infection and may require focused ultrasonography to recognize more complex physiologic manifestations of shock. Clinicians should understand the importance of prompt administration of intravenous fluids and vasoactive medications aimed at restoring adequate circulation, and the limitations of protocol-based therapy, as guided by recent evidence.
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Affiliation(s)
- Christopher W Seymour
- Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania2Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, Pittsburgh, Pennsylvania
| | - Matthew R Rosengart
- Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, Pittsburgh, Pennsylvania3Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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What's New in Shock? JUNE 2015. Shock 2015; 43:519-21. [PMID: 25978808 DOI: 10.1097/shk.0000000000000374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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