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Stampfl M, DeBlieux P. A Clinical Review of Vasopressors in Emergency Medicine. J Emerg Med 2024; 67:e31-e41. [PMID: 38789351 DOI: 10.1016/j.jemermed.2024.03.004] [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: 06/18/2023] [Revised: 01/22/2024] [Accepted: 03/06/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Vasopressor medications raise blood pressure through vasoconstriction and are essential in reversing the hypotension seen in many critically ill patients. Previously, vasopressor administration was largely limited to continuous infusions through central venous access. OBJECTIVES OF THE REVIEW This review addresses the clinical use of vasopressors in various shock states, including practical considerations and innovations in vasopressor administration. The focus is on the clinical administration of vasopressors across a range of shock states, including hypovolemic, distributive, cardiogenic, and obstructive shock. DISCUSSION Criteria for starting vasopressors are not clearly defined, though early use may be beneficial. A number of physiologic factors affect the body's response to vasopressors, such as acidosis and adrenal insufficiency. Peripheral and push-dose administration of vasopressors are becoming more common. Distributive shock is characterized by inappropriate vasodilation and vasopressors play a crucial role in maintaining adequate blood pressure. The use of vasopressors is more controversial in hypovolemic shock, as the preferred treatment is correction of the volume deficit. Evidence for vasopressors is limited in cardiogenic shock. For obstructive shock, vasopressors can temporize a patient's blood pressure until definitive therapy can reverse the underlying cause. CONCLUSION Across the categories of shock states, norepinephrine has wide applicability and is a reasonable first-line agent for shock of uncertain etiology. Keeping a broad differential when hypotension is refractory to vasopressors may help to identify adjunctive treatments in physiologic states that impair vasopressor effectiveness. Peripheral administration of vasopressors is safe and facilitates early administration, which may help to improve outcomes in some shock states.
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Affiliation(s)
- Matthew Stampfl
- UW Health Med Flight, Madison, Wisconsin; BerbeeWalsh Department of Emergency Medicine, Madison, Wisconsin.
| | - Peter DeBlieux
- Louisiana State University Medical Center, New Orleans, Louisiana; Tulane University School of Medicine Department of Surgery, New Orleans, Louisiana
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2
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Normand S, Matthews C, Brown CS, Mattson AE, Mara KC, Bellolio F, Wieruszewski ED. Risk of arrhythmia in post-resuscitative shock after out-of-hospital cardiac arrest with epinephrine versus norepinephrine. Am J Emerg Med 2024; 77:72-76. [PMID: 38104386 DOI: 10.1016/j.ajem.2023.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/09/2023] [Accepted: 12/02/2023] [Indexed: 12/19/2023] Open
Abstract
OBJECTIVE To determine the rates of clinically significant tachyarrhythmias and mortality in the management of post-resuscitative shock after return of spontaneous circulation (ROSC) in patients with out-of-hospital cardiac arrest (OHCA) who receive a continuous epinephrine versus norepinephrine infusion. DESIGN Retrospective cohort study. SETTING A large multi-site health system with hospitals across the United States. PATIENTS Adult patients admitted for OHCA with post-resuscitative shock managed with either epinephrine or norepinephrine infusions within 6 h of ROSC. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Between May 5th, 2018, to January 31st, 2022, there were 221 patients admitted for OHCA who received post-resuscitative epinephrine or norepinephrine infusions. There was no difference in the rate of tachyarrhythmias between epinephrine and norepinephrine infusion in univariate (47.1% vs 41.7%, OR 1.24, 95% CI 0.71-2.20) or multivariable analysis (OR 1.34, 95% CI 0.68-2.62). Patients treated with epinephrine were more likely to die during hospitalization than those treated with norepinephrine (90.0% vs 54.3%, OR 6.21, 95% CI 2.37-16.25, p < 0.001). Epinephrine treated patients were more likely to have re-arrest during hospital admission (55.7% vs 14.6%, OR 5.77, 95% CI 2.74-12.18, p < 0.001). CONCLUSION There was no statistically significant difference in clinically significant cardiac tachyarrhythmias in post-OHCA patients treated with epinephrine versus norepinephrine infusions after ROSC. Re-arrest rates and in-hospital mortality were higher in patients who received epinephrine infusions in the first 6 h post-ROSC. Results of this study add to the literature suggesting norepinephrine may be the vasopressor of choice in post-OHCA patients with post-resuscitative shock after ROSC.
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Affiliation(s)
- Sarah Normand
- Department of Pharmacy, Mayo Clinic Health System, Eau Claire, WI, USA.
| | - Courtney Matthews
- Department of Pharmacy, Mayo Clinic Health System, Eau Claire, WI, USA
| | | | | | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
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Krajčová A, Skagen C, Džupa V, Urban T, Rustan AC, Jiroutková K, Bakalář B, Thoresen GH, Duška F. Effect of noradrenaline on propofol-induced mitochondrial dysfunction in human skeletal muscle cells. Intensive Care Med Exp 2022; 10:47. [DOI: 10.1186/s40635-022-00474-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022] Open
Abstract
Abstract
Background
Mitochondrial dysfunction is a hallmark of both critical illness and propofol infusion syndrome and its severity seems to be proportional to the doses of noradrenaline, which patients are receiving. We comprehensively studied the effects of noradrenaline on cellular bioenergetics and mitochondrial biology in human skeletal muscle cells with and without propofol-induced mitochondrial dysfunction.
Methods
Human skeletal muscle cells were isolated from vastus lateralis biopsies from patients undergoing elective hip replacement surgery (n = 14) or healthy volunteers (n = 4). After long-term (96 h) exposure to propofol (10 µg/mL), noradrenaline (100 µM), or both, energy metabolism was assessed by extracellular flux analysis and substrate oxidation assays using [14C] palmitic and [14C(U)] lactic acid. Mitochondrial membrane potential, morphology and reactive oxygen species production were analysed by confocal laser scanning microscopy. Mitochondrial mass was assessed both spectrophotometrically and by confocal laser scanning microscopy.
Results
Propofol moderately reduced mitochondrial mass and induced bioenergetic dysfunction, such as a reduction of maximum electron transfer chain capacity, ATP synthesis and profound inhibition of exogenous fatty acid oxidation. Noradrenaline exposure increased mitochondrial network size and turnover in both propofol treated and untreated cells as apparent from increased co-localization with lysosomes. After adjustment to mitochondrial mass, noradrenaline did not affect mitochondrial functional parameters in naïve cells, but it significantly reduced the degree of mitochondrial dysfunction induced by propofol co-exposure. The fatty acid oxidation capacity was restored almost completely by noradrenaline co-exposure, most likely due to restoration of the capacity to transfer long-chain fatty acid to mitochondria. Both propofol and noradrenaline reduced mitochondrial membrane potential and increased reactive oxygen species production, but their effects were not additive.
Conclusions
Noradrenaline prevents rather than aggravates propofol-induced impairment of mitochondrial functions in human skeletal muscle cells. Its effects on bioenergetic dysfunctions of other origins, such as sepsis, remain to be demonstrated.
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The use of metaraminol as a vasopressor in critically unwell patients: a narrative review and a survey of UK practice. J Crit Care Med (Targu Mures) 2022; 8:193-203. [PMID: 36062042 PMCID: PMC9396948 DOI: 10.2478/jccm-2022-0017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 06/14/2022] [Indexed: 11/20/2022] Open
Abstract
Abstract
Background
Major international guidelines state that norepinephrine should be used as the first-line vasopressor to achieve adequate blood pressure in patients with hypotension or shock. However, recent observational studies report that in the United Kingdom and Australia, metaraminol is often used as second line medication for cardiovascular support.
Aim of the study
The aim of this study was to carry out a systematic review of metaraminol use for management of shock in critically unwell patients and carry out a survey evaluating whether UK critical care units use metaraminol and under which circumstances.
Methods
A systematic review literature search was conducted. A short telephone survey consisting of 6 questions regarding metaraminol use was conducted across 30 UK critical care units which included a mix of tertiary and district general intensive care units.
Results
Twenty-six of thirty contacted centres responded to our survey. Metaraminol was used in 88% of them in various settings and circumstances (emergency department, theatres, medical emergencies on medical wards), with 67% reporting use of metaraminol infusions in the critical care setting. The systematic literature review revealed several case reports and only two studies conducted in the last 20 years investigating the effect of metaraminol as a stand-alone vasopressor. Both studies focused on different aspects of metaraminol use and the data was incomparable, hence we decided not to perform a meta-analysis.
Conclusions
Metaraminol is widely used as a vasopressor inside and outside of the critical care setting in the UK despite limited evidence supporting its safety and efficacy for treating shock. Further service evaluation, observational studies and prospective randomised controlled trials are warranted to validate the role and safety profile of metaraminol in the treatment of the critically unwell patient.
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Admass BA, Endalew NS, Tawye HY, Melesse DY, Workie MM, Filatie TD. Evidence-based airway management protocol for a critical ill patient in medical intensive care unit: Systematic review. Ann Med Surg (Lond) 2022; 80:104284. [PMID: 36045781 PMCID: PMC9422313 DOI: 10.1016/j.amsu.2022.104284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 07/21/2022] [Accepted: 07/26/2022] [Indexed: 11/24/2022] Open
Abstract
Background Airway management outside the theatre is performed either to resuscitate a physiologically unstable critically ill patients or to secure an emergency airway in the absence of essential equipments. It is a life saving procedure for critically ill and injured patients. Delaying in securing airway or awaking the patient is not an option in case of difficult airway in intensive care unit. Therefore, developing and implementation of an evidence-based airway management protocol is important. Objective This review was conducted to develop a clear airway management protocol for a critical ill patient in medical intensive care unit. Methods After formulating the key questions, scope, and eligibility criteria for the evidences to be included, a comprehensive search strategy of electronic sources was conducted. The literatures were searched using advanced searching methods from data bases and websites to get evidences on airway management of a critical ill patient. Duplication of literatures was avoided by endnote. Screening of literatures was conducted based on the level of significance with proper appraisal. This review was carried out in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 statement. Results A total of 626 articles were identified from data bases and websites using an electronic search. Of these articles, 95 were removed for duplication and 305 studies were excluded after reviewing their titles and abstracts. At the screening stage, 79 articles were retrieved and evaluated for the eligibility. Finally, 40 studies related to airway management of a critical ill patient in medical ICU were included in this systematic review. Conclusion A critical ill patient needs oxygenation and ventilation support. A focused and rapid assessment, with special attention of the airway and hemodynamic status of the critical ill patient is paramount. An appropriate airway management option should be employed to resuscitate or to control an emergency airway of a critical ill patent. This could be non invasive ventilation or invasive airway intervention. Airway management outside operating theatre is a common practice. A critical ill patient needs oxygenation and ventilation support. A focused airway assessment even in the most urgent situation is mandatory. Usage of appropriate airway management intervention is paramount.
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Jozwiak M, Geri G, Laghlam D, Boussion K, Dolladille C, Nguyen LS. Vasopressors and Risk of Acute Mesenteric Ischemia: A Worldwide Pharmacovigilance Analysis and Comprehensive Literature Review. Front Med (Lausanne) 2022; 9:826446. [PMID: 35677822 PMCID: PMC9168038 DOI: 10.3389/fmed.2022.826446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 04/21/2022] [Indexed: 12/03/2022] Open
Abstract
Vasodilatory shock, such as septic shock, requires personalized management which include adequate fluid therapy and vasopressor treatments. While these potent drugs are numerous, they all aim to counterbalance the vasodilatory effects of a systemic inflammatory response syndrome. Their specific receptors include α- and β-adrenergic receptors, arginine-vasopressin receptors, angiotensin II receptors and dopamine receptors. Consequently, these may be associated with severe adverse effects, including acute mesenteric ischemia (AMI). As the risk of AMI depends on drug class, we aimed to review the evidence of plausible associations by performing a worldwide pharmacovigilance analysis based on the World Health Organization database, VigiBase®. Among 24 million reports, 104 AMI events were reported, and disproportionality analyses yielded significant association with all vasopressors, to the exception of selepressin. Furthermore, in a comprehensive literature review, we detailed mechanistic phenomena which may enhance vasopressor selection, in the course of treating vasodilatory shock.
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Affiliation(s)
- Mathieu Jozwiak
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire l'Archet 1, Nice, France
- Equipe 2 CARRES UR2CA—Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur UCA, Nice, France
| | - Guillaume Geri
- Service de Médecine Intensive Réanimation, Centre Médico-Chirurgical Ambroise Paré, Neuilly-sur-Seine, France
| | - Driss Laghlam
- Service de Médecine Intensive Réanimation, Centre Médico-Chirurgical Ambroise Paré, Neuilly-sur-Seine, France
- Faculté de Médecine, Université de Paris, Paris, France
| | - Kevin Boussion
- Service de Médecine Intensive Réanimation, Centre Médico-Chirurgical Ambroise Paré, Neuilly-sur-Seine, France
| | | | - Lee S. Nguyen
- Service de Médecine Intensive Réanimation, Centre Médico-Chirurgical Ambroise Paré, Neuilly-sur-Seine, France
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Achieving Functional Outcomes after Surgical Management of Catastrophic Vasopressor-induced Limb Ischemia. Plast Reconstr Surg Glob Open 2022; 10:e4175. [PMID: 35265449 PMCID: PMC8901208 DOI: 10.1097/gox.0000000000004175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/06/2022] [Indexed: 12/02/2022]
Abstract
Vasopressor-induced limb ischemia is an unfortunate complication that can occur in patients treated for septic shock. Current literature lacks surgical treatment recommendations for this condition, besides amputation. We describe various reconstructive surgeries and functional outcomes in patients treated surgically for vasopressor-induced limb ischemia.
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Kjær MN, Granholm A, Vesterlund GK, Estrup S, Sivapalan P, Bruun CRL, Mortensen CB, Poulsen LM, Møller MH, Christensen S, Strøm T, Laerkner E, Brøchner AC, Rasmussen BS, Vestergaard SR, Barot E, Madsen MB, Egerod I, Perner A, Collet MO. Development of a core outcome set for general intensive care unit patients-A protocol. Acta Anaesthesiol Scand 2022; 66:415-424. [PMID: 34961916 DOI: 10.1111/aas.14024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 12/19/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Different outcomes are reported in randomised clinical trials (RCTs) in intensive care unit (ICU) patients, and no core outcome set (COS) is available for ICU patients in general. Accordingly, we aim to develop a COS for ICU patients in general. METHODS The COS will be developed in accordance with the Core Outcome Measures in Effectiveness Trials (COMET) Handbook, using a modified Delphi consensus process and semi-structured interviews involving adults who have survived acute admission to an ICU, family members, clinicians, researchers and other stakeholders. The modified Delphi process will include two steps. Step 1: conduction of a modified Delphi survey, developed and informed by combining the outputs of a literature search of outcomes in previous COSs and semi-structured interviews with key stakeholders. We plan at least two survey rounds to obtain consensus and refine the COS. Step 2: a consensus process regarding instruments or definitions to be recommended for the measurements of the outcomes selected in Step 1. A 'patient and public involvement panel' consisting of a smaller group of patients, family members, clinicians and researchers will be included in the development, analysis and interpretation of the COS. DISCUSSION The outlined multiple method studies will establish a COS for ICU patients in general, which may be used to increase the standardisation and comparability of results of RCTs conducted in patients in the ICU setting.
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Affiliation(s)
| | - Anders Granholm
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
| | - Gitte Kingo Vesterlund
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
| | - Stine Estrup
- Department of Anaesthesiology Zealand University Hospital Køge Denmark
| | - Praleene Sivapalan
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
| | | | | | | | - Morten Hylander Møller
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
| | | | - Thomas Strøm
- Department of Anaesthesiology and Intensive Care Odense University Hospital Odense Denmark
- Department of Anaesthesia and Critical Care Medicine Hospital Sønderjylland University Hospital of Southern Denmark Kolding Denmark
| | - Eva Laerkner
- Department of Anaesthesiology and Intensive Care Odense University Hospital Odense Denmark
| | | | - Bodil Steen Rasmussen
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
| | - Stine Rom Vestergaard
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
| | - Emily Barot
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
| | - Martin Bruun Madsen
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
| | - Ingrid Egerod
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
| | - Marie Oxenbøll Collet
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
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9
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Gao F, Zhang Y. Inotrope Use and Intensive Care Unit Mortality in Patients With Cardiogenic Shock: An Analysis of a Large Electronic Intensive Care Unit Database. Front Cardiovasc Med 2021; 8:696138. [PMID: 34621796 PMCID: PMC8490645 DOI: 10.3389/fcvm.2021.696138] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 08/25/2021] [Indexed: 12/01/2022] Open
Abstract
Purpose: To determine whether inotrope administration is associated with increased all-cause mortality in cardiogenic shock (CS) patients and to identify inotropes superior for improving mortality. Methods: This retrospective cohort study analyzed data retrieved from the Philips Electronic ICU (eICU) database, a clinical database of 200,859 patients from over 208 hospitals located throughout the United States. The database was searched for patients admitted with CS to the intensive care unit (ICU) between 2014 and 2015. We evaluated 34,381 CS patients. They were classified into the inotrope and non-inotrope groups based on whether inotropes were administered during hospitalization. The primary endpoint was all-cause hospital mortality. Findings: In total, 15,021 (43.69%) patients received inotropes during hospitalization. The in-hospital mortality rate was significantly higher in the inotrope group than in the non-inotrope group (2,999 [24.03%] vs. 1,547 [12.40%], adjusted hazard ratio: 2.24; 95% confidence interval [CI]: 2.09–2.39; p < 0.0001). After propensity score matching according to the cardiac index, 359 patients were included in each group. The risk of ICU (OR 5.65, 95% CI, 3.17–10.08, p < 0.001) and hospital (OR 2.63, 95% CI: 1.75–3.95, p < 0.001) mortality in the inotrope group was significantly higher. In the inotrope group, the administration of norepinephrine ≤0.1 μg/kg/min and dopamine ≤15 μg/kg/min did not increase the risk of hospital mortality, and milrinone administration was associated with a lower mortality risk (odds ratio: 0.559, 95% CI: 0.430–0.727, p < 0.001). Meanwhile, the administration of >0.1 μg/kg/min dobutamine, epinephrine, and norepinephrine and dopamine >15 μg/kg/min was associated with a higher risk of hospital mortality. Conclusions: Inotropes should be used cautiously because they may be associated with a higher risk of mortality in CS patients. Low-dose norepinephrine and milrinone may associated with lower risk of hospital mortality in these patients, and supportive therapies should be considered when high-dose inotropes are administered.
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Affiliation(s)
- Fei Gao
- Department of Emergency Medicine, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Yun Zhang
- Department of Emergency Medicine, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
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Belletti A, Lerose CC, Zangrillo A, Landoni G. Vasoactive-Inotropic Score: Evolution, Clinical Utility, and Pitfalls. J Cardiothorac Vasc Anesth 2021; 35:3067-3077. [DOI: 10.1053/j.jvca.2020.09.117] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/16/2020] [Accepted: 09/18/2020] [Indexed: 02/06/2023]
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Yagi T, Nagao K, Tachibana E, Yonemoto N, Sakamoto K, Ueki Y, Imamura H, Miyamoto T, Takahashi H, Hanada H, Chiba N, Tani S, Matsumoto N, Okumura Y. Treatment With Vasopressor Agents for Cardiovascular Shock Patients With Poor Renal Function; Results From the Japanese Circulation Society Cardiovascular Shock Registry. Front Med (Lausanne) 2021; 8:648824. [PMID: 34012971 PMCID: PMC8126606 DOI: 10.3389/fmed.2021.648824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 04/06/2021] [Indexed: 11/13/2022] Open
Abstract
According to the guidelines for cardiogenic shock, norepinephrine is associated with fewer arrhythmias than dopamine and may be the better first-line vasopressor agent. This study aimed to evaluate the utility of norepinephrine vs. dopamine as first-line vasopressor agent for cardiovascular shock depending on the presence and severity of renal dysfunction at hospitalization. This was a secondary analysis of the prospective, multicenter Japanese Circulation Society Cardiovascular Shock Registry (JCS Shock Registry) conducted between 2012 and 2014, which included patients with shock complicating emergency cardiovascular disease at hospital arrival. The analysis included 240 adult patients treated with norepinephrine alone (n = 98) or dopamine alone (n = 142) as the first-line vasopressor agent. Primary endpoint was mortality at 30 days after hospital arrival. The two groups had similar baseline characteristics, including estimated glomerular filtration rate (eGFR), and similar 30-day mortality rates. The analysis of the relationship between 30-day mortality rate after hospital arrival and vasopressor agent used in patients categorized according to the eGFR-based chronic kidney disease classification revealed that norepinephrine as the first-line vasopressor agent might be associated with better prognosis of cardiovascular shock in patients with mildly compromised renal function at admission (0.0 vs. 22.6%; P = 0.010) and that dopamine as the first-line vasopressor agent might be beneficial for cardiovascular shock in patients with severely compromised renal function [odds ratio; 0.22 (95% confidence interval 0.05-0.88; P = 0.032)]. Choice of first-line vasopressor agent should be based on renal function at hospital arrival for patients in cardiovascular shock. Clinical Trial Registration: http://www.umin.ac.jp/ctr/, Unique identifier: 000008441.
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Affiliation(s)
- Tsukasa Yagi
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiology, Kawaguchi Municipal Medical Center, Kawaguchi, Japan.,Department of Cardiology, Nihon University Hospital, Tokyo, Japan
| | - Ken Nagao
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiology, Nihon University Hospital, Tokyo, Japan
| | - Eizo Tachibana
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiology, Kawaguchi Municipal Medical Center, Kawaguchi, Japan
| | - Naohiro Yonemoto
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Biostatistics, Kyoto University School of Public Health, Kyoto, Japan
| | - Kazuo Sakamoto
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Yasushi Ueki
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Emergency and Critical Care Center, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hiroshi Imamura
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Emergency and Critical Care Center, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takamichi Miyamoto
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiology, Musashino Red Cross Hospital, Musashino, Japan
| | - Hiroshi Takahashi
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiology, Steel Memorial Muroran Hospital, Muroran, Japan
| | - Hiroyuki Hanada
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Emergency and Critical Care Center, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Nobutaka Chiba
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Emergency and Critical Care Medicine, Nihon University Hospital, Tokyo, Japan
| | - Shigemasa Tani
- Japanese Circulation Society (JCS) Shock Registry Scientific Committee, Tokyo, Japan.,Department of Cardiology, Nihon University Hospital, Tokyo, Japan
| | - Naoya Matsumoto
- Department of Cardiology, Nihon University Hospital, Tokyo, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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Laake JH, Buanes EA, Småstuen MC, Kvåle R, Olsen BF, Rustøen T, Strand K, Sørensen V, Hofsø K. Characteristics, management and survival of ICU patients with coronavirus disease-19 in Norway, March-June 2020. A prospective observational study. Acta Anaesthesiol Scand 2021; 65:618-628. [PMID: 33501998 PMCID: PMC8014826 DOI: 10.1111/aas.13785] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Norwegian hospitals have operated within capacity during the COVID-19 pandemic. We present patient and management characteristics, and outcomes for the entire cohort of adult (>18 years) COVID-19 patients admitted to Norwegian intensive care units (ICU) from 10 March to 19 June 2020. METHODS Data were collected from The Norwegian intensive care and pandemic registry (NIPaR). Demographics, co-morbidities, management characteristics and outcomes are described. ICU length of stay (LOS) was analysed with linear regression, and associations between risk factors and mortality were quantified using Cox regression. RESULTS In total, 217 patients were included. The male to female ratio was 3:1 and the median age was 63 years. A majority (70%) had one or more co-morbidities, most frequently cardiovascular disease (39%), chronic lung disease (22%), diabetes mellitus (20%), and obesity (17%). Most patients were admitted for acute hypoxaemic respiratory failure (AHRF) (91%) and invasive mechanical ventilation (MV) was used in 86%, prone ventilation in 38% and 25% of patients received a tracheostomy. Vasoactive drugs were used in 79% and renal replacement therapy in 15%. Median ICU LOS and time of MV was 14.0 and 12.0 days. At end of follow-up 45 patients (21%) were dead. Age, co-morbidities and severity of illness at admission were predictive of death. Severity of AHRF and male gender were associated with LOS. CONCLUSIONS In this national cohort of COVID-19 patients, mortality was low and attributable to known risk factors. Importantly, prolonged length-of-stay must be taken into account when planning for resource allocation for any next surge.
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Affiliation(s)
- Jon H. Laake
- Department of Anaesthesiology Division of Emergencies and Critical Care Rikshospitalet Medical Centre Oslo University Hospital Oslo Norway
- Department of Research and Development Division of Emergencies and Critical Care Oslo University Hospital Oslo Norway
| | - Eirik A. Buanes
- Department of Intensive Care Haukeland University Hospital Bergen Norway
- Norwegian Intensive Care and Pandemic Registry Haukeland University Hospital Bergen Norway
| | | | - Reidar Kvåle
- Department of Intensive Care Haukeland University Hospital Bergen Norway
- Norwegian Intensive Care and Pandemic Registry Haukeland University Hospital Bergen Norway
- University of Bergen Bergen Norway
| | - Brita F. Olsen
- Intensive and Postoperative Unit Østfold Hospital Trust Grålum Norway
- Faculty of Health and Welfare Østfold University College Halden Norway
| | - Tone Rustøen
- Department of Research and Development Division of Emergencies and Critical Care Oslo University Hospital Oslo Norway
- Institute of Health and Society Faculty of Medicine University of Oslo Oslo Norway
| | - Kristian Strand
- Department of Intensive Care Stavanger University Hospital Stavanger Norway
| | | | - Kristin Hofsø
- Department of Research and Development Division of Emergencies and Critical Care Oslo University Hospital Oslo Norway
- Lovisenberg Diaconal University College Oslo Norway
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13
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Pinzon D, Baumgarten D, Galetke W. [39-Year-Old Woman with Severe COVID-19 Pneumonia: Successful Weaning after Septic Shock and Forefoot Amputation after Microvascular Complications]. Pneumologie 2021; 75:526-530. [PMID: 33873215 DOI: 10.1055/a-1362-4028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
We present the case of a slightly obese 39-year-old patient with a severe course of COVID-19 pneumonia. The patient was referred from a hospital to regular care with suspected COVID-19 pneumonia. The initial clinical symptoms consisted of dysuria and fever. A bilateral infiltrate was seen in the chest x-ray. In the CT thorax, advanced COVID-19 typical changes were found on both sides. The COVID-19 infection was confirmed by a positive SARS-CoV-2 PCR from the nasopharynx smear. In the case of progressive ARDS with respiratory exhaustion, the patient was intubated and invasively ventilated. When a bacterial superinfection was suspected, we initiated empirical antibiotic therapy. In addition, a therapy with dexamethasone was applied. Therapy with ASA and weight-adapted semi-therapeutic low molecular weight heparin was also carried out. During the intensive care treatment the patient developed a fulminant septic shock with consecutive severe thrombocytopenia. A dilated tracheotomy was performed. The weaning progress was hampered by recurrent septic attacks. Necrosis in the area of the right foot was identified as the cause of the septic relapses. As there was no alternative focus, surgical rehabilitation with partial amputation was carried out. The patient then remained infection-free and could be weaned from the respirator.
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Affiliation(s)
- D Pinzon
- Vamed Klinik Hagen-Ambrock, Klinik für Pneumologie, Hagen Ambrock
| | - D Baumgarten
- Vamed Klinik Hagen-Ambrock, Klinik für Pneumologie, Hagen Ambrock
| | - W Galetke
- Vamed Klinik Hagen-Ambrock, Klinik für Pneumologie, Hagen Ambrock
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Lo Bianco G, Di Pietro S, Mazzuca E, Imburgia A, Tarantino L, Accurso G, Benenati V, Vernuccio F, Bucolo C, Salomone S, Riolo M. Multidisciplinary Approach to the Diagnosis and In-Hospital Management of COVID-19 Infection: A Narrative Review. Front Pharmacol 2020; 11:572168. [PMID: 33362541 PMCID: PMC7758731 DOI: 10.3389/fphar.2020.572168] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 10/27/2020] [Indexed: 01/08/2023] Open
Abstract
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2 or COVID-19 disease) was declared a pandemic on 11th March 2020 by the World Health Organization. This unprecedented circumstance has challenged hospitals' response capacity, requiring significant structural and organizational changes to cope with the surge in healthcare demand and to minimize in-hospital risk of transmission. As our knowledge advances, we now understand that COVID-19 is a multi-systemic disease rather than a mere respiratory tract infection, therefore requiring holistic care and expertise from various medical specialties. In fact, the clinical spectrum of presentation ranges from respiratory complaints to gastrointestinal, cardiac or neurological symptoms. In addition, COVID-19 pandemic has created a global burden of mental illness that affects the general population as well as healthcare practitioners. The aim of this manuscript is to provide a comprehensive and multidisciplinary insight into the complexity of this disease, reviewing current scientific evidence on COVID-19 management and treatment across several medical specialties involved in the in-hospital care of these patients.
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Affiliation(s)
- Giuliano Lo Bianco
- Department of Biomedical and Biotechnological Sciences, School of Medicine, University of Catania, Catania, Italy
- Anesthesiology and Pain Department, Fondazione Istituto G.Giglio, Cefalù, Italy
| | - Santi Di Pietro
- Emergency Medicine Fellowship Programme, University of Pavia, Pavia, Italy
- Emergency Department, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Emilia Mazzuca
- Unità operativa Complessa di Pneumologia, A.O. Ospedali Riuniti Villa Sofia Cervello, Palermo, Italy
| | | | - Luca Tarantino
- Cliniche Humanitas Gavazzeni, U.O. Elettrofisiologia, Bergamo, Italy
| | - Giuseppe Accurso
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | | | - Federica Vernuccio
- Section of Radiology, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BIND), University of Palermo, Palermo, Italy
| | - Claudio Bucolo
- Department of Biomedical and Biotechnological Sciences, School of Medicine, University of Catania, Catania, Italy
| | - Salvatore Salomone
- Department of Biomedical and Biotechnological Sciences, School of Medicine, University of Catania, Catania, Italy
| | - Marianna Riolo
- Struttura Complessa di Neurologia, Ospedale Santa Croce di Moncalieri, Asl TO5, Moncalieri (TO), Italy
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15
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Effect of Continuous Epinephrine Infusion on Survival in Critically Ill Patients: A Meta-Analysis of Randomized Trials. Crit Care Med 2020; 48:398-405. [PMID: 31789701 DOI: 10.1097/ccm.0000000000004127] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Epinephrine is frequently used as an inotropic and vasopressor agent in critically ill patients requiring hemodynamic support. Data from observational trials suggested that epinephrine use is associated with a worse outcome as compared with other adrenergic and nonadrenergic vasoactive drugs. We performed a systematic review and meta-analysis of randomized controlled trials to investigate the effect of epinephrine administration on outcome of critically ill patients. DATA SOURCES PubMed, EMBASE, and Cochrane central register were searched by two independent investigators up to March 2019. STUDY SELECTION Inclusion criteria were: administration of epinephrine as IV continuous infusion, patients admitted to an ICU or undergoing major surgery, and randomized controlled trials. Studies on epinephrine administration as bolus (e.g., during cardiopulmonary resuscitation), were excluded. The primary outcome was mortality at the longest follow-up available. DATA EXTRACTION Two independent investigators examined and extracted data from eligible trials. DATA SYNTHESIS A total of 5,249 studies were assessed, with a total of 12 studies (1,227 patients) finally included in the meta-analysis. The majority of the trials were performed in the setting of septic shock, and the most frequent comparator was a combination of norepinephrine plus dobutamine. We found no difference in all-cause mortality at the longest follow-up available (197/579 [34.0%] in the epinephrine group vs 219/648 [33.8%] in the control group; risk ratio = 0.95; 95% CI, 0.82-1.10; p = 0.49; I = 0%). No differences in the need for renal replacement therapy, occurrence rate of myocardial ischemia, occurrence rate of arrhythmias, and length of ICU stay were observed. CONCLUSIONS Current randomized evidence showed that continuous IV administration of epinephrine as inotropic/vasopressor agent is not associated with a worse outcome in critically ill patients.
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16
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Haas A, Schürholz T, Reuter DA. [Perioperative pharmacological circulatory support in daily clinical routine]. Anaesthesist 2020; 69:781-792. [PMID: 32572502 DOI: 10.1007/s00101-020-00803-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Perioperative phases of hypotension are associated with an increase in postoperative complications and organ damage. Whereas some years ago hemodynamic stabilization was primarily carried out by volume supplementation, in recent years the use and dosing of cardiovascular-active substances has significantly increased. But like intravascular volume therapy, also substances with a cardiovascular effect have therapeutic margins, and thus, potential side effects. This review article discusses indications for each cardiovascular-active agent, weighing up advantages and disadvantages. Special attention is paid to the question how to administrate them: central venous catheter vs. peripheral indwelling venous cannula. The authors come to the conclusion that it is not a question of whether it is principally allowed to apply cardiovascular-active drugs via peripheral veins but more importantly, what should be taken into consideration if a peripheral venous access is used. This article provides concise recommendations.
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Affiliation(s)
- A Haas
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
| | - T Schürholz
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
| | - D A Reuter
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland.
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17
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Silberberg B, Aston S, Boztepe S, Jacob S, Rylance J. Recommendations for fluid management of adults with sepsis in sub-Saharan Africa: a systematic review of guidelines. Crit Care 2020; 24:286. [PMID: 32503647 PMCID: PMC7275525 DOI: 10.1186/s13054-020-02978-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 05/12/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Sepsis guidelines are widely used in high-income countries and intravenous fluids are an important supportive treatment modality. However, fluids have been harmful in intervention trials in low-income countries, most notably in sub-Saharan Africa. We assessed the relevance, quality and applicability of available guidelines for the fluid management of adult patients with sepsis in this region. METHODS We identified sepsis guidelines by systematic review with broad search terms, duplicate screening and data extraction. We included peer-reviewed publications with explicit relevance to sepsis and fluid therapy. We excluded those designed exclusively for specific aetiologies of sepsis, for limited geographic locations, or for non-adult populations. We used the AGREE II tool to assess the quality of guideline development, performed a narrative synthesis and used theoretical case scenarios to assess practical applicability to everyday clinical practice in resource-constrained settings. RESULTS Published sepsis guidelines are heterogeneous in sepsis definition and in quality: 8/10 guidelines had significant deficits in applicability, particularly with reference to resource considerations in low-income settings. Indications for intravenous fluid were hypotension (8/10), clinical markers of hypoperfusion (6/10) and lactataemia (3/10). Crystalloids were overwhelmingly recommended (9/10). Suggested volumes varied; 5/10 explicitly recommended "fluid challenges" with reassessment, totalling between 1 L and 4 L during initial resuscitation. Fluid balance, including later de-escalation of therapy, was not specifically described in any. Norepinephrine was the preferred initial vasopressor (5/10), specifically targeted to MAP > 65 mmHg (3/10), with higher values suggested in pre-existing hypertension (1/10). Recommendations for guidelines were almost universally derived from evidence in high-income countries. None of the guidelines suggested any refinement for patients with malnutrition. CONCLUSIONS Widely used international guidelines contain disparate recommendations on intravenous fluid use, lack specificity and are largely unattainable in low-income countries given available resources. A relative lack of high-quality evidence from sub-Saharan Africa increases reliance on recommendations which may not be relevant or implementable.
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Affiliation(s)
- Benjamin Silberberg
- Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L9 7AL, UK.
- Department of Biostatistics, University of Liverpool, Liverpool, UK.
| | - Stephen Aston
- Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L9 7AL, UK
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Selda Boztepe
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Shevin Jacob
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jamie Rylance
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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18
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Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, Oczkowski S, Levy MM, Derde L, Dzierba A, Du B, Aboodi M, Wunsch H, Cecconi M, Koh Y, Chertow DS, Maitland K, Alshamsi F, Belley-Cote E, Greco M, Laundy M, Morgan JS, Kesecioglu J, McGeer A, Mermel L, Mammen MJ, Alexander PE, Arrington A, Centofanti JE, Citerio G, Baw B, Memish ZA, Hammond N, Hayden FG, Evans L, Rhodes A. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Crit Care Med 2020; 48:e440-e469. [PMID: 32224769 PMCID: PMC7176264 DOI: 10.1097/ccm.0000000000004363] [Citation(s) in RCA: 606] [Impact Index Per Article: 151.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around the world. Urgent guidance for clinicians caring for the sickest of these patients is needed. METHODS We formed a panel of 36 experts from 12 countries. All panel members completed the World Health Organization conflict of interest disclosure form. The panel proposed 53 questions that are relevant to the management of COVID-19 in the ICU. We searched the literature for direct and indirect evidence on the management of COVID-19 in critically ill patients in the ICU. We identified relevant and recent systematic reviews on most questions relating to supportive care. We assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, then generated recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of best practice recommendations. RESULTS The Surviving Sepsis Campaign COVID-19 panel issued 54 statements, of which four are best practice statements, nine are strong recommendations, and 35 are weak recommendations. No recommendation was provided for six questions. The topics were: 1) infection control, 2) laboratory diagnosis and specimens, 3) hemodynamic support, 4) ventilatory support, and 5) COVID-19 therapy. CONCLUSION The Surviving Sepsis Campaign COVID-19 panel issued several recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19. When available, we will provide new evidence in further releases of these guidelines.
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Affiliation(s)
- Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Morten Hylander Møller
- Copenhagen University Hospital Rigshospitalet, Department of Intensive Care, Copenhagen, Denmark
- Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI)
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Mark Loeb
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Michelle Ng Gong
- Division of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Montefiore Healthcare System/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Simon Oczkowski
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Mitchell M Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
- Rhode Island Hospital, Providence, Rhode Island, USA
| | - Lennie Derde
- Department of Intensive Care Medicine, University medical Center Utrecht, Utrecht University, the Netherlands
- Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Amy Dzierba
- Department of Pharmacy, New York-Presbyterian Hospital, Columbia University Irving Medical Center, New York, New York, USA
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing
| | - Michael Aboodi
- Division of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Montefiore Healthcare System/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
- Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Daniel S Chertow
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, USA
| | | | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Emilie Belley-Cote
- Department of Medicine, McMaster University, Hamilton, Canada
- Population Health Research Institute, Hamilton, Canada
| | - Massimiliano Greco
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
- Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Matthew Laundy
- Microbiology and Infection control, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | | | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University medical Center Utrecht, Utrecht University, the Netherlands
| | - Allison McGeer
- Division of Infectious Diseases, University of Toronto, Toronto, Canada
| | - Leonard Mermel
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
| | - Manoj J Mammen
- Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Paul E Alexander
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
- GUIDE Research Methods Group, Hamilton, Canada (https://guidecanada.org)
| | - Amy Arrington
- Houston Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | | | - Giuseppe Citerio
- Department of Medicine and Surgery, Milano-Bicocca University, Milano, Italy
- ASST-Monza, Desio and San Gerardo Hospital, Monza, Italy
| | - Bandar Baw
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Emergency Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Ziad A Memish
- Director, Research & Innovation Centre, King Saud Medical City, Ministry of Health, Riyadh, Kingdom of Saudi Arabia
| | - Naomi Hammond
- Critical Care Division, The George Institute for Global Health and UNSW Sydney, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia
| | - Frederick G Hayden
- Division of Infectious Diseases and International Health, Department of Medicine, University of, Virginia, School of Medicine, Charlottesville, Virginia, USA
| | - Laura Evans
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, USA
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
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19
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Jiménez-Rivera JJ, Álvarez-Castillo A, Ferrer-Rodríguez J, Iribarren-Sarrías JL, García-González MJ, Jorge-Pérez P, Lacalzada-Almeida J, Pérez-Hernández R, Montoto-López J, Martínez-Sanz R. Preconditioning with levosimendan reduces postoperative low cardiac output in moderate-severe systolic dysfunction patients who will undergo elective coronary artery bypass graft surgery: a cost-effective strategy. J Cardiothorac Surg 2020; 15:108. [PMID: 32448319 PMCID: PMC7245898 DOI: 10.1186/s13019-020-01140-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/04/2020] [Indexed: 11/17/2022] Open
Abstract
Background Patients with moderate-severe systolic dysfunction undergoing coronary artery bypass graft have a higher incidence of postoperative low cardiac output. Preconditioning with levosimendan may be a useful strategy to prevent this complication. In this context, design cost-effective strategies like preconditioning with levosimendan may become necessary. Methods In a sequential assignment of patients with Left Ventricle Ejection Fraction less than 40%, two strategies were compared in terms of cost-effectiveness: standard care (n = 41) versus preconditioning with Levosimendan (n = 13). The adverse effects studied included: postoperative new-onset atrial fibrillation, low cardiac output, renal failure and prolonged mechanical ventilation. The costs were evaluated using deterministic and probabilistic sensitivity analysis, and Monte Carlo simulations were performed. Results Preconditioning with levosimendan in moderate to severe systolic dysfunction (Left Ventricle Ejection Fraction < 40%), was associated with a lower incidence of postoperative low cardiac output in elective coronary artery bypass graft surgery 2(15.4%) vs 25(61%) (P < 0.01) and lesser intensive care unit length of stay 2(1–4) vs 4(3–6) days (P = 0.03). Average cost on levosimendan group was 14,792€ while the average cost per patient without levosimendan was 17,007€. Patients with no complications represented 53.8% of the total in the levosimendan arm, as compared to 31.7% in the non-levosimendan arm. In all Montecarlo simulations for sensitivity analysis, use of levosimendan was less expensive and more effective. Conclusions Preconditioning with levosimendan, is a cost-effective strategy preventing postoperative low cardiac output in patients with moderate-severe left ventricular systolic dysfunction undergoing elective coronary artery bypass graft surgery.
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Affiliation(s)
- Juan José Jiménez-Rivera
- Department of Intensive Care, Hospital Universitario de Canarias, La Laguna Tenerife, S.C.Tenerife, Canary Islands, Spain.
| | - Andrea Álvarez-Castillo
- Department of Intensive Care, Hospital Universitario de Canarias, La Laguna Tenerife, S.C.Tenerife, Canary Islands, Spain
| | - Jorge Ferrer-Rodríguez
- Health Economist, University of La Laguna, La Laguna, Tenerife, S.C.Tenerife, Canary Islands, Spain
| | - José Luis Iribarren-Sarrías
- Department of Intensive Care, Hospital Universitario de Canarias, La Laguna Tenerife, S.C.Tenerife, Canary Islands, Spain
| | - Martín Jesús García-González
- Department of Cardiology, Hospital Universitario de Canarias, La Laguna, Tenerife, S.C.Tenerife, Canary Islands, Spain
| | - Pablo Jorge-Pérez
- Department of Cardiology, Hospital Universitario de Canarias, La Laguna, Tenerife, S.C.Tenerife, Canary Islands, Spain
| | - Juan Lacalzada-Almeida
- Department of Cardiology, Hospital Universitario de Canarias, La Laguna, Tenerife, S.C.Tenerife, Canary Islands, Spain
| | - Rosalía Pérez-Hernández
- Department of Intensive Care, Hospital Universitario de Canarias, La Laguna Tenerife, S.C.Tenerife, Canary Islands, Spain
| | - Javier Montoto-López
- Department of Cardiovascular Surgery, Hospital Universitario de Canarias, La Laguna, Tenerife, S.C.Tenerife, Canary Islands, Spain
| | - Rafael Martínez-Sanz
- Department of Cardiovascular Surgery, Hospital Universitario de Canarias, La Laguna, Tenerife, S.C.Tenerife, Canary Islands, Spain
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20
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Long-term outcome of perioperative low cardiac output syndrome in cardiac surgery: 1-year results of a multicenter randomized trial. J Crit Care 2020; 58:89-95. [PMID: 32402931 DOI: 10.1016/j.jcrc.2020.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/23/2020] [Accepted: 04/13/2020] [Indexed: 01/21/2023]
Abstract
PURPOSE Perioperative myocardial dysfunction occurs frequently in cardiac surgery, and is a risk factor for morbidity and mortality. Levosimendan has been suggested to reduce mortality of patients with perioperative myocardial dysfunction. However, long-term outcome data on its efficacy in cardiac surgery are lacking. MATERIALS AND METHODS Cardiac surgery patients with perioperative myocardial dysfunction were randomized to levosimendan or placebo, in addition to standard inotropic care. One-year mortality data were collected. RESULTS We randomized 506 patients (248 to levosimendan 258 to placebo). At 1-year follow-up, 41 patients (16.5%) died in the levosimendan group, while 47 (18.3%) died in the placebo group (absolute risk difference -1.8; 95% CI -8.4 to 4.9; P = .60). Female sex, history of chronic obstructive pulmonary disease, previous myocardial infarction, serum creatinine, hematocrit, mean arterial pressure, and duration of cardiopulmonary bypass were independently associated with 1-year mortality. CONCLUSIONS Levosimendan administration does not improve 1-year survival in cardiac surgery patients with perioperative myocardial dysfunction. One-year mortality in these patients is 17%. Six predictive factors for long-term mortality were identified. STUDY REGISTRATION NUMBER NCT00994825 (ClinicalTrials.gov).
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21
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Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, Oczkowski S, Levy MM, Derde L, Dzierba A, Du B, Aboodi M, Wunsch H, Cecconi M, Koh Y, Chertow DS, Maitland K, Alshamsi F, Belley-Cote E, Greco M, Laundy M, Morgan JS, Kesecioglu J, McGeer A, Mermel L, Mammen MJ, Alexander PE, Arrington A, Centofanti JE, Citerio G, Baw B, Memish ZA, Hammond N, Hayden FG, Evans L, Rhodes A. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med 2020; 46:854-887. [PMID: 32222812 PMCID: PMC7101866 DOI: 10.1007/s00134-020-06022-5] [Citation(s) in RCA: 1306] [Impact Index Per Article: 326.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 03/20/2020] [Indexed: 02/07/2023]
Abstract
Background The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around the world. Urgent guidance for clinicians caring for the sickest of these patients is needed.
Methods We formed a panel of 36 experts from 12 countries. All panel members completed the World Health Organization conflict of interest disclosure form. The panel proposed 53 questions that are relevant to the management of COVID-19 in the ICU. We searched the literature for direct and indirect evidence on the management of COVID-19 in critically ill patients in the ICU. We identified relevant and recent systematic reviews on most questions relating to supportive care. We assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, then generated recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of best practice recommendations.
Results The Surviving Sepsis Campaign COVID-19 panel issued 54 statements, of which 4 are best practice statements, 9 are strong recommendations, and 35 are weak recommendations. No recommendation was provided for 6 questions. The topics were: (1) infection control, (2) laboratory diagnosis and specimens, (3) hemodynamic support, (4) ventilatory support, and (5) COVID-19 therapy.
Conclusion The Surviving Sepsis Campaign COVID-19 panel issued several recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19. When available, we will provide new recommendations in further releases of these guidelines.
Electronic supplementary material The online version of this article (10.1007/s00134-020-06022-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, 4131, Copenhagen, Denmark.,Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI), Copenhagen, Denmark
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Mark Loeb
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Michelle Ng Gong
- Division of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Montefiore Healthcare System/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Simon Oczkowski
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Mitchell M Levy
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA.,Rhode Island Hospital, Providence, RI, USA
| | - Lennie Derde
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Amy Dzierba
- Department of Pharmacy, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing, 100730, China
| | - Michael Aboodi
- Division of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Montefiore Healthcare System/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.,Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Daniel S Chertow
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, Baltimore, USA
| | | | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, PO Box 17666, Al Ain, United Arab Emirates
| | - Emilie Belley-Cote
- Department of Medicine, McMaster University, Hamilton, Canada.,Population Health Research Institute, Hamilton, Canada
| | - Massimiliano Greco
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.,Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Matthew Laundy
- Microbiology and Infection Control, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | | | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Allison McGeer
- Division of Infectious Diseases, University of Toronto, Toronto, Canada
| | - Leonard Mermel
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Manoj J Mammen
- Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, USA
| | - Paul E Alexander
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,GUIDE Research Methods Group, Hamilton, Canada
| | - Amy Arrington
- Houston Children's Hospital, Baylor College of Medicine, Houston, USA
| | | | - Giuseppe Citerio
- Department of Medicine and Surgery, Milano-Bicocca University, Milan, Italy.,ASST-Monza, Desio and San Gerardo Hospital, Monza, Italy
| | - Bandar Baw
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Emergency Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Ziad A Memish
- Director, Research and Innovation Centre, King Saud Medical City, Ministry of Health, Riyadh, Kingdom of Saudi Arabia
| | - Naomi Hammond
- Critical Care Division, The George Institute for Global Health and UNSW, Sydney, Australia.,Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia
| | - Frederick G Hayden
- Division of Infectious Diseases and International Health, Department of Medicine, University, of Virginia, School of Medicine, Charlottesville, VA, USA
| | - Laura Evans
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, USA
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK.
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22
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Abstract
PURPOSE OF REVIEW Data and interventional trials regarding vasopressor and inotrope use during cardiogenic shock are scarce. Their use is limited by their side-effects and the lack of solid evidence regarding their effectiveness in improving outcomes. In this article, we review the current use of vasopressor and inotrope agents during cardiogenic shock. RECENT FINDINGS Two recent Cochrane analyses concluded that there was not sufficient evidence to prove that any one vasopressor or inotrope was superior to another in terms of mortality. A recent RCT and a meta-analysis on individual data suggested that norepinephrine may be preferred over epinephrine in patients with cardiogenic shock . For inotrope agents, when norepinephrine fails to restore perfusion, dobutamine represents the first-line agent. Levosimendan is a calcium sensitizer agent, which improves acute hemodynamics, albeit with uncertain effects on mortality. SUMMARY When blood pressure needs to be restored, norepinephrine is a reasonable first-line agent. Dobutamine is the first-line inotrope agent wheraes levosimendan can be used as a second-line agent or preferentially in patients previously treated with beta-blockers. Current information regarding comparative effective outcomes is nonetheless sparse and their use should be limited as a temporary bridge to recovery, mechanical circulatory support or heart transplantation.
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23
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Juneja D, Savio RD, Srinivasan S, Pandit RA, Ramasubban S, Reddy PK, Singh MK, Gopal PB, Chaudhry D, Govil D, Dixit SB, Samavedam S. Basic Critical Care for Management of COVID-19 Patients: Position Paper of the Indian Society of Critical Care Medicine, Part II. Indian J Crit Care Med 2020; 24:S254-S262. [PMID: 33354049 PMCID: PMC7724927 DOI: 10.5005/jp-journals-10071-23593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
In a resource-limited country like India, rationing of scarce critical care resources might be required to ensure appropriate delivery of care to the critically ill patients suffering from COVID-19 infection. Most of these patients require critical care support because of respiratory failure or presence of multiorgan dysfunction syndrome. As there is no pharmacological therapy available, respiratory support in the form of supplemental oxygen, noninvasive ventilation, and invasive mechanical ventilation remains mainstay of care in intensive care units. As there is still dearth of direct evidence, most of the data are extrapolated from the experience gained from the management of general critical care patients. How to cite this article: Juneja D, Savio RD, Srinivasan S, Pandit RA, Ramasubban S, Reddy PK, et al. Basic Critical Care for Management of COVID-19 Patients: Position Paper of the Indian Society of Critical Care Medicine, Part II. Indian J Crit Care Med 2020;24(Suppl 5):S254–S262.
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Affiliation(s)
- Deven Juneja
- Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi, India
| | - Raymond D Savio
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| | | | - Rahul A Pandit
- Department of Intensive Care, Fortis Hospital, Mulund, Mumbai, Maharashtra, India
| | - Suresh Ramasubban
- Department of Critical Care, Apollo Gleneagles Hospital, Kolkata, West Bengal, India
| | - Pavan K Reddy
- Department of Critical Care, CARE-Banjara, Hyderabad, Telangana, India
| | - Manoj K Singh
- Department of Critical Care, Apollo Hospitals International Limited, Ahmedabad, Gujarat, India
| | - Palepu Bn Gopal
- Department of Critical Care, Continental Hospital, Hyderabad, Telangana, India
| | - Dhruva Chaudhry
- Department of Pulmonary and Critical Care, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Deepak Govil
- Institute of Critical Care and Anesthesia, Medanta: The Medicity, Gurugram, Haryana, India
| | - Subhal B Dixit
- Department of Critical Care Medicine, Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Srinivas Samavedam
- Department of Critical Care, Virinchi Hospital, Hyderabad, Telangana, India
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24
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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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25
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Belletti A, Landoni G, Lomivorotov VV, Oriani A, Ajello S. Adrenergic Downregulation in Critical Care: Molecular Mechanisms and Therapeutic Evidence. J Cardiothorac Vasc Anesth 2019; 34:1023-1041. [PMID: 31839459 DOI: 10.1053/j.jvca.2019.10.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 09/09/2019] [Accepted: 10/10/2019] [Indexed: 02/08/2023]
Abstract
Catecholamines remain the mainstay of therapy for acute cardiovascular dysfunction. However, adrenergic receptors quickly undergo desensitization and downregulation after prolonged stimulation. Moreover, prolonged exposure to high circulating catecholamines levels is associated with several adverse effects on different organ systems. Unfortunately, in critically ill patients, adrenergic downregulation translates into progressive reduction of cardiovascular response to exogenous catecholamine administration, leading to refractory shock. Accordingly, there has been a growing interest in recent years toward use of noncatecholaminergic inotropes and vasopressors. Several studies investigating a wide variety of catecholamine-sparing strategies (eg, levosimendan, vasopressin, β-blockers, steroids, and use of mechanical circulatory support) have been published recently. Use of these agents was associated with improvement in hemodynamics and decreased catecholamine use but without a clear beneficial effect on major clinical outcomes. Accordingly, additional research is needed to define the optimal management of catecholamine-resistant shock.
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Affiliation(s)
- Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Vladimir V Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia; Novosibirsk State University, Novosibirsk, Russia
| | - Alessandro Oriani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Ajello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
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26
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Perner A, Hjortrup PB, Arabi Y. Focus on blood pressure targets and vasopressors in critically ill patients. Intensive Care Med 2019; 45:1295-1297. [PMID: 31384963 DOI: 10.1007/s00134-019-05716-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 07/27/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Peter B Hjortrup
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Køge, Denmark
| | - Yaseen Arabi
- College of Medicine, King Abdullah International Medical Research Center and Intensive Care Department, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
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27
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Landry GJ, Mostul CJ, Ahn DS, McLafferty BJ, Liem TK, Mitchell EL, Jung E, Abraham CZ, Azarbal AF, McLafferty RB, Moneta GL. Causes and outcomes of finger ischemia in hospitalized patients in the intensive care unit. J Vasc Surg 2019; 68:1499-1504. [PMID: 29685512 DOI: 10.1016/j.jvs.2018.01.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 01/22/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Vascular surgeons may be consulted to evaluate hospitalized patients with finger ischemia. We sought to characterize causes and outcomes of finger ischemia in intensive care unit (ICU) patients. METHODS All ICU patients who underwent evaluation for finger ischemia from 2008 to 2015 were reviewed. All were evaluated with finger photoplethysmography. The patients' demographics, comorbidities, ICU care (ventilator status, arterial lines, use of vasoactive medications), finger amputations, and survival were also recorded. ICU patients were compared with concurrently evaluated non-ICU inpatients with finger ischemia. RESULTS There were 98 ICU patients (55 male, 43 female) identified. The mean age was 57.1 ± 16.8 years. Of these patients, 42 (43%) were in the surgical ICU and 56 (57%) in the medical ICU. Seventy (72%) had abnormal findings on finger photoplethysmography, 40 (69%) unilateral and 30 (31%) bilateral. Thirty-six (37%) had ischemia associated with an arterial line. Twelve (13%) had concomitant toe ischemia. Eighty (82%) were receiving vasoactive medications at the time of diagnosis, with the most frequent being phenylephrine (55%), norepinephrine (47%), ephedrine (31%), epinephrine (26%), and vasopressin (24%). Treatment was with anticoagulation in 88 (90%; therapeutic, 48%; prophylactic, 42%) and antiplatelet agents in 59 (60%; aspirin, 51%; clopidogrel, 15%). Other frequently associated conditions included mechanical ventilation at time of diagnosis (37%), diabetes (34%), peripheral arterial disease (32%), dialysis dependence (31%), cancer (24%), and sepsis (20%). Only five patients (5%) ultimately required finger amputation. The 30-day, 1-year, and 3-year survival was 84%, 69%, and 59%. By Cox proportional hazards modeling, cancer (hazard ratio, 2.4; 95% confidence interval, 1.1-5.6; P = .035) was an independent predictor of mortality. There were 50 concurrent non-ICU patients with finger ischemia. Non-ICU patients were more likely to have connective tissue disorders (26% vs 13%; P = .05) and hyperlipidemia (42% vs 24%; P = .03) and to undergo finger amputations (16% vs 5%; P = .03). CONCLUSIONS Finger ischemia in the ICU is frequently associated with the presence of arterial lines and the use of vasopressor medications, of which phenylephrine and norepinephrine are most frequent. Anticoagulation or antiplatelet therapy is appropriate treatment. Whereas progression to amputation is rare, patients with finger ischemia in the ICU have a high rate of mortality, particularly in the presence of cancer. Non-ICU patients hospitalized with finger ischemia more frequently require finger amputations, probably because of more frequent connective tissue disorders.
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Affiliation(s)
- Gregory J Landry
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore.
| | - Courtney J Mostul
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Daniel S Ahn
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Bryant J McLafferty
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Timothy K Liem
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Erica L Mitchell
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Enjae Jung
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Cherrie Z Abraham
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Amir F Azarbal
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Robert B McLafferty
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Gregory L Moneta
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
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28
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Rehn M, Chew MS, Olkkola KT, Örn Sverrison K, Yli-Hankala A, Møller MH. Endorsement of clinical practice guidelines by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand 2019; 63:161-163. [PMID: 30511469 DOI: 10.1111/aas.13306] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 11/13/2018] [Indexed: 12/12/2022]
Abstract
Clinical practice guidelines from other organizations or societies with assumed clinical and contextualized relevance for Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) members, may trigger a formal evaluation by The Clinical Practice Committee (CPC) for possible SSAI endorsement. This avoids unnecessary duplicate processes and minimizes resource-waste. Identified guidelines are assessed for endorsement using the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument. The SSAI CPC utilizes the AGREE II online coordinated group appraisal platform to assess the methodological rigor and transparency in which the guideline was developed. The results of the assessment, including the decision to endorse or not, are presented to the SSAI Board for sanctioning. This document briefly outlines the process for evaluation of non-SSAI guidelines by the CPC for possible SSAI endorsement.
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Affiliation(s)
- Marius Rehn
- Pre-hospital division, Air ambulance department; Oslo university hospital; Oslo Norway
- The Norwegian Air Ambulance Foundation; Drøbak Norway
- Faculty of Health Sciences; University of Stavanger; Stavanger Norway
| | - Michelle S. Chew
- Department of Anaesthesia and Intensive Care, Medicine and Health; Linköping University; Linköping Sweden
| | - Klaus T. Olkkola
- Department of Anaesthesiology, Intensive Care and Pain Medicine; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Kristinn Örn Sverrison
- Department of Anaesthesia and Intensive Care Medicine; Landspitali University Hospital; Reykjavík Iceland
| | - Arvi Yli-Hankala
- Department of Anaesthesia; Tampere University Hospital; Tampere Finland
- Faculty of Medicine and Life Sciences; University of Tampere; Tampere Finland
| | - Morten Hylander Møller
- Department of Intensive Care; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
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29
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Levy B, Clere-Jehl R, Legras A, Morichau-Beauchant T, Leone M, Frederique G, Quenot JP, Kimmoun A, Cariou A, Lassus J, Harjola VP, Meziani F, Louis G, Rossignol P, Duarte K, Girerd N, Mebazaa A, Vignon P, Mattei M, Thivilier C, Perez P, Auchet T, Fritz C, Boisrame-Helme J, Mercier E, Garot D, Perny J, Gette S, Hammad E, Vigne C, Dargent A, Andreu P, Guiot P. Epinephrine Versus Norepinephrine for Cardiogenic Shock After Acute Myocardial Infarction. J Am Coll Cardiol 2018; 72:173-182. [DOI: 10.1016/j.jacc.2018.04.051] [Citation(s) in RCA: 195] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 04/09/2018] [Accepted: 04/15/2018] [Indexed: 12/28/2022]
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30
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Møller MH, Granholm A, Junttila E, Haney M, Oscarsson-Tibblin A, Haavind A, Laake JH, Wilkman E, Sverrisson KÖ, Perner A. Scandinavian SSAI clinical practice guideline on choice of inotropic agent for patients with acute circulatory failure. Acta Anaesthesiol Scand 2018; 62:420-450. [PMID: 29479665 PMCID: PMC5888146 DOI: 10.1111/aas.13089] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 12/28/2017] [Accepted: 01/03/2018] [Indexed: 12/22/2022]
Abstract
Background Adult critically ill patients often suffer from acute circulatory failure and those with low cardiac output may be treated with inotropic agents. The aim of this Scandinavian Society of Anaesthesiology and Intensive Care Medicine guideline was to present patient‐important treatment recommendations on this topic. Methods This guideline was developed according to GRADE. We assessed the following subpopulations of patients with shock: (1) shock in general, (2) septic shock, (3) cardiogenic shock, (4) hypovolemic shock, (5) shock after cardiac surgery, and (6) other types of shock, including vasodilatory shock. We assessed patient‐important outcome measures, including mortality and serious adverse reactions. Results For all patients, we suggest against the routine use of any inotropic agent, including dobutamine, as compared to placebo/no treatment (very low quality of evidence). For patients with shock in general, and in those with septic and other types of shock, we suggest using dobutamine rather than levosimendan or epinephrine (very low quality of evidence). For patients with cardiogenic shock and in those with shock after cardiac surgery, we suggest using dobutamine rather than milrinone (very low quality of evidence). For the other clinical questions, we refrained from giving any recommendations or suggestions. Conclusions We suggest against the routine use of any inotropic agent in adult patients with shock. If used, we suggest using dobutamine rather than other inotropic agents for the majority of patients, however, the quality of evidence was very low, implying high uncertainty on the balance between the benefits and harms of inotropic agents.
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Affiliation(s)
- M. H. Møller
- Department of Intensive Care 4131; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - A. Granholm
- Department of Intensive Care 4131; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - E. Junttila
- Department of Anaesthesiology; Tampere University Hospital; Tampere Finland
| | - M. Haney
- Anaesthesiology and Intensive Care Medicine; Umeå University; Umeå Sweden
| | - A. Oscarsson-Tibblin
- Department of Anaesthesiology and Intensive Care; Department of Medicine and Health; Linköping University; Linköping Sweden
| | - A. Haavind
- Department of Anaesthesiology and Intensive Care; University Hospital Northern Norway; Tromsø Norway
| | - J. H. Laake
- Division of Critical Care; Oslo University Hospital; Oslo Norway
| | - E. Wilkman
- Division of Intensive Care Medicine; Department of Perioperative, Intensive Care and Pain Medicine; Helsinki University Hospital; University of Helsinki; Helsinki Finland
| | - K. Ö. Sverrisson
- Department of Anesthesia & Critical Care; Landspitali University Hospital of Iceland; Reykjavik Iceland
| | - A. Perner
- Department of Intensive Care 4131; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
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31
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Perner A, Holst LB, Haase N, Hjortrup PB, Møller MH. Common Sense Approach to Managing Sepsis. Crit Care Clin 2017; 34:127-138. [PMID: 29149934 DOI: 10.1016/j.ccc.2017.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Sepsis results in many deaths, prolonged suffering among survivors and relatives, and high use of resources both in developed and developing countries. The updated Surviving Sepsis Campaign guidelines should aid clinicians in improving the identification and management of these patients, but many uncertainties remain because most of the guidance is based on low-quality evidence. This article discusses how to use some of the specific items of the guidelines together with a common-sense approach to aid clinical management of patients with sepsis while trying to balance the potential benefit and harm of the items.
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Affiliation(s)
- Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen DK-2100, Denmark.
| | - Lars B Holst
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen DK-2100, Denmark
| | - Nicolai Haase
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen DK-2100, Denmark
| | - Peter B Hjortrup
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen DK-2100, Denmark
| | - Morten H Møller
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen DK-2100, Denmark
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32
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Rui Q, Jiang Y, Chen M, Zhang N, Yang H, Zhou Y. Dopamine versus norepinephrine in the treatment of cardiogenic shock: A PRISMA-compliant meta-analysis. Medicine (Baltimore) 2017; 96:e8402. [PMID: 29069037 PMCID: PMC5671870 DOI: 10.1097/md.0000000000008402] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Guidelines recommend that norepinephrine (NA) should be used to reach the target mean arterial pressure (MAP) during cardiogenic shock (CS), rather than epinephrine and dopamine (DA). However, there has actually been few studies on comparing norepinephrine with dopamine and their results conflicts. These studies raise a heat discussion. This study aimed to validate the effectiveness of norepinephrine for treating CS in comparison with dopamine. METHODS We performed a meta-analysis of randomized controlled trials (RCTs) to assess pooled estimates of risk ratio (RR) and 95% confidence interval (CI) for 28-day mortality, incidence of arrhythmic events, gastrointestinal reaction, and some indexes after treatment. RESULTS Compared with dopamine, patients receiving norepinephrine had a lower 28-day mortality (RR 1.611 [95% CI 1.219-2.129]; P < .001; P heterogeneity = .01), a lower risk of arrhythmic events (RR 3.426 [95% CI 2.120-5.510]; P < .001; P heterogeneity = .875) and a lower risk of gastrointestinal reaction (RR 5.474 [95% CI 2.917-10.273]; P < .001; P heterogeneity = 0). In subgroup analyses on 28-day mortality by causes of CS, there were more benefits from norepinephrine than dopamine in 2 subgroups. CONCLUSIONS Our analysis revealed that norepinephrine was associated with a lower 28-day mortality, a lower risk of arrhythmic events, and gastrointestinal reaction. No matter whether CS is caused by coronary heart disease or not, norepinephrine is superior to dopamine for correcting CS on the 28-day mortality.
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33
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Daroca-Pérez R, Carrascosa MF. Digital necrosis: a potential risk of high-dose norepinephrine. Ther Adv Drug Saf 2017; 8:259-261. [PMID: 28781738 DOI: 10.1177/2042098617712669] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 05/10/2017] [Indexed: 01/22/2023] Open
Affiliation(s)
- Rafael Daroca-Pérez
- Internal Medicine Department, Hospital of San Pedro, Logroño, La Rioja, Spain
| | - Miguel F Carrascosa
- Internal Medicine Department, Hospital of Laredo, Avda Derechos Humanos s/n, 39770 Laredo, Cantabria, Spain
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Guinot PG, Abou-Arab O, Guilbart M, Bar S, Zogheib E, Daher M, Besserve P, Nader J, Caus T, Kamel S, Dupont H, Lorne E. Monitoring dynamic arterial elastance as a means of decreasing the duration of norepinephrine treatment in vasoplegic syndrome following cardiac surgery: a prospective, randomized trial. Intensive Care Med 2017; 43:643-651. [DOI: 10.1007/s00134-016-4666-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 12/27/2016] [Indexed: 11/29/2022]
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Hessler M, Kampmeier T, Rehberg S. Effect of non-adrenergic vasopressors on macro- and microvascular coupling in distributive shock. Best Pract Res Clin Anaesthesiol 2016; 30:465-477. [DOI: 10.1016/j.bpa.2016.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 10/31/2016] [Indexed: 02/07/2023]
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Fuchs C, Ertmer C, Rehberg S. Effects of vasodilators on haemodynamic coherence. Best Pract Res Clin Anaesthesiol 2016; 30:479-489. [DOI: 10.1016/j.bpa.2016.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 10/24/2016] [Indexed: 12/21/2022]
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Møller MH, Claudius C, Junttila E, Haney M, Oscarsson‐Tibblin A, Haavind A, Perner A. Scandinavian SSAI clinical practice guideline on choice of first-line vasopressor for patients with acute circulatory failure. Acta Anaesthesiol Scand 2016; 60:1347-1366. [PMID: 27576362 PMCID: PMC5213738 DOI: 10.1111/aas.12780] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 06/02/2016] [Accepted: 07/26/2016] [Indexed: 12/27/2022]
Abstract
Background Adult critically ill patients often suffer from acute circulatory failure, necessitating use of vasopressor therapy. The aim of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) task force for Acute Circulatory Failure was to present clinically relevant, evidence‐based treatment recommendations on this topic. Methods This guideline was developed according to standards for trustworthy guidelines, including a systematic review of the literature and use of the GRADE methodology for assessment of the quality of evidence and for moving from evidence to recommendations. We assessed the following subpopulations of patients with acute circulatory failure: 1) shock in general, 2) septic shock, 3) cardiogenic shock, 4) hypovolemic shock and 5) other types of shock, including vasodilatory shock. We assessed patient‐important outcome measures, including mortality, serious adverse reactions and quality‐of‐life. Results For patients with shock in general and those with septic shock, we recommend using norepinephrine rather than dopamine, and we suggest using norepinephrine rather than epinephrine, vasopressin analogues, and phenylephrine. For patients with cardiogenic shock and those with hypovolemic shock, we suggest using norepinephrine rather than dopamine, and we provide no recommendations/suggestions of norepinephrine vs. epinephrine, vasopressin analogues, and phenylephrine. For patients with other types of shock, including vasodilatory shock, we suggest using norepinephrine rather than dopamine, epinephrine, vasopressin analogues, and phenylephrine. Conclusions We recommend using norepinephrine rather than other vasopressors as first‐line treatment for the majority of adult critically ill patients with acute circulatory failure.
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Affiliation(s)
- M. H. Møller
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Denmark
| | - C. Claudius
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Denmark
| | - E. Junttila
- Department of Anaesthesiology Tampere University Hospital Tampere Finland
| | - M. Haney
- Anaesthesiology and Intensive Care Medicine Umeå University Umeå Sweden
| | - A. Oscarsson‐Tibblin
- Department of Anaesthesiology and Intensive Care Department of Medicine and Health Linköping University Linköping Sweden
| | - A. Haavind
- Department of Anaesthesiology and Intensive Care University Hospital Northern Norway Tromsø Norway
| | - A. Perner
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Denmark
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