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Persichini R, Lai C, Teboul JL, Adda I, Guérin L, Monnet X. Venous return and mean systemic filling pressure: physiology and clinical applications. Crit Care 2022; 26:150. [PMID: 35610620 PMCID: PMC9128096 DOI: 10.1186/s13054-022-04024-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/17/2022] [Indexed: 01/15/2023] Open
Abstract
Venous return is the flow of blood from the systemic venous network towards the right heart. At steady state, venous return equals cardiac output, as the venous and arterial systems operate in series. However, unlike the arterial one, the venous network is a capacitive system with a high compliance. It includes a part of unstressed blood, which is a reservoir that can be recruited via sympathetic endogenous or exogenous stimulation. Guyton’s model describes the three determinants of venous return: the mean systemic filling pressure, the right atrial pressure and the resistance to venous return. Recently, new methods have been developed to explore such determinants at the bedside. In this narrative review, after a reminder about Guyton’s model and current methods used to investigate it, we emphasize how Guyton’s physiology helps understand the effects on cardiac output of common treatments used in critically ill patients.
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Affiliation(s)
- Romain Persichini
- Service de Réanimation et Soins Continus, Centre Hospitalier de Saintonge, 11 Boulevard Ambroise Paré, 17108, Saintes cedex, France.
| | - Christopher Lai
- Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France
| | - Jean-Louis Teboul
- Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France
| | - Imane Adda
- Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France
| | - Laurent Guérin
- Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France
| | - Xavier Monnet
- Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France
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Laufer‐Perl M, Sadon S, Zahler D, Milwidsky A, Sadeh B, Sapir O, Granot Y, Korotetski L, Ketchker L, Rosh M, Banai S, Havakuk O. Repetitive milrinone therapy in ambulatory advanced heart failure patients. Clin Cardiol 2022; 45:488-494. [PMID: 35243658 PMCID: PMC9045071 DOI: 10.1002/clc.23802] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 02/13/2022] [Accepted: 02/15/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Advanced heart failure (HF) patients usually poorly tolerate guideline-directed HF medical therapy (GDMT) and suffer high rates of morbidity and mortality. The use of continuous inotropes in the outpatient settings is hampered by previous data showing excess morbidity. We aimed to assess the safety and efficacy of repetitive, intermittent, short-term intravenous milrinone therapy in advanced HF patients with an intention to introduce and up-titrate GDMT and improve functional class. HYPOTHESIS Repetitive, intermittent milrinone therapy may assist with the stabilization of advanced HF patients. METHODS Advanced HF patients treated with beta-blockers and implanted with defibrillators were initiated with repetitive, intermittent short-term intravenous milrinone therapy at our HF outpatient unit. Patients were prospectively followed with defibrillator interrogation, functional class assessment, B-natriuretic peptide (BNP) levels, and echocardiography parameters. RESULTS The cohort included 24 patients with a mean 330 ± 240 days of milrinone therapy exposure. Mean age was 73 ± 6 years with male predominance (96%). Following milrinone therapy, median BNP levels decreased significantly (882 [286-3768] to 631 [278-1378] pg/ml, p = .017) with a significant reduction in the number of patients with New York Heart Association (NYHA) Class III and IV (p = .012, 0.013) and an increase in number of patients on GDMT. Importantly, the number of total sustained ventricular tachycardia events and HF hospitalizations did not change. CONCLUSIONS In this small cohort of advanced HF, repetitive, intermittent, short-term milrinone therapy was found to be safe and potentially efficacious.
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Affiliation(s)
- Michal Laufer‐Perl
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Sapir Sadon
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - David Zahler
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Assi Milwidsky
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Ben Sadeh
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Orly Sapir
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Yoav Granot
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Liuba Korotetski
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Liora Ketchker
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Maayan Rosh
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Shmuel Banai
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
| | - Ofer Havakuk
- Cardiology Division, Tel Aviv Sourasky Medical Centeraffiliated to Tel Aviv UniversityTel AvivIsrael
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Schulz O, Wiesner O, Welte T, Bollmann BA, Suhling H, Hoeper MM, Busch M. Enoximone in status asthmaticus. ERJ Open Res 2020; 6:00367-2019. [PMID: 32280667 PMCID: PMC7132035 DOI: 10.1183/23120541.00367-2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 02/18/2020] [Indexed: 12/26/2022] Open
Abstract
Bronchial asthma is a chronic disease affecting >300 million people worldwide [1]. The most severe disease manifestation is status asthmaticus, which can be unresponsive to medical therapy. Patients with severe status asthmaticus who require intubation and mechanical ventilation have mortality rates of up to 20% [2]. Airflow obstruction is often so severe that adequate decarboxylation and protective ventilation are not feasible, and extracorporeal membrane oxygenation (ECMO) support is nowadays an established treatment option as a bridge to recovery [3, 4]. In a patient with severe status asthmaticus, enoximone, a phosphodiesterase-3 inhibitor, caused immediate bronchodilationhttp://bit.ly/38UYpUn
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Affiliation(s)
- Oscar Schulz
- Dept of Respiratory Medicine and German Centre for Lung Research (DZL/BREATH), Hannover Medical School, Hannover, Germany
| | - Olaf Wiesner
- Dept of Respiratory Medicine and German Centre for Lung Research (DZL/BREATH), Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- Dept of Respiratory Medicine and German Centre for Lung Research (DZL/BREATH), Hannover Medical School, Hannover, Germany
| | - Benjamin-Alexander Bollmann
- Dept of Respiratory Medicine and German Centre for Lung Research (DZL/BREATH), Hannover Medical School, Hannover, Germany
| | - Hendrik Suhling
- Dept of Respiratory Medicine and German Centre for Lung Research (DZL/BREATH), Hannover Medical School, Hannover, Germany
| | - Marius M Hoeper
- Dept of Respiratory Medicine and German Centre for Lung Research (DZL/BREATH), Hannover Medical School, Hannover, Germany
| | - Markus Busch
- Dept of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
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Angeloni E, Melina G, Federici F, Pischedda F, Vignaroli W, Rocco M, Sinatra R. Preliminary results of the Multicenter Observational Study with Enoximone in Cardiac surgery (MOSEC). Int J Cardiol 2018; 269:51-55. [PMID: 30037630 DOI: 10.1016/j.ijcard.2018.07.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/04/2018] [Accepted: 07/13/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Perioperative administration of Enoximone has been shown to improve hemodynamics, organ function, and inflammatory response. Aim of the present study was to evaluate the effects of Enoximone after on-pump cardiac surgery. METHODS A protocol for a multicenter observational study was reviewed and approved by local ethic committee. This preliminary report involves the first 29 patients enrolled, in whom Enoximone was perioperatively administered in the context of on-pump cardiac surgery. All patients enrolled were propensity-matched 1:1 with controls not receiving Enoximone, renal function was evaluated in terms of estimated glomerular filtration rate (eGFR) with the CKD-EPI equation. RESULTS After propensity matching, the two cohorts of patients receiving Enoximone or not did not show any significant differences among baseline characteristics. Patients receiving Enoximone showed a progressive improvement of eGFR at each time-point of follow-up: roughly +4.3, +10.0, and +12.3 mL/min/1.73 m2 on postoperative days 2, 7, and 30; respectively. Consistently, maximum difference versus baseline was +12.6 mL/min/1.73 m2 (or +19.3%) among Enoximone patients vs +3.3 mL/min/1.73 m2 (or +4.4%) among controls (p = 0.02). Multivariable regression analysis (R2-adjusted 0.47) showed only age (β -0.53; p = 0.01), preoperative eGFR (β -0.39; p = 0.02), diabetes (β 2.1; p = 0.01), cardio-pulmonary bypass duration (β 0.08; p = 0.05), and Enoximone administration (β -0.74; p = 0.05) to be independently correlated with delta eGFR variation on day 30. CONCLUSION These preliminary results show that perioperative Enoximone administration improved renal function in patients undergoing on-pump cardiac surgery. Further studies are needed to confirm these findings.
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Affiliation(s)
- Emiliano Angeloni
- Department of Cardiac Surgery, Sapienza University of Rome, Policlinico Sant'Andrea, Roma, Italy.
| | - Giovanni Melina
- Department of Cardiac Surgery, Sapienza University of Rome, Policlinico Sant'Andrea, Roma, Italy
| | - Francesco Federici
- Department of Anaesthesiology, Sapienza University of Rome, Policlinico Sant'Andrea, Roma, Italy
| | - Francesca Pischedda
- Department of Anaesthesiology, Sapienza University of Rome, Policlinico Sant'Andrea, Roma, Italy
| | - Walter Vignaroli
- Department of Cardiac Surgery, Sapienza University of Rome, Policlinico Sant'Andrea, Roma, Italy
| | - Monica Rocco
- Department of Anaesthesiology, Sapienza University of Rome, Policlinico Sant'Andrea, Roma, Italy
| | - Riccardo Sinatra
- Department of Cardiac Surgery, Sapienza University of Rome, Policlinico Sant'Andrea, Roma, Italy
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Moin DS, Sackheim J, Hamo CE, Butler J. Cardiac Myosin Activators in Systolic Heart Failure: More Friend than Foe? Curr Cardiol Rep 2017; 18:100. [PMID: 27568794 DOI: 10.1007/s11886-016-0778-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Despite the rising prevalence of HF, new evidence-based novel therapies for patients with worsening HF remain lacking, e.g., safe inotropic therapies. Traditional inotropes increase contractility by altering intracellular calcium flux, a pathway that may be responsible for the multitude of adverse effects associated with current options. Omecamtiv mecarbil, a direct myosin activator, increases contractility through a distinct pathway by increasing the proportion of myosin heads that are bound to actin in a high-affinity state. Phase II clinical trials in patients with chronic HF with this agent seem promising. A phase III trial investigating this therapy has not yet been pursued to date.
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Affiliation(s)
- Danyaal S Moin
- Division of Cardiology, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Julia Sackheim
- Division of Cardiology, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Carine E Hamo
- Division of Cardiology, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Javed Butler
- Division of Cardiology, Stony Brook University School of Medicine, Stony Brook, NY, USA. .,Health Sciences Center, Stony Brook University Medical Center, T16-080, Stony Brook, NY, 11794, USA.
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Sénior JM, Muñoz E, Díaz J. Efecto de los inotrópicos sobre la mortalidad en falla cardiaca aguda. Metaanálisis en red de ensayos clínicos. REVISTA COLOMBIANA DE CARDIOLOGÍA 2017. [DOI: 10.1016/j.rccar.2017.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Long-term intravenous inotropes in low-output terminal heart failure? Clin Res Cardiol 2016; 105:471-81. [DOI: 10.1007/s00392-016-0968-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 02/01/2016] [Indexed: 10/22/2022]
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Belletti A, Castro ML, Silvetti S, Greco T, Biondi-Zoccai G, Pasin L, Zangrillo A, Landoni G. The Effect of inotropes and vasopressors on mortality: a meta-analysis of randomized clinical trials. Br J Anaesth 2015; 115:656-75. [PMID: 26475799 DOI: 10.1093/bja/aev284] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- A Belletti
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, via Olgettina 60, Milan 20132, Italy
| | - M L Castro
- Anaesthesiology Department, Centro Hospitalar Lisboa Central, EPE - Hospital de Santa Marta, Rua de Santa Marta 50, Lisbon 1169-024, Portugal
| | - S Silvetti
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, via Olgettina 60, Milan 20132, Italy
| | - T Greco
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, via Olgettina 60, Milan 20132, Italy Laboratorio di Statistica Medica, Biometria ed Epidemiologia "G. A. Maccacaro", Dipartimento di Scienze Cliniche e di Comunità, University of Milan, Via Festa del Perdono 7, Milan 20122, Italy
| | - G Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, Latina 04100, Italy
| | - L Pasin
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, via Olgettina 60, Milan 20132, Italy
| | - A Zangrillo
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, via Olgettina 60, Milan 20132, Italy Vita-Salute San Raffaele University, via Olgettina 58, Milan 20132, Italy
| | - G Landoni
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, via Olgettina 60, Milan 20132, Italy Vita-Salute San Raffaele University, via Olgettina 58, Milan 20132, Italy
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Persichini R, Guerin L, Monnet X. Physiopathologie du retour veineux systémique au cours de l’insuffisance circulatoire aiguë. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0869-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Angeloni E, Melina G, Roscitano A, Refice S, Capuano F, Comito C, Benedetto U, Sinatra R. Perioperative administration of enoximone and renal function after cardiac surgery: a propensity-matched analysis. Int J Cardiol 2013; 167:1961-6. [PMID: 22633430 DOI: 10.1016/j.ijcard.2012.05.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Accepted: 05/04/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Perioperative administration of enoximone has been shown to improve hemodynamics, organ function, and inflammatory response. Aim of the present study is to evaluate the impact of enoximone on postoperative renal function after on-pump cardiac surgery. METHODS A total of 3727 patients undergoing cardiac surgery at one Institution between May 2004 and November 2010 were reviewed. A propensity score was built and a 1:1 perfect matching was performed, providing two fairly comparable cohorts of 712 patients each, receiving or not enoximone after surgery. Renal function was evaluated by lower glomerular filtration rate (GFR) value reached postoperatively. RESULTS Overall 30-day mortality rate was 4.3% (62/1424). Cumulative incidence of postoperative renal failure (RF) was 157/1424(11%), of which 99/1424(7%) needed renal replacement therapy. Mean lower postoperative GFR in patients who received or not enoximone was 63 ± 30.1 and 53.5 ± 26.1 ml/min/1.73 m(2) (p<0.0001), respectively. At multivariable analysis age (OR2.75, p=0.0004), diabetes (OR1.82, p=0.006), preoperative GFR (OR3.81, p<0.0001), preoperative cardiogenic shock (OR1.65, p=0.004), previous cardiac surgery (OR2.12, p=0.0002), type of intervention (OR1.96, p=0.005), and enoximone (OR0.38, p=0.001) were found to be independently associated with postoperative RF. Logistic regression analysis showed that the administration of enoximone (OR0.41, p=0.0001), and of no inotropes (OR0.27, p<0.0001) were protective vs. the occurrence of postoperative RF. CONCLUSION Patients perioperatively receiving enoximone showed a statistically significant better renal function after cardiac surgery.
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Affiliation(s)
- Emiliano Angeloni
- Sapienza, University of Rome, Policlinico Sant'Andrea, Department of Cardiac Surgery, Rome, Italy.
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Tacon CL, McCaffrey J, Delaney A. Dobutamine for patients with severe heart failure: a systematic review and meta-analysis of randomised controlled trials. Intensive Care Med 2011; 38:359-67. [DOI: 10.1007/s00134-011-2435-6] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Accepted: 11/10/2011] [Indexed: 10/14/2022]
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Abstract
The aim of this article was to provide a resource for critical care nurses wishing to further their understanding of inotropic drugs used in critical care. The physiology of cardiac output and blood pressure is examined along with an explanation of adrenergic receptors acted on by inotropes. Some common indications for inotropic therapy are discussed, along with essential patient monitoring and dose calculations to ensure safe therapeutic ranges are observed. Some of the most commonly used positive inotropes used in critical care environments are individually explored, providing indications and some of the latest research relating to their uses. Frequently, observed side effects of individual inotropes are also offered, enabling the nurse to maintain patient safety when administering these potent drugs. Some major nursing and professional issues related to inotrope therapy and medicine administration are discussed, as well as some recommended practices in renewing infusions.
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Affiliation(s)
- Andrew Parry
- Faculty of Health, Sport and Science, Lower Glyntaf Campus, University of Glamorgan, Pontypridd, UK.
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