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Rehberg S, Frank S, Černý V, Cihlář R, Borgstedt R, Biancofiore G, Guarracino F, Schober A, Trimmel H, Pernerstorfer T, Siebers C, Dostál P, Morelli A, Joannidis M, Pretsch I, Fuchs C, Rahmel T, Podbregar M, Duliczki É, Tamme K, Unger M, Sus J, Klade C, Krejcy K, Kirchbaumer-Baroian N, Krumpl G, Duška F. Landiolol for heart rate control in patients with septic shock and persistent tachycardia. A multicenter randomized clinical trial (Landi-SEP). Intensive Care Med 2024; 50:1622-1634. [PMID: 39297945 DOI: 10.1007/s00134-024-07587-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 08/01/2024] [Indexed: 09/21/2024]
Abstract
PURPOSE Excessive tachycardia in resuscitated septic shock patients can impair hemodynamics and worsen patient outcome. We investigated whether heart rate (HR) control can be achieved without increased vasopressor requirements using the titratable highly selective, ultra-short-acting β1-blocker landiolol. METHODS This randomized, open-label, controlled trial was conducted at 20 sites in 7 European countries from 2018 to 2022 and investigated the efficacy and safety of landiolol in adult patients with septic shock and persistent tachycardia. Patients were randomly assigned to receive either landiolol along with standard treatment (n = 99) or standard treatment alone (n = 101). The combined primary endpoint was HR response (i.e., HR within the range of 80-94 beats per minute) and its maintenance without increasing vasopressor requirements during the first 24 h after treatment start. Key secondary endpoints were 28-day mortality and adverse events. RESULTS Out of 196 included septic shock patients, 98 received standard treatment combined with landiolol and 98 standard treatment alone. A significantly larger proportion of patients met the combined primary endpoint in the landiolol group than in the control group (39.8% [39/98] vs. 23.5% [23/98]), with a between-group difference of 16.5% (95% confidence interval [CI]: 3.4-28.8%; p = 0.013). There were no statistically significant differences between study groups in tested secondary outcomes and adverse events. CONCLUSION The ultra-short-acting beta-blocker landiolol was effective in reducing and maintaining HR without increasing vasopressor requirements after 24 h in patients with septic shock and persistent tachycardia. There were no differences in adverse events and clinical outcomes such as 28-day mortality vs. standard of care. The results of this study, in the context of previous trials, do not support a treatment strategy of stringent HR reduction (< 95 bpm) in an unselected septic shock population with persistent tachycardia. Further investigations are needed to identify septic shock patient phenotypes that benefit clinically from HR control.
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Affiliation(s)
- Sebastian Rehberg
- Department of Anaesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine and Pain Therapy, University Hospital of Bielefeld, Bielefeld, Germany.
| | - Sandra Frank
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Vladimír Černý
- Department of Anaesthesia and Intensive Care, Charles University, 3rd Medical Faculty and University Hospital Královské Vinohrady, Prague, Czech Republic
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital, Ústí Nad Labem, Czech Republic
- Department of Anaesthesiology and Intensive Care Medicine, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Králové, Czech Republic
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Canada
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Radek Cihlář
- Department of Anesthesiology and Intensive Care, Hospital České Budějovice, České Budějovice, Czech Republic
| | - Rainer Borgstedt
- Department of Anaesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine and Pain Therapy, University Hospital of Bielefeld, Bielefeld, Germany
| | - Gianni Biancofiore
- Department of Anaesthesiology and Transplant Intensive Care Unit, University School of Medicine Pisa, Pisa, Italy
| | - Fabio Guarracino
- Department of Anaesthesia and Critical Care Medicine, Cardiothoracic and Vascular Anaesthesiology and Intensive Care, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Andreas Schober
- Department of Cardiology, Klinik Floridsdorf & Karl Landsteiner Institute for Cardiovascular and Critical Care Research C/O Klinik Floridsdorf, Vienna, Austria
| | - Helmut Trimmel
- Department of Anesthesiology, Emergency Medicine and General Intensive Care, State Hospital Wiener Neustadt, Wiener Neustadt, Austria
| | - Thomas Pernerstorfer
- Department of Anaesthesiology and Intensive Care, Ordensklinikum Linz GmbH, Barmherzige Schwestern, Linz, Austria
| | - Christian Siebers
- Department of Anaesthesiology and Intensive Care, Hospital of Garmisch-Partenkirchen, Garmisch-Partenkirchen, Germany
| | - Pavel Dostál
- Department of Anaesthesiology and Intensive Care Medicine, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Králové, Czech Republic
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Andrea Morelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, University of Rome, "La Sapienza", Policlinico Umberto Primo, Rome, Italy
| | - Michael Joannidis
- Division of Emergency Medicine and Intensive Care, Department Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Ingrid Pretsch
- Department of Internal Medicine II, Division of Cardiology and Intensive Care, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Christian Fuchs
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Greifswald, Greifswald, Germany
| | - Tim Rahmel
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Matej Podbregar
- Internal Intensive Care Department, General Hospital Celje, Celje, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Éva Duliczki
- Anaesthesiology and Intensive Care Unit, Szabolcs-Szatmár-Bereg County Hospitals and University Teaching Hospital Jósa András Teaching Hospital, Nyíregyháza, Hungary
| | - Kadri Tamme
- Clinic of Anaesthesiology and Intensive Care, 1St. Intensive Care Unit, Tartu University Hospital, Tartu, Estonia
| | - Martin Unger
- AOP Orphan Pharmaceuticals GmbH, Vienna, Austria
| | - Jan Sus
- AOP Orphan Pharmaceuticals GmbH, Vienna, Austria
| | | | - Kurt Krejcy
- AOP Orphan Pharmaceuticals GmbH, Vienna, Austria
| | | | - Günther Krumpl
- AOP Health International Management AG, Ruggell, Liechtenstein
| | - František Duška
- Department of Anaesthesia and Intensive Care, Charles University, 3rd Medical Faculty and University Hospital Královské Vinohrady, Prague, Czech Republic
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Al-Husinat L, Abu Hmaid A, Abbas H, Abuelsamen B, Albelbisi M, Haddad S, Qamileh I, Quneis O, Al Modanat ZJ, Ferrara G, Dias FS, Cinnella G. Role of aspirin, beta-blocker, statins, and heparin therapy in septic patients under mechanical ventilation: a narrative review. Front Med (Lausanne) 2023; 10:1143090. [PMID: 37492248 PMCID: PMC10364600 DOI: 10.3389/fmed.2023.1143090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 06/22/2023] [Indexed: 07/27/2023] Open
Abstract
Sepsis is the main cause of death among patients admitted to intensive care units. Management of sepsis includes fluid resuscitation, vasopressors, intravenous antimicrobials, source control, mechanical ventilation, and others. New insights into the potential benefits of non-antimicrobial drugs in sepsis have evolved based on the pathophysiology of the disease and the mechanism of action of some drugs, but the findings are still controversial. In this study, we aimed to evaluate the effect of beta-blockers, aspirin, statins, and heparin as adjunctive treatments in septic patients under mechanical ventilation with non-cardiovascular diseases and their effect on mortality. We searched PubMed with relevant keywords (beta-blockers, aspirin, statins, or heparin, and critically ill or sepsis) for the last 10 years and some personal collection of relevant articles, and then we assessed studies according to prespecified inclusion and exclusion criteria. Our results show that beta-blockers, aspirin, and heparin may have promising feedback on reducing mortality. However, new well-controlled, randomized, multicenter studies are needed to confirm that, and multiple issues regarding their usage need to be addressed. On the other hand, the feedback regarding the effectiveness of statins was not as strong as that of the other drugs studied, and we suggest that further research is needed to confirm these results.
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Affiliation(s)
- Lou'i Al-Husinat
- Department of Clinical Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid, Jordan
| | | | - Hadeel Abbas
- Faculty of Medicine, Yarmouk University, Irbid, Jordan
| | | | | | - Said Haddad
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Ibrahim Qamileh
- Department of Anesthesia and Intensive Care, Al-Maqasid Charity Hospital, Amman, Jordan
| | - Ossaid Quneis
- Faculty of Medicine, Yarmouk University, Irbid, Jordan
| | - Zaid Jehad Al Modanat
- Department of Clinical Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid, Jordan
| | - Giuseppe Ferrara
- Department of Anesthesia and Intensive Care, University of Foggia, Foggia, Italy
| | | | - Gilda Cinnella
- Department of Anesthesia and Intensive Care, University of Foggia, Foggia, Italy
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Wang J, Gao X, He Z, Wang J, Xu G, Li T. Evaluating the effects of Esmolol on cardiac function in patients with Septic cardiomyopathy by Speck-tracking echocardiography-a randomized controlled trial. BMC Anesthesiol 2023; 23:51. [PMID: 36765286 PMCID: PMC9912519 DOI: 10.1186/s12871-023-01983-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 01/10/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Esmolol as one treatment of sepsis induced cardiomyopathy (SIC) is still controversial. The objective of this study is to evaluate cardiac function after reducing heart rate by Esmolol in patients with SIC using speck-tracking echocardiography. METHODS This study was a single-center, prospective, and randomized controlled study. A total of 100 SIC patients with a heart rate more than 100/min, admitted to the Intensive Care Department of Tianjin Third Central Hospital from March 1, 2020 to September 30, 2021, were selected as the research subjects. They were randomly divided into the Esmolol group (Group E) and the conventional treatment group (Group C), each with 50 cases. The target heart rate of patients in Group E was controlled between 80/min and 100/min. Speck-tracking echocardiography (STE) and pulse indicating continuous cardiac output monitoring (PICCO) were performed in both groups at 1 h, 24 h, 48 h, 72 h, 96 h and 7 d after admission, with data concerning left ventricular global longitudinal strain (GLS), left ventricular ejection fraction (LVEF) and global ejection fraction (GEF), left ventricular systolic force index (dP/dtmx) were obtained, respectively. Hemodynamics and other safety indicators were monitored throughout the whole process. These subjects were followed up to 90 d, with their mortality recorded at Day 28 and Day 90, respectively. Statistical analyses were performed using SPSS version 21. RESULTS With 24 h of Esmolol, all patients in Group E achieved the target heart rate, and there was no deterioration of GLS, or adverse events. However, compared with those in Group C, their GLS, GEF and dP/dtmx were increased, and the difference was statistically significant (P > 0.05). Compared with patients in Group C, those in Group E had lower short-term mortality, and logistic regression analysis also suggested that Esmolol improved patient outcomes. CONCLUSION In SIC patients, the application of Esmolol to lower heart rate decreased their short-term mortality while not making any impairment on the myocardial contractility. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR2100047513. Registered June 20, 2021- Retrospectively registered, http://www.chictr.org.cn/index.aspx . The study protocol followed the CONSORT guidelines. The study protocol was performed in the relevant guidelines.
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Affiliation(s)
- Junyi Wang
- grid.265021.20000 0000 9792 1228The Third Central Clinical College of Tianjin Medical University, Tianjin, 300170 China ,The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin, 300170 China ,grid.417032.30000 0004 1798 6216Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin, China ,grid.417032.30000 0004 1798 6216Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Xinjing Gao
- The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin, 300170 China ,grid.417032.30000 0004 1798 6216Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin, China ,grid.417032.30000 0004 1798 6216Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Zhengzhong He
- The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin, 300170 China ,grid.417032.30000 0004 1798 6216Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin, China ,grid.417032.30000 0004 1798 6216Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Jinxiang Wang
- grid.33763.320000 0004 1761 2484Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou 325026 Zhejiang, People’s Republic of China ,grid.412645.00000 0004 1757 9434Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, 300052 People’s Republic of China
| | - Guowu Xu
- grid.33763.320000 0004 1761 2484Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou 325026 Zhejiang, People’s Republic of China ,grid.412645.00000 0004 1757 9434Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, 300052 People’s Republic of China
| | - Tong Li
- The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin, 300170, China. .,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin, China. .,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.
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Geevarghese M, Patel K, Gulati A, Ranjan AK. Role of adrenergic receptors in shock. Front Physiol 2023; 14:1094591. [PMID: 36726848 PMCID: PMC9885157 DOI: 10.3389/fphys.2023.1094591] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/04/2023] [Indexed: 01/18/2023] Open
Abstract
Shock is a severe, life-threatening medical condition with a high mortality rate worldwide. All four major categories of shock (along with their various subtypes)-hypovolemic, distributive, cardiogenic, and obstructive, involve a dramatic mismatch between oxygen supply and demand, and share standard features of decreased cardiac output, reduced blood pressure, and overall hypoperfusion. Immediate and appropriate intervention is required regardless of shock type, as a delay can result in cellular dysfunction, irreversible multiple organ failure, and death. Studies have shown that dysfunction and downregulation of adrenergic receptors (ARs) are often implicated in these shock conditions; for example, their density is shown to be decreased in hypovolemic and cardiogenic shock, while their reduced signaling in the brain and vasculature decrease blood perfusion and oxygen supply. There are two main categories of ARs, α, and β, each with its subtypes and distributions. Our group has demonstrated that a dose of .02 mg/kg body wt of centhaquine (CQ) specifically activates α2B ARs on venous circulation along with the central α2A ARs after hypovolemic/hemorrhagic shock. Activating these receptors by CQ increases cardiac output (CO) and reduces systemic vascular resistance (SVR), with a net increase in blood pressure and tissue perfusion. The clinical trials of CQ conducted by Pharmazz Inc. in India have demonstrated significantly improved survival in shock patients. CQ improved blood pressure and shock index, indicating better blood circulation, and reduced lactate levels in the blood compared to in-use standard resuscitative agents. After successful clinical trials, CQ is being marketed as a drug (Lyfaquin®) for hypovolemic/hemorrhagic shock in India, and United States FDA has approved the phase III IND application. It is anticipated that the phase III trial in the United States will begin in 2023. Thus, we have demonstrated that α2 ARs could be suitable targets for treating or managing hypovolemic/hemorrhagic shock. Further understanding of ARs in shock would help find new potential pharmacological targets.
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Affiliation(s)
- Mathew Geevarghese
- Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, IL, United States
| | - Krishna Patel
- Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, IL, United States
| | - Anil Gulati
- Pharmazz Inc., Research and Development, Willowbrook, IL, United States,Department of Bioengineering, The University of Illinois at Chicago, Chicago, IL, United States,Midwestern University College of Pharmacy Downers Grove, Downers Grove, IL, United States,*Correspondence: Anil Gulati, ; Amaresh K. Ranjan,
| | - Amaresh K. Ranjan
- Midwestern University College of Pharmacy Downers Grove, Downers Grove, IL, United States,*Correspondence: Anil Gulati, ; Amaresh K. Ranjan,
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Bruning R, Dykes H, Jones TW, Wayne NB, Sikora Newsome A. Beta-Adrenergic Blockade in Critical Illness. Front Pharmacol 2021; 12:735841. [PMID: 34721025 PMCID: PMC8554196 DOI: 10.3389/fphar.2021.735841] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 09/27/2021] [Indexed: 12/31/2022] Open
Abstract
Catecholamine upregulation is a core pathophysiological feature in critical illness. Sustained catecholamine β-adrenergic induction produces adverse effects relevant to critical illness management. β-blockers (βB) have proposed roles in various critically ill disease states, including sepsis, trauma, burns, and cardiac arrest. Mounting evidence suggests βB improve hemodynamic and metabolic parameters culminating in decreased burn healing time, reduced mortality in traumatic brain injury, and improved neurologic outcomes following cardiac arrest. In sepsis, βB appear hemodynamically benign after acute resuscitation and may augment cardiac function. The emergence of ultra-rapid βB provides new territory for βB, and early data suggest significant improvements in mitigating atrial fibrillation in persistently tachycardic septic patients. This review summarizes the evidence regarding the pharmacotherapeutic role of βB on relevant pathophysiology and clinical outcomes in various types of critical illness.
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Affiliation(s)
- Rebecca Bruning
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, United States
| | - Hannah Dykes
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, United States
| | - Timothy W Jones
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, United States
| | - Nathaniel B Wayne
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, United States
| | - Andrea Sikora Newsome
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, United States
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Mitigating the stress response to improve outcomes for older patients undergoing emergency surgery with the addition of beta-adrenergic blockade. Eur J Trauma Emerg Surg 2021; 48:799-810. [PMID: 33847766 PMCID: PMC9001541 DOI: 10.1007/s00068-021-01647-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/11/2021] [Indexed: 12/14/2022]
Abstract
As population age, healthcare systems and providers are likely to experience a substantial increase in the proportion of elderly patients requiring emergency surgery. Emergency surgery, compared with planned surgery, is strongly associated with increased risks of adverse postoperative outcomes due to the short time available for diagnosis, optimization, and intervention in patients presenting with physiological derangement. These patient populations, who are often frail and burdened with a variety of co-morbidities, have lower reserves to deal with the stress of the acute condition and the required emergency surgical intervention. In this review article, we discuss topical areas where mitigation of the physiological stress posed by the acute condition and asociated surgical intervention may be feasible. We consider the impact of the adrenergic response and use of beta blockers for these high-risk patients and discuss common risk factors such as frailty and delirium. A proactive multidisciplinary approach to peri-operative care aimed at mitigation of the stress response and proactive management of common conditions in the older emergency surgical patient could yield more favorable outcomes.
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Domizi R, Calcinaro S, Harris S, Beilstein C, Boerma C, Chiche JD, D'Egidio A, Damiani E, Donati A, Koetsier PM, Madden MP, McAuley DF, Morelli A, Pelaia P, Royer P, Shankar-Hari M, Wickboldt N, Zolfaghari P, Singer M. Relationship between norepinephrine dose, tachycardia and outcome in septic shock: A multicentre evaluation. J Crit Care 2020; 57:185-190. [DOI: 10.1016/j.jcrc.2020.02.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 02/04/2020] [Accepted: 02/21/2020] [Indexed: 01/07/2023]
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Lee YR, Seth MS, Soney D, Dai H. Benefits of Beta-Blockade in Sepsis and Septic Shock: A Systematic Review. Clin Drug Investig 2019; 39:429-440. [DOI: 10.1007/s40261-019-00762-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Durand M, Louis H, Fritz C, Levy B, Kimmoun A. β-bloquants dans la prise en charge du choc septique. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Les adrénorécepteurs α et en particulier β sont les principales cibles de l’adrénaline et de la noradrénaline libérées par le système sympathique activé. Durant le choc septique, la dysautonomie est une stimulation prolongée à un haut niveau d’intensité du système nerveux sympathique à l’origine d’une altération de la contractilité, de la vasoréactivité et d’une immunodépression. Ainsi, l’administration précoce d’un traitement β-bloquant lors du choc septique pourrait pondérer les effets délétères de cette surstimulation sympathique. Néanmoins, si les preuves expérimentales sont en faveur de cette approche, l’accumulation des preuves cliniques reste encore insuffisante.
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Unger M, Morelli A, Singer M, Radermacher P, Rehberg S, Trimmel H, Joannidis M, Heinz G, Cerny V, Dostál P, Siebers C, Guarracino F, Pratesi F, Biancofiore G, Girardis M, Kadlecova P, Bouvet O, Zörer M, Grohmann-Izay B, Krejcy K, Klade C, Krumpl G. Landiolol in patients with septic shock resident in an intensive care unit (LANDI-SEP): study protocol for a randomized controlled trial. Trials 2018; 19:637. [PMID: 30454042 PMCID: PMC6245811 DOI: 10.1186/s13063-018-3024-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 10/26/2018] [Indexed: 12/21/2022] Open
Abstract
Background In patients with septic shock, the presence of an elevated heart rate (HR) after fluid resuscitation marks a subgroup of patients with a particularly poor prognosis. Several studies have shown that HR control in this population is safe and can potentially improve outcomes. However, all were conducted in a single-center setting. The aim of this multicenter study is to demonstrate that administration of the highly beta1-selective and ultrashort-acting beta blocker landiolol in patients with septic shock and persistent tachycardia (HR ≥ 95 beats per minute [bpm]) is effective in reducing and maintaining HR without increasing vasopressor requirements. Methods A phase IV, multicenter, prospective, randomized, open-label, controlled study is being conducted. The study will enroll a total of 200 patients with septic shock as defined by The Third International Consensus Definitions for Sepsis and Septic Shock criteria and tachycardia (HR ≥ 95 bpm) despite a hemodynamic optimization period of 24–36 h. Patients are randomized (1:1) to receive either standard treatment (according to the Surviving Sepsis Campaign Guidelines 2016) and continuous landiolol infusion to reach a target HR of 80–94 bpm or standard treatment alone. The primary endpoint is HR response (HR 80–94 bpm), the maintenance thereof, and the absence of increased vasopressor requirements during the first 24 h after initiating treatment. Discussion Despite recent studies, the role of beta blockers in the treatment of patients with septic shock remains unclear. This study will investigate whether HR control using landiolol is safe, feasible, and effective, and further enhance the understanding of beta blockade in patients with septic shock. Trial registration EU Clinical Trials Register; EudraCT, 2017-002138-22. Registered on 8 August 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-3024-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Martin Unger
- AOP Orphan Pharmaceuticals AG, Wilhelminenstraße 91/II f, 1160, Vienna, Austria.
| | - Andrea Morelli
- Department of Anesthesiology and Intensive Care, University Hospital La Sapienza, Policlinico Umberto I, Rome, Italy
| | - Mervyn Singer
- Intensive Care Medicine, University College London, London, UK
| | - Peter Radermacher
- Institute of Anesthesiologic Pathophysiology and Process Engineering, Ulm University Hospital, Ulm, Germany
| | - Sebastian Rehberg
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Greifswald, Greifswald, Germany
| | - Helmut Trimmel
- Department of Anesthesiology, Emergency Medicine and General Intensive Care, State Hospital Wiener Neustadt, Wiener Neustadt, Austria
| | - Michael Joannidis
- Division of Emergency Medicine and Intensive Care, Department Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Gottfried Heinz
- Department of Internal Medicine II, Division of Cardiology, Intensive Care Unit, Medical University General Hospital, Vienna, Austria
| | - Vladimír Cerny
- Department of Anesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital, Usti Nad Labem, Czech Republic
| | - Pavel Dostál
- Department of Anesthesiology, Resuscitation and Intensive Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Christian Siebers
- Department of Anesthesiology, University Hospital Munich, Munich, Germany
| | - Fabio Guarracino
- Department of Anesthesiology and Resuscitation 5, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Francesca Pratesi
- Department of Anesthesiology and Resuscitation 6, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Gianni Biancofiore
- Division of Transplant Anesthesia and Critical Care, University School of Medicine Pisa, Pisa, Italy
| | - Massimo Girardis
- Department of Anesthesia and Intensive Care, University Hospital of Modena, Modena, Italy
| | | | | | - Michael Zörer
- AOP Orphan Pharmaceuticals AG, Wilhelminenstraße 91/II f, 1160, Vienna, Austria
| | | | - Kurt Krejcy
- AOP Orphan Pharmaceuticals AG, Wilhelminenstraße 91/II f, 1160, Vienna, Austria
| | - Christoph Klade
- AOP Orphan Pharmaceuticals AG, Wilhelminenstraße 91/II f, 1160, Vienna, Austria
| | - Günther Krumpl
- AOP Orphan Pharmaceuticals AG, Wilhelminenstraße 91/II f, 1160, Vienna, Austria
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Poveda-Jaramillo R, Monaco F, Zangrillo A, Landoni G. Ultra-Short–Acting β-Blockers (Esmolol and Landiolol) in the Perioperative Period and in Critically Ill Patients. J Cardiothorac Vasc Anesth 2018; 32:1415-1425. [DOI: 10.1053/j.jvca.2017.11.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Indexed: 01/16/2023]
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Neural pathways involved in infection-induced inflammation: recent insights and clinical implications. Clin Auton Res 2018. [PMID: 29541878 DOI: 10.1007/s10286-018-0518-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Although the immune and nervous systems have long been considered independent biological systems, they turn out to mingle and interact extensively. The present review summarizes recent insights into the neural pathways activated by and involved in infection-induced inflammation and discusses potential clinical applications. The simplest activation concerns a reflex action within C-fibers leading to neurogenic inflammation. Low concentrations of pro-inflammatory cytokines or bacterial fragments may also act on these afferent nerve fibers to signal the central nervous system and bring about early fever, hyperalgesia and sickness behavior. In the brain, the preoptic area and the paraventricular hypothalamus are part of a neuronal network mediating sympathetic activation underlying fever while brainstem circuits play a role in the reduction of food intake after systemic exposure to bacterial fragments. A vagally-mediated anti-inflammatory reflex mechanism has been proposed and, in turn, questioned because the major immune organs driving inflammation, such as the spleen, are not innervated by vagal efferent fibers. On the contrary, sympathetic nerves do innervate these organs and modulate immune cell responses, production of inflammatory mediators and bacterial dissemination. Noradrenaline, which is both released by these fibers and often administered during sepsis, along with adrenaline, may exert pro-inflammatory actions through the stimulation of β1 adrenergic receptors, as antagonists of this receptor have been shown to exert anti-inflammatory effects in experimental sepsis.
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Singer KE, Collins CE, Flahive JM, Wyman AS, Ayturk MD, Santry HP. Outpatient beta-blockers and survival from sepsis: Results from a national cohort of Medicare beneficiaries. Am J Surg 2017; 214:577-582. [PMID: 28666578 DOI: 10.1016/j.amjsurg.2017.06.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 05/04/2017] [Accepted: 06/18/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Elderly Americans suffer increased mortality from sepsis. Given that beta-blockers have been shown to be cardioprotective in critical care, we investigated outpatient beta-blocker prescriptions and mortality among Medicare beneficiaries admitted for sepsis. METHODS We queried a 5% random sample of Medicare beneficiaries for patients admitted with sepsis. We used in-hospital and outpatient prescription drug claims to compare in-hospital and 30-day mortality based on pre-admission beta-blocker prescription and class of beta-blocker prescribed using univariate tests of comparison and multivariable logistic regression models and another class of medications for control. RESULTS Outpatient beta-blocker prescription was associated with a statistically significant decrease in in-hospital and 30-day mortality. In multivariable modeling, beta-blocker prescription was associated with 31% decrease in in-hospital mortality and 41% decrease in 30-day mortality. Both cardioselective and non-selective beta-blockers conferred mortality benefit. CONCLUSIONS Our data suggests that there may be a role for preadmission beta-blockers in reducing sepsis-related mortality.
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Affiliation(s)
- Kathleen E Singer
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Courtney E Collins
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Julie M Flahive
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Allison S Wyman
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - M Didem Ayturk
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Heena P Santry
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA; Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.
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