Vasoactive Agents for Adult Septic Shock: An Update and Review

Longitudinal Vasoactive Inotrope Score Trajectories and Their Prognostic Significance in Critically Ill Sepsis Patients: A Retrospective Cohort Analysis

PURPOSE

Sepsis continues to be a critical issue in intensive care, characterized by significant morbidity and mortality. This study explores the association between Vasoactive Inotrope Score (VIS) trajectories and 28-day mortality in ICU patients with sepsis, employing VIS trajectories as a marker for assessing severity and guiding therapy.

METHODS

We conducted a retrospective analysis of the MIMIC-IV database, which included sepsis patients admitted to the ICU between 2008 and 2019. VIS calculations were performed bi-hourly during the first 72 hours of ICU admission. Using latent growth mixture modeling, we identified distinct VIS trajectory patterns, and multivariate Cox proportional hazards models were employed to evaluate their association with 28-day mortality.

FINDINGS

Among 6,802 sepsis patients who met the inclusion criteria, four distinct VIS trajectory patterns were identified: "Low-Decreasing" (52.1%), "Mild-Ascending" (13.2%), "Moderate-Decreasing" (23.0%), and "High-Stable" (11.6%). The 28-day survival analysis demonstrated that, compared to the "Low-Decreasing" group, the "Mild-Ascending" group had a hazard ratio (HR) for mortality of 2.55 (95% CI: 2.19-2.97, P < 0.001), the "Moderate-Decreasing" group had an HR of 1.20 (95% CI: 1.03-1.41, P = 0.021), and the "High-Stable" group presented the highest risk with an HR of 4.19 (95% CI: 3.43-5.12, P < 0.001).

IMPLICATIONS

This study offers significant insights into the prognostic value of VIS trajectories in sepsis patients. The identification of distinct trajectory patterns not only underscores the heterogeneity in sepsis but also emphasizes the importance of personalized management strategies. The findings underscore the potential of VIS trajectory monitoring in predicting 28-day outcomes and in guiding clinical decision-making in ICU settings.

Analysis of the effects of early screening combined with blood lactate on the severity of patients with sepsis

This work aimed to investigate the adoption value of blood lactic acid (BLA) combined with the National Early Warning Score (NEWS) in the early screening of sepsis patients and assessing their severity. The data and materials utilized in this work were obtained from the electronic medical record system of 537 anonymized sepsis patients who received emergency rescue in the emergency rescue area of Liuzhou People's Hospital, Guangxi, from July 1, 2020, to December 26, 2020. Based on the 28-day outcomes of sepsis patients, the medical records were rolled into Group S (407 survival cases) and Group D (130 dead cases). Basic information such as the mode of hospital admission, initial management, use of emergency ventilator within 24 h of admission, NEWS score, arterial oxygen pressure/alveolar oxygen pressure ratio (PaO2/PAO2), alveolar-arterial oxygen difference (A-aDO2), serum creatinine (SCr), blood urea nitrogen (BUN), oxygenation index (OI), Glasgow Coma Scale (GCS), D-dimer, use of vasoactive drugs within 24 h of admission, C-reactive protein (CRP), procalcitonin (PCT), interleukin-6 (IL-6), N-terminal pro-B-type natriuretic peptide (NT-proBNP), quick Sequential Organ Failure Assessment (qSOFA) score, SOFA score, BLA level, NEWS with lactate (NEWS-L) score, SOFA score including lactate level (SOFA-L) score, Intensive Care Unit (ICU) length of stay, total hospital stay, ICU stay/total hospital stay, and septic shock condition were compared between groups. Logistic regression analysis was performed to assess the impact of various predictive factors on prognosis and to plot the receiver operating characteristic (ROC) curve. The results suggested marked differences between Group S and Group D in terms of mean age (t = -5.620; OR = -9.96, 95 % CI: -13.44∼-6.47; P < 0.001). Group S showed drastic differences in terms of mode of hospital admission (χ2 = 9.618, P < 0.01), method of initial management (χ2 = 51.766, P < 0.001), use of emergency ventilator within 24 h of admission (χ2 = 98.564, P < 0.001), incidence of septic shock (χ2 = 77.545, P < 0.001), use of vasoactive drugs within 24 h of admission (χ2 = 102.453, P < 0.001), heart rate (t = -4.063, P < 0.001), respiratory rate (t = -4.758, P < 0.001), oxygenation status (χ2 = 20.547, P < 0.001), NEWS score (t = -6.120, P < 0.001), PaO2/PAO2 ratio (t = 2.625, P < 0.01), A-aDO2 value (Z = -3.581, P < 0.001), OI value (Z = -3.106, P < 0.01), PLT value (Z = -2.305, P < 0.05), SCr value (Z = -3.510, P < 0.001), BUN value (Z = -3.170, P < 0.01), D-dimer (Z = -4.621, P < 0.001), CRP level (Z = -4.057, P < 0.001), PCT value (Z = -2.783, P < 0.01), IL-6 level (Z = -2.904, P < 0.001), length of hospital stay (Z = -4.138, P < 0.001), total hospital stay (Z = -8.488, P < 0.001), CCU/total hospital stay (Z = -9.118, P < 0.001), NEWS score (t = -6.120, P < 0.001), SOFA score (t = -6.961, P < 0.001), SOFA-L score (Z = -4.609, P < 0.001), NEWS-L score (Z = -5.845, P < 0.001), BLA level (Z = -6.557, P < 0.001), and GCS score (Z = 6.909, P < 0.001) when compared to Group D. The use of ventilators, septic shock, PCT, NEWS score, GCS score, SOFA score, SOFA-L score, NEWS-L score, and BLA level were identified as independent risk factors for predicting the prognosis of sepsis patients (P < 0.001). The areas under ROC curve (AUC) of blood lactic acid, PCT, NEWS, NEWS-L, GCS, SOFA, and SOFA-L were 0.695, 0.665, 0.692, 0.698, 0.477, 0.700, and 0.653, respectively. These findings indicate that the combination of BLA with NEWS (NEWS-L) score and SOFA score has certain advantages in assessing the prognosis of sepsis.

Tendency of dynamic vasoactive and inotropic medications data as a robust predictor of mortality in patients with septic shock: An analysis of the MIMIC-IV database

Background

Septic shock patients fundamentally require delicate vasoactive and inotropic agent administration, which could be quantitatively and objectively evaluated by the vasoactive–inotropic score (VIS); however, whether the dynamic trends of high-time-resolution VIS alter the clinical outcomes remains unclear. Thus, this study proposes the term VIS Reduction Rate (VRR) to generalise the tendency of dynamic VIS, to explore the association of VRR and mortality for patients with septic shock.

Methods

We applied dynamic and static VIS data to predict ICU mortality by two models: the long short-term memory (LSTM) deep learning model, and the extreme gradient boosting (XGBoost), respectively. The specific target cohort was extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database by the sophisticated structured query language (SQL). Enrolled patients were divided into four groups by VRR value: ≥50%, 0 ~ 50%, −50% ~ 0, and &lt; −50%. Statistical approaches included pairwise propensity score matching (PSM), Cox proportional hazards regression, and two doubly robust estimation models to ensure the robustness of the results. The primary and secondary outcomes were ICU mortality and in-hospital mortality, respectively.

Results

VRR simplifies the dosing trends of vasoactive and inotropic agents represented by dynamic VIS data while requiring fewer data. In total, 8,887 septic shock patients were included. Compared with the VRR ≥50% group, the 0 ~ 50%, −50% ~ 0, and &lt; −50% groups had significantly higher ICU mortality [hazard ratio (HR) 1.32, 95% confidence interval (CI) 1.17–1.50, p &lt; 0.001; HR 1.79, 95% CI 1.44–2.22, p &lt; 0.001; HR 2.07, 95% CI 1.61–2.66, p &lt; 0.001, respectively] and in-hospital mortality [HR 1.43, 95% CI 1.28–1.60, p &lt; 0.001; HR 1.75, 95% CI 1.45–2.11, p &lt; 0.001; HR 2.00, 95% CI 1.61–2.49, p &lt; 0.001, respectively]. Similar findings were observed in two doubly robust estimation models.

Conclusion

The trends of dynamic VIS in ICU might help intensivists to stratify the prognosis of adult patients with septic shock. A lower decline of VIS was remarkably associated with higher ICU and in-hospital mortality among septic shock patients receiving vasoactive–inotropic therapy for more than 24 h.

Effect Evaluation of Norepinephrine on Cardiac Function in Patients with Sepsis by Cardiac Ultrasound Imaging

In order to investigate the therapeutic effect of norepinephrine on patients with sepsis and the effect of echocardiography on the diagnosis of cardiac function in patients with sepsis, 86 patients with sepsis were selected as research objects and randomly divided into two groups. Patients in the control group (N = 43 cases) received conventional treatment (1~15 μg/kg∗min dopamine), and those in the experimental group (N = 43 cases) received conventional treatment+norepinephrine therapy (0.05~0.5 μg∗kg⁻¹/min). The clinical efficacy, cardiac ultrasonography results, and hemodynamic indexes of patients between the two groups were analyzed and compared. The results showed that the total effective rate of treatment in the experimental group (97.7%) was significantly higher than that in the control group (81.4%) (P < 0.05). The maximum, minimum, and average values of mitral valve E peak flow velocity (VEpeak) and left ventricular outflow tract peak flow velocity (Vpeak), respiratory variability of mitral valve E peak flow velocity (ΔVEpeak), and respiratory variability of peak flow velocity (ΔVpeak) were all significantly greater than those of the control group (P < 0.05). The area under the receiver operating characteristic curve (AUC) of ΔVEpeak and ΔVpeak for predicting positive volume response in patients with sepsis was 0.934 and 0.913, respectively; the sensitivity was 0.828 and 0.827; the specificity was 0.936 and 0.893; and the Youden indices were 0.765 and 0.712, respectively. In short, norepinephrine had a high total response rate in patients with sepsis, and echocardiography can well evaluate the effect of norepinephrine on cardiac function in patients with sepsis, which is worthy of further promotion.

Predictors of Requirement of Inotrope Among Patients With Early Sepsis: Special Reference to Microcirculatory Parameters

Introduction

The management of septic shock and refractory septic shock is essential in preventing sepsis-related death. The handheld vital microscope is a new modality of investigation for sepsis for microcirculatory assessment. This study aimed to identify predictors of inotrope requirements among patients with early sepsis and impending septic shock with particular reference to sublingual microcirculation assessment parameters.

Methodology

We conducted an observational cross-sectional hospital-based study in central India. The formal sample size was calculated to be 52 patients using a convenient sampling technique. The study was initiated with ethics approval (IHEC-LOP/2019/ MD0090) with consent from the patients. We used the MicroScan (MicroVision Medical, Netherlands) Video Microscope System (No.16A00102) to obtain sidestream dark-field imaging along with the AVA 4.3C software (MicroVision Medical).

Results

Of 51 cases, 60.8% were women, and 39.2% were men, and the study population had a mean age of 41.0 ± 14.9 years. Patients were recruited from medical wards (64.7%) and emergency departments (35.3%). The most common site of infection was gastrointestinal (33.3%), followed by respiratory infections (25.5%) and genitourinary infections (11.8%). The quick sequential organ failure assessment score was 2.0 ± 0.1. Eight patients required inotropes, and six patients died. High respiratory rates and lactate levels were important predictors of inotrope requirements in patients with early sepsis. Sublingual microcirculatory parameters at baseline did not significantly affect the requirement of inotropes consequently.

Conclusions

Sublingual microscopy is a suggested tool for the management of sepsis. However, without clearly defined cut-off values, handheld vital microscopy could not predict fluid responsiveness among patients with early sepsis. Also, it would be difficult to incorporate this technology into regular practice without equipment upgrades and image acquisition software.

Insights Into Thiamine Supplementation in Patients With Septic Shock

Septic shock is associated with unacceptably high mortality rates, mainly in developing countries. New adjunctive therapies have been explored to reduce global mortality related to sepsis. Considering that metabolic changes, mitochondrial dysfunction and increased oxidative stress are specific disorders within the path of septic shock, several micronutrients that could act in cellular homeostasis have been studied in recent decades. Thiamine, also known as vitamin B1, plays critical roles in several biological processes, including the metabolism of glucose, synthesis of nucleic acids and reduction of oxidative stress. Thiamine deficiency could affect up to 70% of critically ill patients, and thiamine supplementation appears to increase lactate clearance and decrease the vasopressor dose. However, there is no evident improvement in the survival of septic patients. Other micronutrients such as vitamin C and D, selenium and zinc have been tested in the same context but have not been shown to improve the outcomes of these patients. Some problems related to the neutrality of these clinical trials are the study design, doses, route, timing, length of intervention and the choice of endpoints. Recently, the concept that multi-micronutrient administration may be better than single-micronutrient administration has gained strength. In general, clinical trials consider the administration of a single micronutrient as a drug. However, the antioxidant defense is a complex system of endogenous agents in which micronutrients act as cofactors, and the physiological interactions between micronutrients are little discussed. In this context, the association of thiamine, vitamin C and corticoids was tested as an adjunctive therapy in septic shock resulting in a significant decrease in mortality. However, after these initial results, no other study conducted with this combination could reproduce those benefits. In addition, the use of low-dose corticosteroids is recommended in patients with septic shock who do not respond to vasopressors, which can affect the action of thiamine. Therefore, given the excellent safety profile, good biologic rationale and promising clinical studies, this review aims to discuss the mechanisms behind and the evidence for single or combined thiamine supplementation improving the prognosis of patients with septic shock.