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Schaubroeck H, Rossberg M, Thiele H, Pöss J. ICU management of cardiogenic shock before mechanical support. Curr Opin Crit Care 2024; 30:362-370. [PMID: 38872375 DOI: 10.1097/mcc.0000000000001182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
PURPOSE OF REVIEW Treatment of cardiogenic shock remains largely driven by expert consensus due to limited evidence from randomized controlled trials. In this review, we aim to summarize the approach to the management of patients with cardiogenic shock in the ICU prior to mechanical circulatory support (MCS). RECENT FINDINGS Main topics covered in this article include diagnosis, monitoring, initial management and key aspects of pharmacological therapy in the ICU for patients with cardiogenic shock. SUMMARY Despite efforts to improve therapy, short-term mortality in patients with cardiogenic shock is still reaching 40-50%. Early recognition and treatment of cardiogenic shock are crucial, including early revascularization of the culprit lesion with possible staged revascularization in acute myocardial infarction (AMI)-CS. Optimal volume management and vasoactive drugs titrated to restore arterial pressure and perfusion are the cornerstone of cardiogenic shock therapy. The choice of vasoactive drugs depends on the underlying cause and phenotype of cardiogenic shock. Their use should be limited to the shortest duration and lowest possible dose. According to recent observational evidence, assessment of the complete hemodynamic profile with a pulmonary artery catheter (PAC) was associated with improved outcomes and should be considered early in patients not responding to initial therapy or with unclear shock. A multidisciplinary shock team should be involved early in order to identify potential candidates for temporary and/or durable MCS.
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Affiliation(s)
| | - Michelle Rossberg
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Holger Thiele
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Janine Pöss
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
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2
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De Backer D, Hajjar L, Monnet X. Vasoconstriction in septic shock. Intensive Care Med 2024; 50:459-462. [PMID: 38358543 DOI: 10.1007/s00134-024-07332-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 01/20/2024] [Indexed: 02/16/2024]
Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Boulevard du Triomphe 201, 1160, Brussels, Belgium.
| | - Ludhmila Hajjar
- Intensive Care and Emergency Medicine, Hospital das Clinicas, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Xavier Monnet
- Service de Médecine Intensive-Réanimation DMU 4 CORREVE, Inserm UMR S_999, AP-HPHôpital de Bicêtre FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
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Priya V, Ninave S, Sen J, Bele A. Anaesthetic Management of Diabetic Ketoacidosis (DKA) in a Cesarean Section: A Case Report. Cureus 2023; 15:e51014. [PMID: 38264396 PMCID: PMC10804210 DOI: 10.7759/cureus.51014] [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: 10/24/2023] [Accepted: 12/23/2023] [Indexed: 01/25/2024] Open
Abstract
Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus that poses unique challenges during pregnancy. We present a case of a 36-year-old pregnant woman with a history of type 1 diabetes mellitus who developed severe DKA at 33.5 weeks of gestation, necessitating an emergency cesarean section. Despite a known history of diabetes, the patient's infrequent clinic attendance and suboptimal disease management contributed to her critical condition. DKA was promptly diagnosed, and a multidisciplinary team comprising obstetricians, endocrinologists, anesthesiologists, and neonatologists collaborated to provide comprehensive care. The preoperative assessment revealed dehydration and electrolyte imbalances, necessitating meticulous planning for IV fluid administration and hemodynamic stability during the cesarean section. Regional anaesthesia was chosen as the anaesthetic approach, and close postoperative monitoring was initiated. The neonate, delivered with satisfactory Apgar scores, was transferred to the neonatal ICU for observation. The patient's gradual clinical improvement over 48 hours demonstrated the importance of ongoing care. This case highlights the significance of early recognition, multidisciplinary teamwork, and meticulous perioperative care in managing DKA during pregnancy, ensuring favourable outcomes for both the mother and the neonate.
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Affiliation(s)
- Vishnu Priya
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Sanjot Ninave
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Jayshree Sen
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Amol Bele
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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Kamath S, Hammad Altaq H, Abdo T. Management of Sepsis and Septic Shock: What Have We Learned in the Last Two Decades? Microorganisms 2023; 11:2231. [PMID: 37764075 PMCID: PMC10537306 DOI: 10.3390/microorganisms11092231] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/20/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
Sepsis is a clinical syndrome encompassing physiologic and biological abnormalities caused by a dysregulated host response to infection. Sepsis progression into septic shock is associated with a dramatic increase in mortality, hence the importance of early identification and treatment. Over the last two decades, the definition of sepsis has evolved to improve early sepsis recognition and screening, standardize the terms used to describe sepsis and highlight its association with organ dysfunction and higher mortality. The early 2000s witnessed the birth of early goal-directed therapy (EGDT), which showed a dramatic reduction in mortality leading to its wide adoption, and the surviving sepsis campaign (SSC), which has been instrumental in developing and updating sepsis guidelines over the last 20 years. Outside of early fluid resuscitation and antibiotic therapy, sepsis management has transitioned to a less aggressive approach over the last few years, shying away from routine mixed venous oxygen saturation and central venous pressure monitoring and excessive fluids resuscitation, inotropes use, and red blood cell transfusions. Peripheral vasopressor use was deemed safe and is rising, and resuscitation with balanced crystalloids and a restrictive fluid strategy was explored. This review will address some of sepsis management's most important yet controversial components and summarize the available evidence from the last two decades.
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Affiliation(s)
| | | | - Tony Abdo
- Section of Pulmonary, Critical Care and Sleep Medicine, The University of Oklahoma Health Sciences Center, The Oklahoma City VA Health Care System, Oklahoma City, OK 73104, USA; (S.K.); (H.H.A.)
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5
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Leone M, Einav S, Antonucci E, Depret F, Lakbar I, Martin-Loeches I, Wieruszewski PM, Myatra SN, Khanna AK. Multimodal strategy to counteract vasodilation in septic shock. Anaesth Crit Care Pain Med 2023; 42:101193. [PMID: 36621622 DOI: 10.1016/j.accpm.2023.101193] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/26/2022] [Accepted: 12/30/2022] [Indexed: 01/07/2023]
Abstract
Early initiation of a multimodal treatment strategy in the management of vasopressors during septic shock has been advocated to reduce delays in restoring adequate organ perfusion and to mitigate side effects associated with the administration of high-dose catecholamines. We provide a review that summarises the pathophysiology of vasodilation, the physiologic response to the vascular response, and the different drugs used in this situation, focusing on the need to combine early different vasopressors. Fluid loading being insufficient for counteracting vasoplegia, norepinephrine is usually the first-line vasopressor used to restore hemodynamics. Norepinephrine sparing is discussed in further detail through the concomitant use of adrenergic, vasopressinergic, and renin-angiotensin systems and the optimisation of endothelial reactivity with methylene blue. A blueprint for the construction of new studies is outlined to address the question of vasopressor selection and timing in septic shock.
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Affiliation(s)
- Marc Leone
- Department of Anesthesiology and Intensive Care Unit, North Hospital, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Marseille, France.
| | - Sharon Einav
- Surgical Intensive Care, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Elio Antonucci
- Intermediate Care Unit, Emergency Department, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - François Depret
- GH St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, St-Louis Hospital, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Ines Lakbar
- Department of Anesthesiology and Intensive Care Unit, North Hospital, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Marseille, France
| | - Ignacio Martin-Loeches
- Intensive Care Unit, Trinity Centre for Health Science HRB-Wellcome Trust, St James's Hospital, Dublin, Ireland
| | | | - Sheila Nainan Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA; Outcomes Research Consortium, Cleveland, OH, USA
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6
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Muacevic A, Adler JR. Efficacy and Safety of Vasopressin Alone or in Combination With Catecholamines in the Treatment of Septic Shock: A Systematic Review. Cureus 2022; 14:e29143. [PMID: 36258986 PMCID: PMC9561545 DOI: 10.7759/cureus.29143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 09/13/2022] [Indexed: 11/05/2022] Open
Abstract
Septic shock is one of the life-threatening emergencies in hospital settings. Patients with septic shock have been treated with various vasopressors alone as a first-line or in combination with other agents to improve blood pressure and increase the chance of survival. Our study focuses particularly on the efficacy and safety of vasopressin (VP) alone and in combination with other vasopressors. Our study used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 2020 to do our systematic review. We searched thoroughly for articles in PubMed, PubMed Central (PMC), Medline, and ScienceDirect. To locate all pertinent papers, we employed the medical subject headings (MeSH) systematic search technique. Twelve papers that were related to the study's issue and passed the quality check were extracted after we applied inclusion/exclusion criteria and reviewed the titles and abstracts. We used a variety of assessment methods for diverse study designs as a quality check. We compared all included studies after reviewing them thoroughly. VP and its synthetic variants (Terlipressin and Selepressin) have always been given as adjuvants to catecholamine, especially with Noradrenaline, in low to moderate doses with continuous infusion in patients with septic shock. Furthermore, VP is a better adjuvant agent than Dopamine and Dobutamine. Though VP has been proven superior to other vasopressors as an adjuvant agent in patients with septic shock, it can cause digital ischemia in high doses.
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Albertson TE, Chenoweth JA, Lewis JC, Pugashetti JV, Sandrock CE, Morrissey BM. The pharmacotherapeutic options in patients with catecholamine-resistant vasodilatory shock. Expert Rev Clin Pharmacol 2022; 15:959-976. [PMID: 35920615 DOI: 10.1080/17512433.2022.2110067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Septic and vasoplegic shock are common types of vasodilatory shock (VS) with high mortality. After fluid resuscitation and the use of catecholamine-mediated vasopressors (CMV), vasopressin, angiotensin II, methylene blue (MB) and hydroxocobalamin can be added to maintain blood pressure. AREAS COVERED VS treatment utilizes a phased approach with secondary vasopressors added to vasopressor agents to maintain an acceptable mean arterial pressure (MAP). This review covers additional vasopressors and adjunctive therapies used when fluid and catecholamine-mediated vasopressors fail to maintain target MAP. EXPERT OPINION Evidence supporting additional vasopressor agents in catecholamine resistant VS is limited to case reports, series, and a few randomized control trials (RCTs) to guide recommendations. Vasopressin is the most common agent added next when MAPs are not adequately supported with CMV. VS patients failing fluids and vasopressors with cardiomyopathy may have cardiotonic agents such as dobutamine or milrinone added before or after vasopressin. Angiotensin II, another class of vasopressor is used in VS to maintain adequate MAP. MB and/or hydoxocobalamin, vitamin C, thiamine and corticosteroids are adjunctive therapies used in refractory VS. More RCTs are needed to confirm the utility of these drugs, at what doses, which combinations and in what order they should be given.
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Affiliation(s)
- Timothy E Albertson
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA.,Department of Clinical Pharmacy, University of California, San Francisco, CA, USA
| | - James A Chenoweth
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA
| | - Justin C Lewis
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Clinical Pharmacy, University of California, San Francisco, CA, USA
| | - Janelle V Pugashetti
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA
| | - Christian E Sandrock
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA
| | - Brian M Morrissey
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA
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Sedhai YR, Shrestha DB, Budhathoki P, Memon W, Acharya R, Gaire S, Pokharel N, Maharjan S, Jasaraj R, Sodhi A, Kadariya D, Asija A, Kashiouris MG. Vasopressin versus norepinephrine as the first-line vasopressor in septic shock: A systematic review and meta-analysis. J Clin Transl Res 2022; 8:185-199. [PMID: 35813900 PMCID: PMC9260345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 03/21/2022] [Accepted: 03/30/2022] [Indexed: 10/25/2022] Open
Abstract
Background and Aim Norepinephrine is currently the first-line vasopressor for septic shock. We conducted this meta-analysis to examine the outcomes of adult patients with septic shock who received vasopressin instead of norepinephrine. Methods We selected studies in adults with septic shock that compared the outcomes of patients treated with vasopressin versus norepinephrine. Cochrane ROB 2.0 and the Joanna Briggs Institute quality assessment tools were used to assess the risk of bias in RCTs and observational studies. Meta-analysis was conducted using RevMan 5.4. Results Eight studies were included in this meta-analysis. There were no significant differences in 28-day mortality rates (OR, 1.07; CI, 0.80-1.44) and intensive care unit (ICU) mortality (OR, 0.74; CI, 0.21-2.67) between the two groups. Similarly, length of ICU stay, length of hospital stay, mean arterial pressure at 24 h, urine output at 24 h, and serious adverse events also did not differ significantly. However, the odds of renal replacement therapy (RRT) requirement in the vasopressin group were substantially lower than in the norepinephrine group (OR, 0.68; CI, 0.47-0.98). Conclusion There were no differences in mortality, duration of hospitalization, and adverse effects in adults with septic shock across the two groups. However, the patients treated with vasopressin had lower chances of requiring RRT. Relevance for Patients Vasopressin use as the first-line vasopressor in septic shock showed a significant reduction in RRT, though there were no significant differences in terms of mortality and other adverse events. Therefore, vasopressin can be considered as a first-line vasopressor in septic shock patients with other risk factors which may contribute to renal failure requiring RRT.
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Affiliation(s)
- Yub Raj Sedhai
- 1Department of Internal Medicine, Division of Hospital Medicine, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, United States
| | - Dhan Bahadur Shrestha
- 2Department of Internal Medicine, Mount Sinai Hospital, Chicago, Illinois, United States,Corresponding author: Dhan Bahadur Shrestha Department of Internal Medicine, Mount Sinai Hospital, Chicago, Illinois, United States.
| | - Pravash Budhathoki
- 3Department of Internal Medicine, Bronxcare Health System, Bronx, New York, United States
| | - Waqas Memon
- 4Department of Internal Medicine, Division of Nephrology, University of Virginia School of Medicine, Charlottesville, Virginia, United States
| | - Roshan Acharya
- 5Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, North Carolina, United States
| | - Suman Gaire
- 6Department of Emergency Medicine, Palpa Hospital, Palpa, Nepal
| | - Nisheem Pokharel
- 7Department of Emergency Medicine, KIST Medical College, Lalitpur, Nepal
| | - Swojay Maharjan
- 8Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Ranjit Jasaraj
- 2Department of Internal Medicine, Mount Sinai Hospital, Chicago, Illinois, United States
| | - Amik Sodhi
- 9Department of Internal Medicine, Division of Pulmonary Disease and Critical Care Medicine, University of Wisconsin, Madison, Wisconsin, United States
| | - Dipen Kadariya
- 10Attending Physician, Pulmonary Disease and Critical Care Medicine, Independent Practitioner
| | - Ankush Asija
- 11Department of Internal Medicine, West Virginia University, Morgan Town, West Virginia, United States
| | - Markos G. Kashiouris
- 12Department of Internal Medicine, Division of Pulmonary Disease and Critical Care Medicine, VCU School of Medicine, Richmond, Virginia, United States
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9
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Wang X, Jamil K. Pharmacokinetic and pharmacodynamic analyses of terlipressin in patients with hepatorenal syndrome. AAPS OPEN 2022. [DOI: 10.1186/s41120-022-00052-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Abstract
The objective of this population pharmacokinetics (PK) analysis was to characterize the PK of terlipressin and its active metabolite, lysine-vasopressin (L-VP), in patients with hepatorenal syndrome (HRS), following intravenous administration of terlipressin 1 mg to 2 mg every 6 h. Sparse PK samples from 69 patients with HRS who participated in terlipressin phase 3 clinical studies were used for model development. In addition, mean arterial pressure (MAP) and heart rate (HR) from 40 patients with HRS were available to explore the relationship between terlipressin and L-VP plasma concentrations and pharmacodynamic (PD) response. A two-compartment model with first-order elimination adequately described the PK of terlipressin. L-VP was well characterized as the active metabolite of terlipressin by a one-compartment model with first-order elimination. The population PK modeling results showed that the estimated clearances for terlipressin and L-VP are 27.4 L/h and 318 L/h, respectively, for a typical patient with a body weight of 86 kg. Body weight was identified as the only covariate for the clearance of terlipressin. However, simulation suggested that body weight had no clinically meaningful effects on the exposure of L-VP through terlipressin. Therefore, no weight-based dose is needed for terlipressin to treat HRS patients. PD response, change in MAP, and HR were well correlated to L-VP concentrations; compared with baseline values, the estimated maximum decrease in HR would be 10.6 bpm and the estimated maximum increase in MAP would be 16.2 mm Hg.
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Sacha GL, Kiser TH, Wright GC, Vandivier RW, Moss M, Burnham EL, Ho PM, Reynolds PM, Bauer SR. Association Between Vasopressin Rebranding and Utilization in Patients With Septic Shock. Crit Care Med 2022; 50:644-654. [PMID: 34605778 DOI: 10.1097/ccm.0000000000005305] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Vasopressin is suggested as an adjunct to norepinephrine in patients with septic shock. However, after vasopressin was rebranded in November 2014, its cost exponentially increased. Utilization patterns of vasopressin after its rebranding are unclear. The objective of this study was to determine if there is an association between the rebranding of vasopressin in November 2014 and its utilization in vasopressor-dependent patients with severe sepsis or septic shock. DESIGN Retrospective, multicenter, database study between January 2010 and March 2017. SETTING Premier Healthcare Database hospitals. PATIENTS Adult patients admitted to an ICU with severe sepsis or septic shock, who received at least one vasoactive agent for two or more calendar days were included. INTERVENTIONS The proportion of patients who received vasopressin and vasopressin cost was assessed before and after rebranding, and evaluated with segmented regression. MEASUREMENTS AND MAIN RESULTS Among 294,733 patients (mean age, 66 ± 15 yr), 27.8% received vasopressin, and ICU mortality was 26.5%. The proportion of patients receiving vasopressin was higher after rebranding (31.2% postrebranding vs 25.8% prerebranding). Before vasopressin rebranding, the quarterly proportion of patients who received vasopressin had an increasing slope (prerebranding slope 0.41% [95% CI, 0.35-0.46%]), with no difference in slope detected after vasopressin rebranding (postrebranding slope, 0.47% [95% CI, 0.29-0.64%]). After vasopressin rebranding, mean vasopressin cost per patient was higher ($527 ± 1,130 vs $77 ± 160), and the quarterly slope of vasopressin cost was higher (change in slope $77.18 [95% CI, $75.73-78.61]). Total vasopressin billed cost postrebranding continually increased by ~$294,276 per quarter from less than $500,000 in Q4 2014 to over $3,000,000 in Q1 2017. CONCLUSIONS After vasopressin rebranding, utilization continued to increase quarterly despite a significant increase in vasopressin cost. Vasopressin appeared to have price inelastic demand in septic shock.
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Affiliation(s)
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Garth C Wright
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - R William Vandivier
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Marc Moss
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Ellen L Burnham
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - P Michael Ho
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Paul M Reynolds
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO
- Colorado Pulmonary Outcomes Research Group (CPOR), University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
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11
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Saghafi F, Bagheri N, Salehi-Abargouei A, Sahebnasagh A. Efficacy of combination triple therapy with vasopressin, steroid, and epinephrine in cardiac arrest: a systematic review and meta-analysis of randomized-controlled trials. J Intensive Care 2022; 10:5. [PMID: 35109925 PMCID: PMC8809021 DOI: 10.1186/s40560-022-00597-5] [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: 12/04/2021] [Accepted: 01/16/2022] [Indexed: 11/10/2022] Open
Abstract
Background This study investigated whether combination therapy with vasopressin, steroid, and epinephrine (VSE) improves in-hospital survival and return of spontaneous circulation (ROSC) during and after resuscitation in-hospital cardiac arrest (CA). Materials and methods Various databases were explored from inception until October 2021 for relevant published clinical trials and cohort studies. Results Three clinical trials were included. Pooled analysis suggested that VSE was significantly associated with increased ROSC in patients with in-hospital CA (IHCA) (odds ratio (OR): 2.281, 95% confidence interval (CI): 1.304–3.989, P value = 0.004). Meta-analysis of two studies (368 patients) demonstrated a significant difference in the reduction of mean arterial pressure (MAP) during and 15–20 min after cardiopulmonary resuscitation (standardized mean difference (SMD): 1.069, 95% CI: 0.851–1.288, P value < 0.001), renal failure free days (SMD = 0.590; 95% CI: 0.312–0.869 days; P value < 0.001), and coagulation failure free days (SMD = 0.403; 95% CI: 0.128–0.679, P value = 0.004). However, no significant difference was observed for survival-to-discharge ratio (OR: 2.082, 95% CI: 0.638–6.796, P value = 0.225) and ventilator free days (SMD = 0.201, 95% CI: − 0.677, 1.079 days; P value = 0.838). Conclusions VSE combination therapy during and after IHCA may have beneficial effects in terms of the ROSC, renal and circulatory failure free days, and MAP. Prospero registration: CRD42020178297 (05/07/2020). Supplementary Information The online version contains supplementary material available at 10.1186/s40560-022-00597-5.
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Affiliation(s)
- Fatemeh Saghafi
- Department of Clinical Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Negar Bagheri
- Pharmaceutical Sciences Research Center, School of Pharmacy, Student Research Committee, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Amin Salehi-Abargouei
- Nutrition and Food Security Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.,Department of Nutrition, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Adeleh Sahebnasagh
- Clinical Research Center, Department of Internal Medicine, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran.
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12
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Monitoring, management, and outcome of hypotension in Intensive Care Unit patients, an international survey of the European Society of Intensive Care Medicine. J Crit Care 2021; 67:118-125. [PMID: 34749051 DOI: 10.1016/j.jcrc.2021.10.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/24/2021] [Accepted: 10/09/2021] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Hypotension in the ICU is common, yet management is challenging and variable. Insight in management by ICU physicians and nurses may improve patient care and guide future hypotension treatment trials and guidelines. METHODS We conducted an international survey among ICU personnel to provide insight in monitoring, management, and perceived consequences of hypotension. RESULTS Out of 1464 respondents, 1197 (81.7%) were included (928 physicians (77.5%) and 269 nurses (22.5%)). The majority indicated that hypotension is underdiagnosed (55.4%) and largely preventable (58.8%). Nurses are primarily in charge of monitoring changes in blood pressure, physicians are in charge of hypotension treatment. Balanced crystalloids, dobutamine, norepinephrine, and Trendelenburg position were the most frequently reported fluid, inotrope, vasopressor, and positional maneuver used to treat hypotension. Reported complications believed to be related to hypotension were AKI and myocardial injury. Most ICUs do not have a specific hypotension treatment guideline or protocol (70.6%), but the majority would like to have one in the future (58.1%). CONCLUSIONS Both physicians and nurses report that hypotension in ICU patients is underdiagnosed, preventable, and believe that hypotension influences morbidity. Hypotension management is generally not protocolized, but the majority of respondents would like to have a specific hypotension management protocol.
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Datt V, Wadhhwa R, Sharma V, Virmani S, Minhas HS, Malik S. Vasoplegic syndrome after cardiovascular surgery: A review of pathophysiology and outcome-oriented therapeutic management. J Card Surg 2021; 36:3749-3760. [PMID: 34251716 DOI: 10.1111/jocs.15805] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 06/29/2021] [Accepted: 07/02/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Vasoplegic syndrome (VPS) is defined as systemic hypotension due to profound vasodilatation and loss of systemic vascular resistance (SVR), despite normal or increased cardiac index, and characterized by inadequate response to standard doses of vasopressors, and increased morbidity and mortality. It occurs in 9%-44% of cardiac surgery patients after cardiopulmonary bypass (CPB). The underlying pathophysiology following CPB consists of resistance to vasopressors (inactivation of Ca2+ voltage gated channels) on the one hand and excessive activation of vasodilators (SIRS, iNOS, and low AVP) on the other. Use of angiotensin-converting enzyme inhibitor (ACE-I), calcium channel blockers, amiodarone, heparin, low cardiac reserve (EF < 35%), symptomatic congestive heart failure, and diabetes mellitus are the perioperative risk factors for VPS after cardiac surgery in adults. Till date, there is no consensus about the outcome-oriented therapeutic management of VPS. Vasopressors such as norepinephrine (NE; 0.025-0.2 µg/kg/min) and vasopressin (0.06 U/min or 6 U/h median dose) are the first choice for the treatment. The adjuvant therapy (hydrocortisone, calcium, vitamin C, and thiamine) and rescue therapy (methylene blue [MB] and hydroxocobalamin) are also considered when perfusion goals (meanarterial pressure [MAP] > 60-70 mmHg) are not achieved with nor-epinephrine and/or vasopressin. AIMS The aims of this systematic review are to collect all the clinically relevant data to describe the VPS, its potential risk factors, pathophysiology after CPB, and to assess the efficacy, safety, and outcome of the therapeutic management with catecholamine and non-catecholamine vasopressors employed for refractory vasoplegia after cardiac surgery. Also, to elucidate the current and practical approach for management of VPS after cardiac surgery. MATERIAL AND METHODS "PubMed," "Google," and "Medline" weresearched, and over 150 recent relevant articles including RCTs, clinical studies, meta-analysis, reviews, case reports, case series and Cochrane data were analyzed for this systematic review. The filter was applied specificallyusing key words like VPS after cardiac surgery, perioperative VPS following CPB, morbidity, and mortality in VPS after cardiac surgery, vasopressors for VPS that improve outcomes, VPS after valve surgery, VPS after CABG surgery, VPS following complex congenital cardiac anomalies corrective surgery, rescue therapy for VPS, adjuvant therapy for VPS, definition of VPS, outcome in VPS after cardiac surgery, etiopathology of VPS following CPB. This review did not require any ethical approval or consent from the patients. RESULTS Despite the recent advances in therapy, the mortality remains as high as 30%-50%. NE has been recommended the most frequent used vasopressor for VPS. It restores and maintain the MAP and provides the outcome benefits. Vasopressin rescue therapy is an alternative approach, if catecholamines and fluid infusions fail to improve hemodynamics. It effectively increases vascular tone and lowers CO, and significantly decreases the 30 days mortality. Hence, suggested a first-line vasopressor agent in postcardiac surgery VPS. Terlipressin (1.3μg/kg/h), a longer acting and more specific vasoconstrictor prevents the development of VPS after CPB in patients treated with ACE-I. MB significantly reduces morbidity and mortality of VPS. The Preoperative MB (1%, 2mg/kg/30min, 1h before surgery) administration in high risk (on ACE-I) patients for VPS undergoing CABG surgery, provides 100% protection against VPS, and early of MB significantly reduces operative mortality, and recommended as a rescue therapy for VPS. Hydroxocobalamin (5 g) has been recommended as a rescue agent in VPS refractory to multiple vasopressors. A combination of ascorbic acid (6 g), hydrocortisone (200 mg/day), and thiamine (400 mg/day) as an adjuvant therapy significantly reduces the vasopressors requirement, and provides mortality and morbidity benefits. CONCLUSION Currently, the VPS is frequently encountered (9%-40%) in cardiac surgical patients with predisposing patient-specific risk factors and combined with inflammatory response to CPB. Multidrug therapy (NE, MB, AVP, ATII, terlipressin, hydroxocobalamin) targeting multiple receptor systems is recommended in refractory VPS. A combination of high dosage of ascorbic acid, hydrocortisone and thiamine has been used successfully as adjunctive therapyto restore the MAP. We also advocate for the early use of multiagent vasopressors therapy and catecholamine sparing adjunctive agents to restore the systemic perfusion pressure with a goal of preventing the progressive refractory VPS.
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Affiliation(s)
- Vishnu Datt
- Department of Cardiac Anaesthesia and Cardiothoracic and Vascular Surgery, GB Pant Hospital [GIPMER], New Delhi, India
| | - Rachna Wadhhwa
- Department of Cardiac Anaesthesia and Cardiothoracic and Vascular Surgery, GB Pant Hospital [GIPMER], New Delhi, India
| | - Varun Sharma
- Department of Cardiac Anaesthesia and Cardiothoracic and Vascular Surgery, GB Pant Hospital [GIPMER], New Delhi, India
| | - Sanjula Virmani
- Department of Cardiac Anaesthesia and Cardiothoracic and Vascular Surgery, GB Pant Hospital [GIPMER], New Delhi, India
| | - Harpreet S Minhas
- Department of Cardiac Anaesthesia and Cardiothoracic and Vascular Surgery, GB Pant Hospital [GIPMER], New Delhi, India
| | - Shardha Malik
- Department of Cardiac Anaesthesia and Cardiothoracic and Vascular Surgery, GB Pant Hospital [GIPMER], New Delhi, India
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Einav S, Helviz Y, Ippolito M, Cortegiani A. Vasopressor and inotrope treatment for septic shock: An umbrella review of reviews. J Crit Care 2021; 65:65-71. [PMID: 34090150 DOI: 10.1016/j.jcrc.2021.05.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/13/2021] [Accepted: 05/25/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE To review the characteristics, findings and quality of systematic reviews (SRs) on the effect of any vasopressor/inotrope on outcomes in adult patients with sepsis compared with either no treatment, another vasopressor or inotrope or fluids. MATERIALS AND METHODS We systematically searched Cochrane Central Register of Controlled Trials, PubMed and Embase (January 1993-March 2021). Descriptive statistics were used. RESULTS Among the 28 SRs identified, mortality was the primary outcome in most (26/28) and mortality was usually (23/28) studied using randomised controlled trials (RCTs). Fifteen SRs focused exclusively on patients with sepsis or septic shock. Sepsis and septic shock were always grouped for the analysis. Publication bias was consistently low when studied. The most consistent findings were a survival advantage with norepinephrine versus dopamine, which disappeared in analyses restricted to 28-day mortality, and more arrhythmias with dopamine. However, these analyses were dominated by a single study. Only 2 SRs were judged to be of moderate-high quality. Lack of blinding and attrition bias may have affected the outcomes. CONCLUSIONS The quality of SRs on the effect of vasopressors/inotropes on the outcomes of adult patients with sepsis can be improved, but high-quality, multicenter, RCTs should be preferred to additional SRs on this topic.
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Affiliation(s)
- Sharon Einav
- Intensive Care Unit of the Shaare Zedek Medical Medical Centre and Hebrew University Faculty of Medicine, Jerusalem, Israel.
| | - Yigal Helviz
- Intensive Care Unit of the Shaare Zedek Medical Medical Centre and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Mariachiara Ippolito
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy; Department of Anaesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
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Guarracino F, Habicher M, Treskatsch S, Sander M, Szekely A, Paternoster G, Salvi L, Lysenko L, Gaudard P, Giannakopoulos P, Kilger E, Rompola A, Häberle H, Knotzer J, Schirmer U, Fellahi JL, Hajjar LA, Kettner S, Groesdonk HV, Heringlake M. Vasopressor Therapy in Cardiac Surgery-An Experts' Consensus Statement. J Cardiothorac Vasc Anesth 2020; 35:1018-1029. [PMID: 33334651 DOI: 10.1053/j.jvca.2020.11.032] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 11/09/2020] [Accepted: 11/13/2020] [Indexed: 12/17/2022]
Abstract
Hemodynamic conditions with reduced systemic vascular resistance commonly are observed in patients undergoing cardiac surgery and may range from moderate reductions in vascular tone, as a side effect of general anesthetics, to a profound vasodilatory syndrome, often referred to as vasoplegic shock. Therapy with vasopressors is an important pillar in the treatment of these conditions. There is limited guidance on the appropriate choice of vasopressors to restore and optimize systemic vascular tone in patients undergoing cardiac surgery. A panel of experts in the field convened to develop statements and evidence-based recommendations on clinically relevant questions on the use of vasopressors in cardiac surgical patients, using a critical appraisal of the literature following the GRADE system and a modified Delphi process. The authors unanimously and strongly recommend the use of norepinephrine and/or vasopressin for restoration and maintenance of systemic perfusion pressure in cardiac surgical patients; despite that, the authors cannot recommend either of these drugs with respect to the risk of ischemic complications. The authors unanimously and strongly recommend against using dopamine for treating post-cardiac surgery vasoplegic shock and against using methylene blue for purposes other than a rescue therapy. The authors unanimously and weakly recommend that clinicians consider early addition of a second vasopressor (norepinephrine or vasopressin) if adequate vascular tone cannot be restored by a monotherapy with either norepinephrine or vasopressin and to consider using vasopressin as a first-line vasopressor or to add vasopressin to norepinephrine in cardiac surgical patients with pulmonary hypertension or right-sided heart dysfunction.
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Affiliation(s)
- Fabio Guarracino
- Department of Anesthesia and Intensive Care Medicine, University Hospital of Pisa, Pisa, Italy
| | - Marit Habicher
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Gieβen, Justus-Liebig University Gieβen, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Operative Intensive Care Medicine Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany
| | - Michael Sander
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Gieβen, Justus-Liebig University Gieβen, Germany
| | - Andrea Szekely
- Department of Anesthesia, Semmelweis University Budapest, Budapest, Hungary
| | - Gianluca Paternoster
- Division of Cardiac Resuscitation, Cardiovascular Anesthesia and Intensive Care, San Carlo Hospital, Potenza, Italy
| | - Luca Salvi
- IRCCS Centro Cardiologico Monzino, Milano, Italy
| | - Lidia Lysenko
- Department of Anesthesiology and Intensive Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Phillipe Gaudard
- Department of Anaesthesiology and Critical Care Medicine Arnaud de Villeneuve, CHU Montpellier, University of Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France
| | | | - Erich Kilger
- Department of Anesthesiology, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Amalia Rompola
- Department of Cardiac Surgery Intensive Care, Onassis Cardiac Center, Kallithea Athens, Greece
| | - Helene Häberle
- Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany
| | - Johann Knotzer
- Department of Anaesthesiology and Critical Care Medicine, County Hospital Wels, Wels, Austria
| | - Uwe Schirmer
- Institute for Anesthesiology, Heart, and Diabetes Center, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Jean-Luc Fellahi
- Department of Anesthesiology and Critical Care, Hôpital Cardiologique Louis Pradel, Lyon, France
| | - Ludhmila Abrahao Hajjar
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clínicas, Sao Paulo, Brazil
| | - Stephan Kettner
- Department of Anesthesiology and Intensive Care, Vienna Hospital Association, Vienna, Austria
| | | | - Matthias Heringlake
- Department of Anesthesiology and Intensive Care, Heart- and Diabetes Center Mecklenburg - Western Pomerania, Karlsburg, Germany.
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Zhong L, Ji XW, Wang HL, Zhao GM, Zhou Q, Xie B. Non-catecholamine vasopressors in the treatment of adult patients with septic shock-evidence from meta-analysis and trial sequential analysis of randomized clinical trials. J Intensive Care 2020; 8:83. [PMID: 33292658 PMCID: PMC7603734 DOI: 10.1186/s40560-020-00500-0] [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: 07/04/2020] [Accepted: 10/18/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Norepinephrine (NE) has currently been the first-choice vasopressor in treating septic shock despite generally insufficient for patients with refractory septic shock. The aim of this update meta-analysis was to assess the safety and efficacy of a combination of non-catecholamine vasopressors (vasopressin/pituitrin/terlipressin/selepressin/angiotensin II) and NE versus NE in managing adult septic shock patients. METHODS We conducted this study of literatures published from the inception to April 30, 2020, using PubMed, Embase, and the Cochrane Library databases without language restriction. Randomized controlled trials comparing NE with non-catecholamine vasopressors among adult septic shock patients were included in this meta-analysis. Pooled effects of relative risk (RR) or standard mean difference (SMD) and corresponding 95% confidence interval (CI) were calculated using a random-effects model. RESULTS Twenty-three studies covering 4380 participants were finally enrolled. The combined analysis of non-catecholamine vasopressors resulted in a nonsignificant reduction in 90-day/ICU/hospital mortality except for a decreased in 28-day mortality (n = 4217; RR, 0.92; 95% CI 0.86-0.99; P = 0.02). This favorable result was subsequently verified by the subgroup analyses of low risk of bias studies (RR = 0.91, 95% CI = 0.84 to 0.98; P = 0.02) and catecholamine-resistant refractory shock patients group (RR, 0.84; 95% CI = 0.70-1.00; P = 0.048). The pooled analysis of non-catecholamine vasopressors showed a 14% higher success rate of shock reversal at 6 h, a 29% decreased risk of continuous renal replacement therapy, but a 51% increased risk of hyponatremia and a 2.43 times higher risk of digital ischemia. Besides, the pooled data showed that non-catecholamine vasopressors decreased heart rate (HR) (SMD, - 0.43; 95% CI - 0.66 - - 0.19; P < 0.001), serum creatinine (- 0.15; 95% CI - 0.29 - - 0.01; P = 0.04), and the length of mechanical ventilation (MV) (- 0.19; 95% CI - 0.31 - - 0.07; P < 0.01, but there was no significant difference in other parameters. CONCLUSIONS Current pooled results suggest that the addition of NE to non-catecholamine vasopressors was associated with a marginally significant reduction in 28-day mortality. Moreover, they were able to shorten the length of MV, improved renal function, decreased HR, and increased the 6-h shock reversal success rate at the expense of increased the risk of hyponatremia and digital ischemia.
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Affiliation(s)
- Lei Zhong
- grid.411440.40000 0001 0238 8414Department of Intensive Care Units, Huzhou Central Hospital, Affiliated Central Hospital, HuZhou University, 198 Hongqi Rd, Huzhou, 313000 Zhejiang PR China
| | - Xiao-Wei Ji
- grid.411440.40000 0001 0238 8414Department of Intensive Care Units, Huzhou Central Hospital, Affiliated Central Hospital, HuZhou University, 198 Hongqi Rd, Huzhou, 313000 Zhejiang PR China
| | - Hai-Li Wang
- grid.411440.40000 0001 0238 8414Department of Obstetrics and Gynecology, Huzhou Central Hospital, Affiliated Central Hospital, Huzhou University, Huzhou, 313000 Zhejiang PR China
| | - Guang-Ming Zhao
- grid.268415.cDepartment of Intensive Care Unit, Affiliated Hospital of Yangzhou University, Yangzhou, 225000 Jiangsu Province PR China
| | - Qing Zhou
- grid.411440.40000 0001 0238 8414Department of Intensive Care Units, Huzhou Central Hospital, Affiliated Central Hospital, HuZhou University, 198 Hongqi Rd, Huzhou, 313000 Zhejiang PR China
| | - Bo Xie
- Department of Intensive Care Units, Huzhou Central Hospital, Affiliated Central Hospital, HuZhou University, 198 Hongqi Rd, Huzhou, 313000, Zhejiang, PR China.
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Vasopressin Versus Norepinephrine for the Management of Septic Shock in Cancer Patients: The VANCS II Randomized Clinical Trial. Crit Care Med 2020; 47:1743-1750. [PMID: 31609774 DOI: 10.1097/ccm.0000000000004023] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Previous trials suggest that vasopressin may improve outcomes in patients with vasodilatory shock. The aim of this study was to evaluate whether vasopressin could be superior to norepinephrine to improve outcomes in cancer patients with septic shock. DESIGN Single-center, randomized, double-blind clinical trial, and meta-analysis of randomized trials. SETTING ICU of a tertiary care hospital. PATIENTS Two-hundred fifty patients 18 years old or older with cancer and septic shock. INTERVENTIONS Patients were assigned to either vasopressin or norepinephrine as first-line vasopressor therapy. An updated meta-analysis was also conducted including randomized trials published until October 2018. MEASUREMENTS AND MAIN RESULTS The primary outcome was all-cause mortality at 28 days after randomization. Prespecified secondary outcomes included 90-days all-cause mortality rate; number of days alive and free of advanced organ support at day 28; and Sequential Organ Failure Assessment score 24 hours and 96 hours after randomization. We also measure the prevalence of adverse effects in 28 days. A total of 250 patients were randomized. The primary outcome was observed in 71 patients (56.8%) in the vasopressin group and 66 patients (52.8%) in the norepinephrine group (p = 0.52). There were no significant differences in 90-day mortality (90 patients [72.0%] and 94 patients [75.2%], respectively; p = 0.56), number of days alive and free of advanced organ support, adverse events, or Sequential Organ Failure Assessment score. CONCLUSIONS In cancer patients with septic shock, vasopressin as first-line vasopressor therapy was not superior to norepinephrine in reducing 28-day mortality rate.
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Just a Little Off the Top, Please. Crit Care Med 2020; 47:1810-1813. [PMID: 31738251 DOI: 10.1097/ccm.0000000000004050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Yao RQ, Xia DM, Wang LX, Wu GS, Zhu YB, Zhao HQ, Liu Q, Xia ZF, Ren C, Yao YM. Clinical Efficiency of Vasopressin or Its Analogs in Comparison With Catecholamines Alone on Patients With Septic Shock: A Systematic Review and Meta-Analysis. Front Pharmacol 2020; 11:563. [PMID: 32435192 PMCID: PMC7218087 DOI: 10.3389/fphar.2020.00563] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/14/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Vasopressin is an efficient remedy for septic shock patients as its great capacity in promoting hemodynamic stabilization. The aim of current systematic review and meta-analysis is to compare the clinical efficiency of vasopressin or its analogs with sole catecholamines on patients with septic shock. METHODS A systematic search of Cochrane Library, EMBASE, and PubMed online databases was performed up to 30 Oct 2019 to identify randomized controlled trials comparing use of vasopressin or its analogs (e.g., terlipressin, selepressin) with administration of catecholamines alone. RESULTS We included 23 RCTs with 4,225 patients in the current study. Compared with solely use of catecholamines, administration of vasopressin or its analogs was not associated with reduced 28-day or 30-day mortality among patients with septic shock [RR=0.94 (95% CI, 0.87-1.01), P=0.08, I2 = 0%]. The result of primary endpoint remained unchanged after conducting sensitivity analysis. Despite a significantly higher risk of digital ischemia in patients receiving vasopressin or its analogs [RR=2.65 (95% CI, 1.26-5.56), P < 0.01, I2 = 48%], there was no statistical significance in the pooled estimate for other secondary outcomes, including total adverse events, arrhythmia, acute myocardial infarction (AMI) and cardiac arrest, acute mesenteric ischemia, ICU/hospital length of stay, and mechanical ventilation (MV) duration. CONCLUSIONS The administration of vasopressin or its analogs was not associated with reduced 28-day or 30-day mortality among patients with septic shock, while an increased incidence of digital ischemia should be noted in patients receiving agonists for vasopressin receptors.
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Affiliation(s)
- Ren-qi Yao
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - De-meng Xia
- Department of Emergency, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Li-xue Wang
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China
| | - Guo-sheng Wu
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Yi-bing Zhu
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Beijing, China
| | - Hong-qiang Zhao
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China
| | - Qi Liu
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China
| | - Zhao-fan Xia
- Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Chao Ren
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China
| | - Yong-ming Yao
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China
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Patel A, Beauchesne A, Bredenkamp N, McGloin R, Stabler SN, Boyce K. Vasopressin for Septic Shock in a Medical-Surgical Intensive Care Unit. Can J Hosp Pharm 2020; 73:209-215. [PMID: 32616947 PMCID: PMC7308152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Critically ill patients often need vasopressors to treat hypotension related to septic shock and to maintain adequate systemic perfusion. Although the 2017 guidelines of the Surviving Sepsis Campaign recommend norepinephrine as first-line therapy, they also state that vasopressin may be considered as an adjunctive agent for patients with refractory shock. Limited evidence is available for directing optimal administration of vasopressin. As such, prescribing practices are not standardized and may vary according to the particular clinician, the clinical scenario, and various patient-specific factors. OBJECTIVES To review the current practice of administering concomitant norepinephrine and vasopressin therapy to patients with septic shock, to describe variability in vasopressin administration, and to evaluate effects on patient safety in a medical-surgical intensive care unit (ICU). METHODS This single-centre retrospective chart review involved 100 adult patients admitted to the ICU who received vasopressin and norepinephrine for septic shock between April and December 2017. The data were analyzed with descriptive statistics. RESULTS The mean time to initiation of vasopressin was 12.0 (standard deviation [SD] 21.6) h after initiation of norepinephrine. The mean dose of norepinephrine at the time of vasopressin initiation was 29.5 (SD 19.7) μg/min. The mean vasopressin dose prescribed was 0.04 (SD 0.03) units/min, with a range of tapering and discontinuation regimens. The mean duration of vasopressin therapy was 49.1 (SD 65.2) h, and vasopressin was discontinued before norepinephrine in 49 of the patients. A total of 60 hypotensive events occurred after vasopressor discontinuation and were more common when vasopressin was discontinued before norepinephrine. CONCLUSIONS Vasopressin dosing was comparable to that reported elsewhere; however, discontinuation practices were inconsistent. These results show that variability in the literature supporting vasopressin use has led to variability in vasopressin administration and discontinuation practices; however, correlation with improvement in clinical outcomes, such as mortality or ICU length of stay, is unclear, and further research is required to determine the ideal approach to vasopressin use.
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Affiliation(s)
- Arpita Patel
- , BSc(Hons), PharmD, was, at the time of this study, an Entry-to-Practice PharmD candidate with the University of British Columbia, Vancouver, British Columbia
| | - Arielle Beauchesne
- , PharmD, is with the Lower Mainland Pharmacy Services Residency Program, Vancouver, British Columbia. She is a Post-Graduate Year 1 candidate in the Accredited Canadian Pharmacy Residency program
| | - Nina Bredenkamp
- , BSc(Pharm), ACPR, is with the Department of Pharmacy Services, Surrey Memorial Hospital, Surrey, British Columbia
| | - Rumi McGloin
- , BSc(Pharm), ACPR, PharmD, is with the Department of Pharmacy Services and the Department of Critical Care, Surrey Memorial Hospital, Surrey, British Columbia
| | - Sarah N Stabler
- , BSc(Pharm), ACPR, PharmD, is with the Department of Pharmacy Services and the Department of Critical Care, Surrey Memorial Hospital, Surrey, British Columbia
| | - Krystin Boyce
- , BSc, BSc(Pharm), ACPR, is with the Department of Pharmacy Services and the Department of Emergency Medicine, Surrey Memorial Hospital, Surrey, British Columbia
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Knotzer H, Poidinger B, Kleinsasser A. Pharmacologic Agents for the Treatment of Vasodilatory Shock. Curr Pharm Des 2020; 25:2133-2139. [PMID: 31272348 DOI: 10.2174/1381612825666190704101907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/20/2019] [Indexed: 01/05/2023]
Abstract
Vasodilatory shock is a life-threatening syndrome in critically ill patients and is characterized by severe hypotension and resultant tissue hypoperfusion. This shock state requires the use of vasopressor agents to restore adequate vascular tone. Norepinephrine is still recommended as first-line vasopressor in the management of critically ill patients suffering from severe vasodilation. In the recent time, catecholaminergic vasopressor drugs have been associated with possible side effects at higher dosages. This so-called catecholamine toxicity has focused on alternative noncatecholaminergic vasopressors or the use of moderate doses of multiple vasopressors with complementary mechanisms of action. Besides vasopressin and terlipressin, angiotensin II may be a promising drug for the management of vasodilatory shock. In addition, adjunctive drugs, such as hydrocortisone, methylene blue or ascorbic acid can be added to conventional vasopressor therapy. The objective of this review is to give an overview of the current available vasopressor agents used in vasodilatory shock. A thorough search of PubMed was conducted in order to identify the majority of studies related to the subject. Data on the outcome of several drugs and future perspective of possible management strategies for the therapy of vasodilatory shock are discussed.
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Affiliation(s)
- Hans Knotzer
- Institute of Anesthesiology and Critical Care Medicine II, Klinikum Wels, Wels, Austria
| | - Bernhard Poidinger
- Institute of Anesthesiology and Critical Care Medicine II, Klinikum Wels, Wels, Austria
| | - Axel Kleinsasser
- Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
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Huang L, Zhang S, Chang W, Xia F, Liu S, Yang Y, Qiu H. Terlipressin for the treatment of septic shock in adults: a systematic review and meta-analysis. BMC Anesthesiol 2020; 20:58. [PMID: 32138657 PMCID: PMC7057452 DOI: 10.1186/s12871-020-00965-4] [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: 08/30/2019] [Accepted: 02/20/2020] [Indexed: 12/12/2022] Open
Abstract
Background Catecholamines are the first-line vasopressors used in patients with septic shock. However, the search for novel drug candidates is still of great importance due to the development of adrenergic hyposensitivity accompanied by a decrease in catecholamine activity. Terlipressin (TP) is a synthetic vasopressin analogue used in the management of patients with septic shock. In the current study, we aimed to compare the effects of TP and catecholamine infusion in treating septic shock patients. Methods A systematic review and meta-analysis was conducted by searching articles published in PUBMED, EMBASE, and the Cochrane Central Register of Controlled Trials between inception and July 2018. We only selected randomized controlled trials evaluating the use of TP and catecholamine in adult patients with septic shock. The primary outcome was overall mortality. The secondary outcomes were the ICU length of stay, haemodynamic changes, tissue perfusion, renal function, and adverse events. Results A total of 9 studies with 850 participants were included in the analysis. Overall, no significant difference in mortality was observed between the TP and catecholamine groups (risk ratio(RR), 0.85 (0.70 to 1.03); P = 0.09). In patients < 60 years old, the mortality rate was lower in the TP group than in the catecholamine group (RR, 0.66 (0.50 to 0.86); P = 0.002). There was no significant difference in the ICU length of stay (mean difference, MD), − 0.28 days; 95% confidence interval (CI), − 1.25 to 0.69; P = 0.58). Additionally, TP improved renal function. The creatinine level was decreased in patients who received TP therapy compared to catecholamine-treated participants (standard mean difference, SMD), − 0.65; 95% CI, − 1.09 to − 0.22; P = 0.003). No significant difference was found regarding the total adverse events (Odds Ratio(OR), 1.48(0.51 to 4.24); P = 0.47), whereas peripheral ischaemia was more common in the TP group (OR, 8.65(1.48 to 50.59); P = 0.02). Conclusion The use of TP was associated with reduced mortality in septic shock patients less than 60 years old. TP may also improve renal function and cause more peripheral ischaemia. PROSPERO registry: CRD42016035872.
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Affiliation(s)
- Lili Huang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Shi Zhang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Wei Chang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Feiping Xia
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Songqiao Liu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yi Yang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Haibo Qiu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China.
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Liu ZM, Lai HJ, Guan XD, Wen SH, Shen JT, Nie Y, Liu N, Zhang XY. Terlipressin relieves intestinal and renal injuries induced by acute mesenteric ischemia via PI3K/Akt pathway. Int J Med Sci 2020; 17:2751-2762. [PMID: 33162803 PMCID: PMC7645354 DOI: 10.7150/ijms.46302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 09/16/2020] [Indexed: 12/13/2022] Open
Abstract
Background: To date, the effect of vasopressin on organ damages after acute mesenteric ischemia (MI) remains poorly understood. Aims: To investigate the effect of terlipressin, a selective vasopressin V1 receptor agonist, versus norepinephrine on the intestinal and renal injuries after acute MI, and to explore the underlying mechanism of terlipressin. Methods: Acute MI model was produced by clamping the superior mesenteric artery for 1 hour. Immediately after unclamping, terlipressin or norepinephrine was intravenously administered for 2 hours. Meanwhile, in vitro, RAW264.7 cells were treated with lipopolysaccharide or lipopolysaccharide+terlipressin. In addition, wortmannin was used to determine the role of phosphoinositide 3-kinase (PI3K)/ protein kinase B (Akt) pathway in the potential impacts of terlipressin. Results: MI led to severe hypotension, caused notable intestinal and renal impairments and resulted in high mortality, which were markedly improved by terlipressin or norepinephrine. Terlipressin increased mean arterial pressure, decreased intestinal epithelial cell apoptosis, inhibited the generation of M1 macrophage in intestinal and renal tissues, and hindered the release of inflammatory cytokines after MI. Moreover, in cultured macrophages, terlipressin reduced the mRNA level of specific M1 markers and the release of inflammatory cytokines caused by lipopolysaccharide challenge. Wortmannin decreased the expression of PI3K and Akt induced by terlipressin in cells and in tissues, and abolished the above protective effects conferred by terlipressin. Conclusions: Terlipressin or norepinephrine could effectively improve organ damages and mortality after acute MI. Terlipressin elevates blood pressure and inhibits intestinal epithelial apoptosis and macrophage M1 polarization via the PI3K/Akt pathway.
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Affiliation(s)
- Zi-Meng Liu
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, No.58, Zhongshan 2nd Road, Guangzhou 510089, China
| | - Han-Jin Lai
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, No.58, Zhongshan 2nd Road, Guangzhou 510089, China
| | - Xiang-Dong Guan
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, No.58, Zhongshan 2nd Road, Guangzhou 510089, China
| | - Shi-Hong Wen
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No.58, Zhongshan 2nd Road, Guangzhou 510089, China
| | - Jian-Tong Shen
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No.58, Zhongshan 2nd Road, Guangzhou 510089, China
| | - Yao Nie
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, No.58, Zhongshan 2nd Road, Guangzhou 510089, China
| | - Ning Liu
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, No.58, Zhongshan 2nd Road, Guangzhou 510089, China
| | - Xu-Yu Zhang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No.58, Zhongshan 2nd Road, Guangzhou 510089, China
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Huang P, Guo Y, Li B, Liu Q. Terlipressin Versus Norepinephrine for Septic Shock: A Systematic Review and Meta-Analysis. Front Pharmacol 2019; 10:1492. [PMID: 31920672 PMCID: PMC6936170 DOI: 10.3389/fphar.2019.01492] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 11/19/2019] [Indexed: 12/28/2022] Open
Abstract
Purpose: The meta-analysis aims to evaluate the efficacy and safety of terlipressin compared with norepinephrine for septic shock. Materials and Methods: The relevant studies from MEDLINE, Cochrane Library, Embase were searched by two independent investigators. A variety of keywords were used to search the studies. Stata software (version 11.0, Stata Corp LP, College Station, TX, USA) was used for statistical analysis. Results: A total of six studies were identified and incorporated into the meta-analysis. The results showed that there was no difference for 28-day mortality (RR = 0.99, 95% CI = [0.85,1.15], P = 0.849), AE (RR = 2.54, 95% CI = [0.58,11.08], P = 0.214), and MAP (SMD = -0.10, 95% CI = [-0.35,0.14], P = 0.405), OI, urinary output, Scr, total bilirubin, ALT, and AST between TP group and NE group. While TP could decrease HR at 24 and 48 h compared with NE. Conclusions: Current results suggest that terlipressin showed no added survival benefit for septic shock when compared with norepinephrine, while terlipressin could decrease heart rate in the late phase of septic shock compared with norepinephrine without further liver and kidney injury. Systematic Review Registration: PROSPERO (ID: CRD42019128743). Available online at: http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42019128743.
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Affiliation(s)
- Po Huang
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Yuhong Guo
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Bo Li
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Infection and Immunity Laboratory, Beijing Institute of Traditional Chinese Medicine, Beijing, China
| | - Qingquan Liu
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Infection and Immunity Laboratory, Beijing Institute of Traditional Chinese Medicine, Beijing, China.,Infection and Immunity Laboratory, Beijing Key Laboratory of Basic Research With Traditional Chinese Medicine on Infectious Diseases, Beijing, China
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Habicher M, Zajonz T, Heringlake M, Böning A, Treskatsch S, Schirmer U, Markewitz A, Sander M. [S3 guidelines on intensive medical care of cardiac surgery patients : Hemodynamic monitoring and cardiovascular system-an update]. Anaesthesist 2019; 67:375-379. [PMID: 29644444 DOI: 10.1007/s00101-018-0433-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
An update of the S3- guidelines for treatment of cardiac surgery patients in the intensive care unit, hemodynamic monitoring and cardiovascular system was published by the Association of Scientific Medical Societies in Germany (AWMF) in January 2018. This publication updates the guidelines from 2006 and 2011. The guidelines include nine sections that in addition to different methods of hemodynamic monitoring also reviews the topic of volume therapy as well as vasoactive and inotropic drugs. Furthermore, the guidelines also define the goals for cardiovascular treatment. This article describes the most important innovations of these comprehensive guidelines.
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Affiliation(s)
- M Habicher
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Gießen, Rudolf-Buchheim-Straße 7, 35392, Gießen, Deutschland
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité - Universitätsmedizin Berlin, Charité Campus Mitte und Campus Virchow Klinikum, Berlin, Deutschland
| | - T Zajonz
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Gießen, Rudolf-Buchheim-Straße 7, 35392, Gießen, Deutschland
| | - M Heringlake
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Lübeck, Deutschland
| | - A Böning
- Klinik für Herz- und Gefäßchirurgie, Universitätsklinikum Gießen, Gießen, Deutschland
| | - S Treskatsch
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité - Universitätsmedizin Berlin, Charité Campus Mitte und Campus Virchow Klinikum, Berlin, Deutschland
| | - U Schirmer
- Herz- und Diabeteszentrum NRW Institut für Anästhesiologie, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Deutschland
| | - A Markewitz
- Klinik für Herz- und Gefäßchirurgie, Bundeszentralwehrkrankenhaus Koblenz, Koblenz, Deutschland
| | - M Sander
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Gießen, Rudolf-Buchheim-Straße 7, 35392, Gießen, Deutschland.
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Lam SW, Barreto EF, Scott R, Kashani KB, Khanna AK, Bauer SR. Cost-effectiveness of second-line vasopressors for the treatment of septic shock. J Crit Care 2019; 55:48-55. [PMID: 31706118 DOI: 10.1016/j.jcrc.2019.10.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/04/2019] [Accepted: 10/17/2019] [Indexed: 01/27/2023]
Abstract
PURPOSE To determine the cost-effectiveness of escalating doses of norepinephrine or norepinephrine plus the adjunctive use of vasopressin or angiotensin II as a second-line vasopressor for septic shock. MATERIALS AND METHODS Decision tree analysis was performed to compare costs and outcomes associated with norepinephrine monotherapy or the two adjunctive second-line vasopressors. Short- and long-term outcomes modeled included ICU survival and lifetime quality-adjusted-life-years (QALY) gained. Costs were modeled from a payer's perspective, with a willingness-to-pay threshold set at $100,000/unit gained. One-way (tornado diagrams) and probabilistic sensitivity analyses were performed. RESULTS Adjunctive vasopressin was the most cost-effective therapy, and dominated both norepinephrine monotherapy and adjunctive angiotensin II by producing higher ICU survival at less cost. For the lifetime horizon, while norepinephrine monotherapy was least expensive, adjunctive vasopressin was the most cost-effective with an incremental cost-effectiveness ratio of $19,762 / QALY gained. Although adjunctive angiotensin II produced more QALYs compared to norepinephrine monotherapy, it was dominated in the long-term evaluation by second-line vasopressin. Sensitivity analyses demonstrated model robustness and medication costs were not significant drivers of model results. CONCLUSIONS Vasopressin is the most cost-effective second-line vasopressor in both the short- and long-term evaluations. Vasopressor price is a minor contributor to overall cost.
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Affiliation(s)
- Simon W Lam
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA.
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Rachael Scott
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Kianoush B Kashani
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA; Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA; Wake Forest Center for Biomedical Informatics, and the Critical Injury, Illness and Recovery Research Center (CIIRRC), USA
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
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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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Efficacy of IgM-enriched Immunoglobulin for Vasopressor-resistant Vasoplegic Shock After Liver Transplantation. Transplantation 2019; 103:381-386. [PMID: 29944619 DOI: 10.1097/tp.0000000000002344] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Vasoplegia is a clinical condition typically manifested by cardiovascular instability unresponsive to the usual doses of inotropes or vasopressors. It can occur in a variety of clinical settings including liver transplantation (LT). Immunoglobulins have been used to treat sepsis-related vasoplegia. We performed a retrospective study to evaluate the efficacy of IgM-enriched immunoglobulin (IgMIg) on 30-day mortality and its ability to reverse vasoplegia in patients undergoing LT. METHODS Between May 2013 and November 2017, 473 LT were performed at our institution. We identified 21 patients who received IgMIg for 3 days to treat vasoplegia. Patients included in the study met the criteria for having vasoplegia and required noradrenaline administration greater than 1 μg·kg·min for more than 24 hours to maintain a mean arterial pressure of 70 mm Hg or greater. Procalcitonin and interleukin-6 (IL-6) levels were used as surrogate markers for inflammation and were measured at the beginning and end of IgM treatment. RESULTS After IgMIg administration, median noradrenaline infusion rates could be significantly reduced from 1.6 μg·kg·min (1.3-2 μg·kg·min) to 0.16 μg·kg·min (0.08-0.34 μg·kg·min) (P < 0.001). In addition, after treatment, procalcitonin levels decreased significantly from 44 ng/mL (24-158) to 26.1 ng/mL (10.9-48.7) (P < 0.001) and IL-6 levels decreased significantly from 63 pg/mL (29-102) to 20 pg/mL (11-20) (P < 0.001). Thirty-day morality was 14.3%. CONCLUSIONS The administration of IgMIg in patients with vasoplegia after LT is associated with a return of hemodynamic stability. Despite a predicted mortality of over 90% by Sepsis-Related Organ Failure Assessment score, the mortality rate of patients receiving IgMIg in our study was less than 20%.
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Morin L, Pierre A, Tissieres P, Miatello J, Durand P. Actualités sur le sepsis et le choc septique de l’enfant. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2018-0080] [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
L’incidence du sepsis de l’enfant augmente en réanimation pédiatrique. La définition du sepsis et du choc septique de l’enfant est amenée à évoluer à l’instar de celle du choc septique de l’adulte pour détecter les patients nécessitant une prise en charge urgente et spécialisée. La prise en charge d’un patient septique repose sur une oxygénothérapie, une expansion volémique au sérum salé isotonique, une antibiothérapie et un transfert dans un service de réanimation ou de surveillance continue pédiatrique. Le taux et la cinétique d’élimination du lactate plasmatique est un bon critère diagnostic et pronostic qui permet de guider la prise en charge. La présence de plusieurs défaillances d’organes ou une défaillance circulatoire aiguë signe le diagnostic de sepsis encore dit sévère, et leur persistance et/ou la non-correction de l’hypotension artérielle malgré un remplissage vasculaire d’au moins 40 ml/kg définit le choc septique chez l’enfant. Dans ce cas, la correction rapide de l’hypotension artérielle persistante repose sur la noradrénaline initiée sur une voie intraveineuse périphérique dans l’attente d’un accès veineux central. L’échographie cardiaque est un examen clé de l’évaluation hémodynamique du patient, pour guider la poursuite de l’expansion volémique ou détecter une cardiomyopathie septique. Des thérapeutiques additionnelles ont été proposées pour prendre en charge certains patients avec des défaillances d’organes particulières. L’immunomonitorage et la modulation sont un ensemble de techniques qui permettent la recherche et le traitement de certaines complications. La Surviving Sepsis Campaign a permis d’améliorer la prise en charge de ces patients par l’implémentation d’algorithmes de détection et de prise en charge du sepsis de l’enfant. Une révision pédiatrique de cette campagne est attendue prochainement.
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Inotropes and Vasoactive Agents: Differences Between Europe and the United States. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00323-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Cheng L, Yan J, Han S, Chen Q, Chen M, Jiang H, Lu J. Comparative efficacy of vasoactive medications in patients with septic shock: a network meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:168. [PMID: 31088524 PMCID: PMC6518735 DOI: 10.1186/s13054-019-2427-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 04/09/2019] [Indexed: 12/12/2022]
Abstract
Background Catecholamines, especially norepinephrine, are the most frequently used vasopressors for treating patients with septic shock. During the recent decades, terlipressin, vasopressin V1A agonist, and even Ca2+ sensitizer were increasingly used by physicians. The aim of this study is to compare the efficacy of such different kinds of vasoactive medications on mortality among patients with septic shock. Methods Relevant randomized controlled trials were identified by searching PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials updated to February 22, 2018. A network meta-analysis was performed to evaluate the effect of different types of vasoactive medications. The primary outcome was 28-day mortality. Intensive care unit (ICU) mortality, hospital and ICU length of stay (LOS), and adverse events were also assessed. Results A total of 43 trials with 5767 patients assessing 17 treatment modalities were included. Treatments ranking based on surface under the cumulative ranking curve values from largest to smallest were NE/DB 85.9%, TP 75.1%, NE/EP 74.6%, PI 74.1%, EP 72.5%, VP 66.1%, NE 59.8%, PE 53.0%, DA 42.1%, DX 38.2%, SP 27.0%, PA 24.3%, EX 22.8%, LE 21.5%, and DB 13.3% for 28-day mortality. Treatments ranking for ICU mortality were TP/NE 86.4%, TP 80.3%, TP/DB/NE 65.7%, VP/NE 62.8%, NE 57.4%, VP 56.5%, PE 48.4%, DA 33.0%, PA 27.5%, LE 22.1%, and DB 9.9%. The incidence of myocardial infarction was reported with NE/EP 3.33% (n = 1 of 30), followed by EP 3.11% (n = 5 of 161), and then VP 3.10% (n = 19 of 613), NE 3.03% (n = 43 of 1417), DA 2.21% (n = 19 of 858), NE/DB 2.01% (n = 4 of 199), LE 1.16% (n = 3 of 258), and PA 0.39% (n = 1 of 257). The incidence of arrhythmia was reported with DA 26.01% (n = 258 of 992), followed by EP 22.98% (n = 37 of 161), and then NE/DB 20.60% (n = 41 of 199), NE/EP 20.0% (n = 6 of 30), NE 8.33% (n = 127 of 1525), LE 5.81% (n = 15 of 258), PA 2.33% (n = 6 of 257), and VP 1.67% (n = 10 of 600). Conclusions The use of norepinephrine plus dobutamine was associated with lower 28-day mortality for septic shock, especially among patients with lower cardiac output. Electronic supplementary material The online version of this article (10.1186/s13054-019-2427-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lu Cheng
- Department of Intensive Care Unit, Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Jing Yan
- Key Laboratory for Metabolic Diseases in Chinese Medicine, First Clinical Medical College, Nanjing University of Chinese Medicine, 138 Xianlin Avenue, Nanjing, 210013, China
| | - Shutang Han
- Department of Center of Gastrointestinal Endoscopy, Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Qiuhua Chen
- Department of Intensive Care Unit, Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Mingqi Chen
- Department of Intensive Care Unit, Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Hua Jiang
- Department of Intensive Care Unit, Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Jun Lu
- Department of Intensive Care Unit, Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China.
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Rocha DL, Moreira FT, Serpa Neto A. Terlipressin as a first choice in septic shock-not yet. J Thorac Dis 2019; 11:S1384-S1386. [PMID: 31245140 DOI: 10.21037/jtd.2019.03.49] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Daniel Lima Rocha
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Fabio Tanzillo Moreira
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands.,Cardio-Pulmonary Department, Pulmonary Division, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
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Williams MD, Russell JA. Terlipressin or norepinephrine in septic shock: do we have the answer? J Thorac Dis 2019; 11:S1270-S1273. [PMID: 31245106 DOI: 10.21037/jtd.2019.05.07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Mark D Williams
- Department of Medicine, Indiana University School of Medicine, Indiana University Health Methodist Hospital, Indianapolis, IN, USA
| | - James A Russell
- Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
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Orozco Vinasco DM, Triana Schoonewolff CA, Orozco Vinasco AC. Vasoplegic syndrome in cardiac surgery: Definitions, pathophysiology, diagnostic approach and management. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2019; 66:277-287. [PMID: 30736984 DOI: 10.1016/j.redar.2018.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/22/2018] [Accepted: 12/24/2018] [Indexed: 06/09/2023]
Abstract
Vasoplegic syndrome is a state of vasopressor resistant systemic vasodilation in the presence of a normal cardiac output. Its definition, pathophysiology, risk factors, diagnosis and therapeutic approach will be reviewed in this paper. It occurs frequently during cardiac surgery and is associated with high morbidity and mortality. A search in the LILACS, MEDLINE, and GOOGLE SCHOLAR databases was conducted to find the most relevant papers during the last 18 years. Prompt identification and diagnosis of patients at risk must be undertaken in order to implement an optimal therapeutic approach. This latter includes early treatment with vasopressors with different mechanisms of action.
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Affiliation(s)
- D M Orozco Vinasco
- Departamento de Anestesia cardiovascular, Clínica Colsubsidio Calle 100, Instituto del Corazón de Bucaramanga sede Bogotá, Bogotá, Colombia.
| | - C A Triana Schoonewolff
- Departamento de Anestesia cardiovascular, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - A C Orozco Vinasco
- Departamento de Anestesia, Hospital Universitario Severo Ochoa, Leganés Madrid, España
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Jiang L, Sheng Y, Feng X, Wu J. The effects and safety of vasopressin receptor agonists in patients with septic shock: a meta-analysis and trial sequential analysis. Crit Care 2019; 23:91. [PMID: 30871607 PMCID: PMC6419432 DOI: 10.1186/s13054-019-2362-4] [Citation(s) in RCA: 14] [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: 09/18/2018] [Accepted: 02/17/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The aim of this study was to evaluate the effects and safety of vasopressin receptor agonists in patients with septic shock. METHODS PubMed, EMBASE, and Cochrane library were searched for randomized controlled trials evaluating the effects of vasopressin receptor agonists in septic shock patients. Two reviewers performed literature selection, data extraction, and quality evaluation independently. The primary outcome was mortality. And secondary outcomes included intensive care unit (ICU) length of stay, duration of mechanical ventilation, and incidence of adverse events. In addition, a trial sequential analysis (TSA) was performed. RESULTS Twenty studies were eligible for meta-analysis. The results showed vasopressin receptor agonists use was associated with reduced mortality (relative risk (RR) 0.92; 95% confidence interval (CI) 0.84 to 0.99; I2 = 0%). Nevertheless, they had no significant effects on ICU length of stay (mean deviation (MD) - 0.08, 95% CI, - 0.68 to 0.52, I2 = 0%) and duration of mechanical ventilation (MD - 0.58, 95% CI - 1.47 to 0.31, I2 = 57%). Additionally, there was no significant difference in total adverse events between two groups (RR 1.28, 95% CI 0.87 to 1.90, I2 = 57%), but vasopressin receptor agonists administration could significantly increase the risk of digital ischemia (RR 4.85, 95% CI 2.81 to 8.39, I2 = 26%). Finally, there was no statistical difference of cardiovascular events (RR 0.91, 95% CI 0.53 to 1.57, I2 = 1%), arrhythmia (0.77, 95% CI 0.48 to 1.23, I2 = 23%), mesenteric ischemia (0.83, 95% CI 0.44 to 1.55, I2 = 0%), diarrhea (2.47, 95% CI 0.77 to 7.96, I2 = 49%), cerebrovascular events (1.36, 95% CI 0.18 to 10.54, I2 = 0%), and hyponatremia (1.47, 95% CI 0.84 to 2.55, I2 = 0%) between two groups. Egger's test showed there was no significant publication bias among studies (P = 0.36). CONCLUSIONS The use of vasopressin might result in reduced mortality in patients with septic shock. An increased risk of digital ischemia must be taken into account.
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Affiliation(s)
- Libing Jiang
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, No 88, Jiefang Rd, Hangzhou, China
| | - Yi Sheng
- Yuhang Branch of The Second Affiliated Hospital of Zhenjiang University, No.369 Yingbin Road, Yuhang District, Hangzhou, 311100 Zhenjiang Province China
| | - Xia Feng
- Department of Respiratory, The Third People’s Hospital of Hangzhou, West Lake Avenue 38, Hangzhou, China
| | - Jing Wu
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, No 88, Jiefang Rd, Hangzhou, China
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Zhu Y, Huang H, Xi X, Du B. Terlipressin for septic shock patients: a meta-analysis of randomized controlled study. J Intensive Care 2019; 7:16. [PMID: 30923620 PMCID: PMC6419496 DOI: 10.1186/s40560-019-0369-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 02/21/2019] [Indexed: 12/13/2022] Open
Abstract
Background Catecholamines are commonly used in septic shock but face limitations of their hypo-responsiveness and adverse events due to high dose. Terlipressin is a synthetic vasopressin analog with greater selectivity for the V1-receptor. A meta-analysis was conducted to evaluate the efficacy and safety of terlipressin in septic shock. Methods We searched for relevant studies in PubMed, Embase, and the Cochrane database from inception up to July 15, 2018. Randomized controlled trials (RCTs) were included if they reported data on any of the predefined outcomes in patients with septic shock and managed with terlipressin or any catecholamines. Results were expressed as risk ratio (RR) or mean difference (MD) with accompanying 95% confidence interval (CI). Heterogeneity, subgroup analysis, sensitivity analysis, and publication bias were explored. Results Ten studies with 928 patients were included. Despite the shorter duration of mechanical ventilation, use of terlipressin did not reduce the risk of mortality (RR = 0.94; 95% CI, 0.85 to 1.05; I2 = 0%; P = 0.28) when compared with control. This finding was confirmed by further subgroup and sensitivity analyses. In addition, lactate clearance, length of stay in ICU or hospital, total adverse events, digital ischemia, and arrhythmia were also similar between groups, while terlipressin was associated with shorter duration of mechanical ventilation and less norepinephrine requirements. Conclusions Current results suggest terlipressin did not show added survival benefit in septic shock therapy when compared with catecholamines. Electronic supplementary material The online version of this article (10.1186/s40560-019-0369-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yibing Zhu
- 1ICU, Fuxing Hospital, Capital Medical University, Peking, China
| | - Huibin Huang
- 2Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Peking, China.,3Department of Critical Care Medicine, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Xiuming Xi
- 1ICU, Fuxing Hospital, Capital Medical University, Peking, China
| | - Bin Du
- 2Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Peking, China
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Kunkes JH, Baker WL, Hammond JA, Gluck J. Vasopressin therapy in cardiac surgery. J Card Surg 2018; 34:20-27. [DOI: 10.1111/jocs.13968] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Jordan H. Kunkes
- Hartford Hospital; Hartford Connecticut
- University of Connecticut School of Medicine; Farmington Connecticut
| | - William L. Baker
- University of Connecticut School of Pharmacy; Storrs Connecticut
| | - Jonathan A. Hammond
- Hartford Hospital; Hartford Connecticut
- University of Connecticut School of Medicine; Farmington Connecticut
- Heart and Vascular Institute; Hartford Healthcare; Hartford Connecticut
| | - Jason Gluck
- Hartford Hospital; Hartford Connecticut
- University of Connecticut School of Medicine; Farmington Connecticut
- Heart and Vascular Institute; Hartford Healthcare; Hartford Connecticut
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Russell JA, Wellman H, Walley KR. Vasopressin versus norepinephrine in septic shock: a propensity score matched efficiency retrospective cohort study in the VASST coordinating center hospital. J Intensive Care 2018; 6:73. [PMID: 30473792 PMCID: PMC6240281 DOI: 10.1186/s40560-018-0344-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 11/01/2018] [Indexed: 01/12/2023] Open
Abstract
Purpose It is not clear whether vasopressin versus norepinephrine changed mortality in clinical practice in the Vasopressin and Septic Shock Trial (VASST) coordinating center hospital after VASST was published. We tested the hypothesis that vasopressin changed mortality compared to norepinephrine using propensity matching of vasopressin to norepinephrine-treated patients in the VASST coordinating center hospital before (SPH1) and after (SPH2) VASST was published. Methods Vasopressin-treated patients were propensity score matched to norepinephrine-treated patients based on age, APACHE II, respiratory, renal, and hematologic dysfunction, mechanical ventilation status, medical/surgical status, infection site, and norepinephrine dose. The propensity score estimated the probability that a patient would have received vasopressin given baseline characteristics. For sensitivity analysis, we then excluded patients who had underlying severe congestive heart failure. The primary outcome was 28-day mortality. Results Vasopressin- and norepinephrine-treated patients were similar after matching in SPH1 (pre-VASST); vasopressin-treated patients (n = 158) had a significantly higher mortality than norepinephrine-treated patients (n = 158) (60.8 vs. 46.2%, p = 0.009). In SPH2 after matching, the 28-day mortality rates were not significantly different; 31.2% and 26.9% in the vasopressin (n = 93) and norepinephrine (n = 93) groups, respectively (p = 0.518). The day 1 vasopressin dose in SPH1 vs. SPH2 was 0.036 units/min (SD 0.009) vs. 0.032 units/min (SD 0.005), p = 0.001, significantly lower in SPH2 after VASST. Conclusions Before VASST, vasopressin use was associated with increased mortality compared to norepinephrine in the VASST coordinating center hospital. After VASST, there was no difference in mortality between vasopressin- and norepinephrine-treated patients. This may be the first retrospective propensity-matched cohort study of a sepsis treatment in a center that had previously coordinated a large pivotal randomized controlled trial of that treatment and could be a useful approach for other sepsis therapies. Trial registration Registration: ISRCTN94845869 Electronic supplementary material The online version of this article (10.1186/s40560-018-0344-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- James A Russell
- 1Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada.,2Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
| | - Hugh Wellman
- 3GenomeDx Biosciences Inc., 1038 Homer Street, Vancouver, BC V6B 2W9 Canada
| | - Keith R Walley
- 1Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada.,2Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
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Dünser MW, Bouvet O, Knotzer H, Arulkumaran N, Hajjar LA, Ulmer H, Hasibeder WR. Vasopressin in Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2018; 32:2225-2232. [DOI: 10.1053/j.jvca.2018.04.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Indexed: 01/29/2023]
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Jentzer JC, Vallabhajosyula S, Khanna AK, Chawla LS, Busse LW, Kashani KB. Management of Refractory Vasodilatory Shock. Chest 2018; 154:416-426. [DOI: 10.1016/j.chest.2017.12.021] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 12/18/2017] [Accepted: 12/21/2017] [Indexed: 12/24/2022] Open
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Bauer SR, Sacha GL, Lam SW. Safe Use of Vasopressin and Angiotensin II for Patients with Circulatory Shock. Pharmacotherapy 2018; 38:851-861. [DOI: 10.1002/phar.2147] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Seth R. Bauer
- Department of Pharmacy; Cleveland Clinic; Cleveland Ohio
| | | | - Simon W. Lam
- Department of Pharmacy; Cleveland Clinic; Cleveland Ohio
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Terlipressin versus norepinephrine as infusion in patients with septic shock: a multicentre, randomised, double-blinded trial. Intensive Care Med 2018; 44:1816-1825. [PMID: 29971593 DOI: 10.1007/s00134-018-5267-9] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 06/05/2018] [Indexed: 02/05/2023]
Abstract
PURPOSE Recent clinical data suggest that terlipressin, a vasopressin analogue, may be more beneficial in septic shock patients than catecholamines. However, terlipressin's effect on mortality is unknown. We set out to ascertain the efficacy and safety of continuous terlipressin infusion compared with norepinephrine (NE) in patients with septic shock. METHODS In this multicentre, randomised, double-blinded trial, patients with septic shock recruited from 21 intensive care units in 11 provinces of China were randomised (1:1) to receive either terlipressin (20-160 µg/h with maximum infusion rate of 4 mg/day) or NE (4-30 µg/min) before open-label vasopressors. The primary endpoint was mortality 28 days after the start of infusion. Primary efficacy endpoint analysis and safety analysis were performed on the data from a modified intention-to-treat population. RESULTS Between 1 January 2013 and 28 February 2016, 617 patients were randomised (312 to the terlipressin group, 305 to the NE group). The modified intention-to-treat population comprised 526 (85.3%) patients (260 in the terlipressin group and 266 in the NE group). There was no significant difference in 28-day mortality rate between the terlipressin group (40%) and the NE group (38%) (odds ratio 0.93 [95% CI 0.55-1.56]; p = 0.80). Change in SOFA score on day 7 was similar between the two groups: - 7 (IQR - 11 to 3) in the terlipressin group and - 6 (IQR - 10 to 5) in the NE group. There was no difference between the groups in the number of days alive and free of vasopressors. Overall, serious adverse events were more common in the terlipressin group than in the NE group (30% vs 12%; p < 0.001). CONCLUSIONS In this multicentre, randomised, double-blinded trial, we observed no difference in mortality between terlipressin and NE infusion in patients with septic shock. Patients in the terlipressin group had a higher number of serious adverse events. TRIAL REGISTRATION This trial is registered at ClinicalTrials.gov: ID NCT01697410.
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Quan AT, Li F. Hyperinflation of Vasopressors (Vasopressin, Norepinephrine, Ephedrine, etc). J Pharm Pract 2018; 31:399-402. [PMID: 29938596 DOI: 10.1177/0897190018770062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Hyperinflation refers to the increasing cost of drugs which occurs due to continued drug shortages and rebranding. Hyperinflation has significant implications in increasing overall healthcare costs with reduced reimbursement, increased patient acuity, and an aging population, but published strategies to reduce costs and minimize waste are limited. OBJECTIVE To describe the hyperinflation and cost mitigation strategies of three vasopressor medications, vasopressin, epinephrine, and ephedrine. CONCLUSION The steep increase in medications is expected to continue, and mitigation strategies to reduce waste and select the most cost effective therapy to offset the price increase is crucial for healthcare systems.
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Affiliation(s)
- Ashley Thompson Quan
- 1 University of California San Francisco Medical Center at Parnassus, San Francisco, CA, USA
| | - Fanny Li
- 1 University of California San Francisco Medical Center at Parnassus, San Francisco, CA, USA
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Desai SR, Hwang NC. Advances in Left Ventricular Assist Devices and Mechanical Circulatory Support. J Cardiothorac Vasc Anesth 2018. [DOI: 10.1053/j.jvca.2018.01.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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45
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S3-Leitlinie zur intensivmedizinischen Versorgung herzchirurgischer Patienten. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2018. [DOI: 10.1007/s00398-018-0242-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Liu X, Luo G, Jiang J, Ma T, Lin X, Jiang L, Cheng J, Tao R. Signaling through hepatocyte vasopressin receptor 1 protects mouse liver from ischemia-reperfusion injury. Oncotarget 2018; 7:69276-69290. [PMID: 27713143 PMCID: PMC5342477 DOI: 10.18632/oncotarget.12472] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 09/29/2016] [Indexed: 12/12/2022] Open
Abstract
Terlipressin has been used extensively in the management of certain complications associated with end-stage liver diseases (ESLDs). In our pilot study, terlipressin treatment showed beneficial effects on liver function in patients with decompensated cirrhosis, however whether it plays a role in liver ischemia-reperfusion injury (IRI) remains unknown. Using a mouse nonlethal hepatic IR model, we found terlipressin administration significantly ameliorated IR-induced liver apoptosis, necrosis and inflammation. Furthermore, despite its known effect on visceral vasoconstriction, hemodynamic evaluation of murine hepatic tissue after IR revealed no change of overall hepatic blood flow after terlipressin treatment. Further studies identified the upregulation of vasopressin receptor 1 (V1R) expression on hepatocytes upon IR. In isolated hepatocyte hypoxia/reoxygenation model, the active component of terlipressin, lysine vasopressin, conferred hepatocytes resistant to oxidative stress-induced apoptosis. Mechanistic studies revealed the V1R engagement activated the Wnt/β-catenin/FoxO3a/AKT pathway, which subsequently circumvented the proapoptotic events, thus ameliorated hepatocyte apoptosis. Furthermore, genetic knockdown of V1R expression in hepatocyte cell lines or blockade of this signaling pathway abrogated such protective effect. CONCLUSION These data highlight the functional importance of the hepatocyte V1R/Wnt/β-catenin/FoxO3a/AKT pathway in protecting liver from oxidative stress-induced injury.
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Affiliation(s)
- Xiqiang Liu
- Department of Hepatobiliary-Pancreatic Surgery, Zhejiang Provincial People's Hospital (ZJPPH), Hangzhou, Zhejiang, PR China
| | - Gaojian Luo
- Department of General Surgery, Affiliated Yiwu Hospital, Wenzhou Medical University, Yiwu, Zhejiang, PR China
| | - Jingbo Jiang
- Department of Surgery, Qilu Hospital, Shandong University School of Medicine, Jinan, Shandong, PR China
| | - Tonghui Ma
- Department of Hepatobiliary-Pancreatic Surgery, Zhejiang Provincial People's Hospital (ZJPPH), Hangzhou, Zhejiang, PR China
| | - Xiaozhu Lin
- Department of Radiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, PR China
| | - Liping Jiang
- Department of Hepatobiliary-Pancreatic Surgery, Zhejiang Provincial People's Hospital (ZJPPH), Hangzhou, Zhejiang, PR China
| | - Jilin Cheng
- Department of Gastroenterology, Shanghai Public Health Clinical Center, Fudan University, Shanghai, PR China
| | - Ran Tao
- Department of Hepatobiliary-Pancreatic Surgery, Zhejiang Provincial People's Hospital (ZJPPH), Hangzhou, Zhejiang, PR China
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Kny KT, Ferreira MAP, Pizzol TDSD. Use of vasopressin in the treatment of refractory septic shock. Rev Bras Ter Intensiva 2018; 30:423-428. [PMID: 30570030 PMCID: PMC6334485 DOI: 10.5935/0103-507x.20180060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 06/13/2018] [Indexed: 11/25/2022] Open
Abstract
Objective To evaluate the short-term evolution of patients with septic shock refractory
to norepinephrine treated with vasopressin in an intensive care unit of a
university hospital. Methods An unmatched retrospective study (case series) was performed. Clinical,
laboratory, and anthropometric data were collected from patients who
received vasopressin infusion for treatment of catecholamine-refractory
shock from December 2014 to June 2016. For the assessment of severity,
APACHE II and SOFA scores were used. The main outcome was mortality at 3 and
30 days. Results A total of 80 patients were included, of which 60% were male. In 86.3% of the
cases, APACHE II was observed in the highest ranges (> 20). The 30-day
mortality was 86.2%, and 75% of the patients died within 72 hours after
starting vasopressin. Conclusion The series evaluated had high mortality in the first 72 hours of treatment
with vasopressin. The use of vasopressin in patients who are refractory to
norepinephrine had little or no impact on mortality. It was not possible to
exclude the possibility that the high mortality in the present study was
linked to the relatively late onset (after established refractoriness of
norepinephrine) of vasopressin; this hypothesis should be further evaluated
in a randomized study.
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Affiliation(s)
- Katiuce Tomazi Kny
- Núcleo de Avaliação e Tecnologias
em Saúde, Hospital de Clínicas de Porto Alegre, Universidade Federal
do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Maria Angélica Pires Ferreira
- Núcleo de Avaliação e Tecnologias
em Saúde, Hospital de Clínicas de Porto Alegre, Universidade Federal
do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Tatiane da Silva Dal Pizzol
- Departamento de Produção e Controle de
Medicamentos, Faculdade de Farmácia, Universidade Federal do Rio Grande do
Sul - Porto Alegre (RS), Brasil.,Corresponding Author: Tatiane da Silva Dal Pizzol,
Departamento de Produção e Controle de Medicamentos, Faculdade de
Farmácia, Universidade Federal do Rio Grande do Sul, Avenida Ipiranga,
2.752 - Azenha, Zip code: 90610-00 - Porto Alegre (RS), Brazil, E-mail:
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Galiero F, Consani G, Biancofiore G, Ruschi S, Forfori F. Metformin intoxication: Vasopressin's key role in the management of severe lactic acidosis. Am J Emerg Med 2017; 36:341.e5-341.e6. [PMID: 29089189 DOI: 10.1016/j.ajem.2017.10.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 10/24/2017] [Accepted: 10/25/2017] [Indexed: 12/29/2022] Open
Abstract
Vasopressin is a potent vasopressor used for improving organ perfusion during cardiac arrest, septic and catecholamine-resistant shock; with reference to this, it is useful for the treatment of vasoplegic shock because, restoring organ perfusion pressure by contraction of vascular smooth muscle through a non-catecholamine receptor pathway, it can be employed when catecholamines are ineffective. A 49-yr-old woman was admitted to the Emergency Department after having intentionally taken 95.2g of metformin, 1.6g of pioglitazone and 40 UI of insulin glargine in a suicide attempt. Despite fluid resuscitation, CVVHDF (continuous veno-venous hemodiafiltration) treatment, norepinephrine and epinephrine infusion, she developed a severe lactic acidosis and a catecholamines-refractive vasodilatory shock. Only the vasopressin infusion, in association with catecholamines, gradually stabilized the patient's hemodynamic status.
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Affiliation(s)
- Francesca Galiero
- Anesthesia, Intensive Care, Reanimation and Pain Medicine School of Medicine, University of Pisa, Pisa, Italy.
| | - Giovanni Consani
- Anesthesiology, Reanimation and Intensive Care Medicine, University of Pisa, Pisa, Italy
| | - Gianni Biancofiore
- Anesthesiology, Reanimation and Intensive Care Medicine, University of Pisa, Pisa, Italy.
| | - Stefano Ruschi
- Anesthesiology, Reanimation and Intensive Care Medicine, University of Pisa, Pisa, Italy.
| | - Francesco Forfori
- Anesthesia, Intensive Care, Reanimation and Pain Medicine School of Medicine, University of Pisa, Pisa, Italy.
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Abstract
RATIONALE Vasopressin may be used to treat vasodilatory hypotension in septic shock, but it is not recommended by guidelines as a first- or second-line agent. Little is known about how often the drug is used currently in septic shock. OBJECTIVES We conducted this study to describe patterns of vasopressin use in a large cohort of U.S. adults with septic shock and to identify patient and hospital characteristics associated with vasopressin use. METHODS This was a retrospective cohort study of adults admitted to U.S. hospitals with septic shock in the Premier healthcare database (July 2008 to June 2013). We performed multilevel mixed-effects logistic regression with hospitals as a random effect to identify factors associated with use of vasopressin alone or in combination with other vasopressors on at least 1 day of hospital admission. We calculated quotients of Akaike Information Criteria (AIC) to determine relative contributions of patient and hospital characteristics to observed variation. MEASUREMENTS AND MAIN RESULTS Among 584,421 patients with septic shock in 532 hospitals, 100,923 (17.2%) received vasopressin. A total of 6.1% of patients receiving vasopressin received vasopressin alone, and 93.9% received vasopressin in combination with other vasopressors (up to five vasopressors in 15 different combinations). The mean monthly rate of vasopressin use increased from 14.5 to 19.6% over the study period, representing an average annual relative increase of 8% (P < 0.001). The median hospital rate of vasopressin use for septic shock was 11.7% (range, 0-69.7%). Patient demographic and clinical characteristics, including patient age (adjusted odds ratio, 0.71 for age > 85 yr compared with the reference group of age < 50 yr; 95% confidence interval, 0.69-0.74) and acute respiratory dysfunction (adjusted odds ratio, 3.25; 95% confidence interval, 3.20-3.31), were responsible for the majority of observed variation in vasopressin use (quotient of AICs, 0.56). However, hospital of admission also contributed substantially to observed variation (quotient of AICs, 0.37). CONCLUSIONS Approximately one-fifth of patients with septic shock received vasopressin, but rarely as a single vasopressor. The use of vasopressin has increased over time. The likelihood of receiving vasopressin was strongly associated with the specific hospital to which each patient was admitted.
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