Cardiac ischemia in patients with septic shock randomized to vasopressin or norepinephrine

Catecholamine treatment induces reversible heart injury and cardiomyocyte gene expression

BACKGROUND

Catecholamines are commonly used as therapeutic drugs in intensive care medicine to maintain sufficient organ perfusion during shock. However, excessive or sustained adrenergic activation drives detrimental cardiac remodeling and may lead to heart failure. Whether catecholamine treatment in absence of heart failure causes persistent cardiac injury, is uncertain. In this experimental study, we assessed the course of cardiac remodeling and recovery during and after prolonged catecholamine treatment and investigated the molecular mechanisms involved.

RESULTS

C57BL/6N wild-type mice were assigned to 14 days catecholamine treatment with isoprenaline and phenylephrine (IsoPE), treatment with IsoPE and subsequent recovery, or healthy control groups. IsoPE improved left ventricular contractility but caused substantial cardiac fibrosis and hypertrophy. However, after discontinuation of catecholamine treatment, these alterations were largely reversible. To uncover the molecular mechanisms involved, we performed RNA sequencing from isolated cardiomyocyte nuclei. IsoPE treatment resulted in a transient upregulation of genes related to extracellular matrix formation and transforming growth factor signaling. While components of adrenergic receptor signaling were downregulated during catecholamine treatment, we observed an upregulation of endothelin-1 and its receptors in cardiomyocytes, indicating crosstalk between both signaling pathways. To follow this finding, we treated mice with endothelin-1. Compared to IsoPE, treatment with endothelin-1 induced minor but longer lasting changes in cardiomyocyte gene expression. DNA methylation-guided analysis of enhancer regions identified immediate early transcription factors such as AP-1 family members Jun and Fos as key drivers of pathological gene expression following catecholamine treatment.

CONCLUSIONS

The results from this study show that prolonged catecholamine exposure induces adverse cardiac remodeling and gene expression before the onset of left ventricular dysfunction which has implications for clinical practice. The observed changes depend on the type of stimulus and are largely reversible after discontinuation of catecholamine treatment. Crosstalk with endothelin signaling and the downstream transcription factors identified in this study provide new opportunities for more targeted therapeutic approaches that may help to separate desired from undesired effects of catecholamine treatment.

Vasopressin in Sepsis and Other Shock States: State of the Art

This review of the use of vasopressin aims to be comprehensive and highly practical, based on the available scientific evidence and our extensive clinical experience with the drug. It summarizes controversies about vasopressin use in septic shock and other vasodilatory states. Vasopressin is a natural hormone with powerful vasoconstrictive effects and is responsible for the regulation of plasma osmolality by maintaining fluid homeostasis. Septic shock is defined by the need for vasopressors to correct hypotension and lactic acidosis secondary to infection, with a high mortality rate. The Surviving Sepsis Campaign guidelines recommend vasopressin as a second-line vasopressor, added to norepinephrine. However, these guidelines do not address specific debates surrounding the use of vasopressin in real-world clinical practice.

Comparison of Hemodynamic Effects of Dobutamine and Ephedrine Infusions in Isoflurane-Anesthetized Horses

The objective of this study was to compare the hemodynamic effects of dobutamine and ephedrine during the management of anesthesia-related hypotension in healthy horses. Thirteen horses underwent general anesthesia with isoflurane and were randomly divided into two different groups, one of which received a dobutamine constant rate infusion (CRI) (1 µg/kg bwt/min) and the other received an ephedrine CRI (20 µg/kg bwt/min) when hypotension (<60 mmHg) was identified, following up to 15 min after the blood pressure reached 70 mmHg. All horses were equipped with a pulmonary artery catheter and a peripheral artery catheter, and multiparameter monitoring commenced as soon as they were under mechanical ventilation. Hemodynamic parameters were recorded, while tissue perfusion markers (peripheral oxygen saturation, arterial oxygen partial pressure, arterial carbon dioxide partial pressure, arterial pH, arterial plasma bicarbonate concentration, arterial oxygen saturation, mixed venous oxygen saturation, mixed venous oxygen content, arterial oxygen content, arteriovenous oxygen difference, oxygen delivery index, oxygen consumption index, and oxygen extraction ratio), serum lactate concentration, and troponin I concentrations were analyzed before the start of infusions (T0), when the blood pressure reached 70 mmHg (T1), and 15 min after T1 (T2). The time to restore the arterial pressure was similar in both groups (p > 0.05); however, the heart rate was higher in the ephedrine group (p = 0.0098), and sinus bradyarrhythmia occurred in the dobutamine group. Furthermore, both experimental protocols increased cardiac output (p = 0.0012), cardiac index (p = 0.0013), systemic vascular resistance (p = 0.008), systemic vascular resistance index (p < 0.001), and ameliorated perfusion markers. In the dobutamine group, the pulmonary artery wedge pressure (p < 0.001) and systolic index (p = 0.003) were elevated, while the arteriovenous oxygen difference was reduced in the ephedrine group (p = 0.02). Troponin I was used as a myocardial injury indicator, and did not differ between moments or between groups (p > 0.05). We concluded that both drugs were effective and safe to treat anesthetic hypotension under the conditions of this study.

Norepinephrine dose, lactate or heart rate: what impacts prognosis in sepsis and septic shock? Results from a prospective, monocentric registry

OBJECTIVE

The study comprehensively investigates the prognostic value of norepinephrine (NE) dose, lactate and heart rate in patients with sepsis and septic shock.

BACKGROUND

Limited data regarding the prognostic value of NE dose, lactate and heart rate in patients meeting the sepsis-3 criteria is available.

METHODS

Consecutive patients with sepsis and septic shock from 2019 to 2021 were included. The prognostic value of NE dose, lactate and heart rate was tested for 30-day all-cause mortality. Statistical analyses included univariable t-tests, Spearman's correlations, C-statistics, Kaplan-Meier analyses, as well as one-factorial repeated measures analysis of variance (ANOVA) and Cox proportional regression analyses.

RESULTS

339 patients with sepsis or septic shock were included. With an area under the curve (AUC) of up to 0.638 and 0.685, NE dose and lactate revealed moderate prognostic accuracy for 30-day all-cause mortality, whereas heart rate was not associated with prognosis. Very high NE doses (i.e. > 1.0 mcg/kg/min) (HR = 2.938; 95% CI 1.933 - 4.464; p = .001) and lactate levels (i.e. ≥ 4 mmol/l) (HR = 2.963; 95% CI 2.095 - 4.191; p = .001) on admission were associated with highest risk of death. Finally, increasing NE doses and lactate levels from day 1 to 3 indicated increased risk of death, which was consistent after multivariable adjustment.

CONCLUSION

Both very high NE doses and lactate levels - but not heart rate - were associated with increased risk of 30-d all-cause mortality in patients with sepsis and septic shock.

Cardiac Troponin I Reveals Diagnostic and Prognostic Superiority to Aminoterminal Pro-B-Type Natriuretic Peptide in Sepsis and Septic Shock

Data regarding the prognostic value of cardiac biomarkers in patients suffering from sepsis or septic shock is scarce. Studies investigating the prognostic role of cardiac biomarkers in patients with sepsis and septic shock were commonly published prior to the sepsis-3 criteria and were often not restricted to septic patients only, too. This study investigated the diagnostic and prognostic value of the aminoterminal pro-B-type Natriuretic Peptide (NT-pro BNP) and cardiac troponin I (cTNI) in patients with sepsis and septic shock. Consecutive patients with sepsis and septic shock were included from 2019 to 2021. Blood samples were retrieved from the day of disease onset (i.e., day 1), day 2 and 3. Firstly, the diagnostic value of the NT-pro BNP and cTNI to diagnose sepsis or septic shock was tested. Secondly, the prognostic value of the NT-pro BNP and cTNI was examined with regard to the 30-day all-cause mortality. The statistical analyses included univariable t-tests, Spearman’s correlations, C-statistics, Kaplan–Meier analyses and Cox proportional regression analyses. A total of 162 patients were included prospectively, of which 57% had a sepsis and 43% a septic shock. The overall rate of all-cause mortality at 30 days was 53%. With an area under the curve (AUC) of 0.658 on day 1 and 0.885 on day 3, cTNI expressed a better diagnostic value than NT-pro BNP, especially on day 3 (ΔAUCd3 = 0.404; p = 0.022). Furthermore, cTNI displayed a moderate but slightly better prognostic value than NT-pro BNP on all examined days (AUC for cTNI, d1 = 0.635; 95% CI 0.541–0.729; p = 0.007 vs. AUC for NT-pro BNP, d1 = 0.582; 95% CI 0.477–0.687; p = 0.132). In conclusion, cTNI was a reliable diagnostic parameter for the diagnosis of sepsis and septic shock, as well as a reliable prognostic tool with regard to 30-day all-cause mortality in patients suffering from sepsis and septic shock.

Demand Ischemia as a Predictor of Mortality in Older Patients With Delirium

Introduction

The impact of demand ischemia on clinical outcomes in patients with delirium remains largely unexplored. This study aims to evaluate the effects of demand ischemia in older patients with delirium on in-hospital mortality and length of stay (LOS) using the largest US inpatient care database, National Inpatient Sample (NIS).

Methods

We obtained data from the year 2010 to 2014 National Inpatient Sample (NIS). We used the International Classification of Diseases-Ninth Edition-Clinical Modification (ICD-9-CM) diagnosis codes to identify all the records with a primary or secondary diagnosis of delirium with or without demand ischemia and other clinical characteristics. We then compared in-hospital mortality and length of stay (LOS) in patients with and without demand ischemia.

Results

We analyzed 232,137 records. Patients with demand ischemia had higher overall in-hospital mortality than those without demand ischemia (28 vs. 12%, p &lt; 0.001). After adjusting for clinical comorbidities and complications, demand ischemia was no longer associated with increased in-hospital mortality (OR: 1.14; 95% CI: 0.96–1.35; p = 0.141). However, further analysis with the exclusion of critically ill patients with non-cardiogenic shock or mechanical ventilation showed a significant association of demand ischemia with increased in-hospital mortality (adjusted OR: 1.39; 95% CI: 1.13–1.71; p = 0.002). Among non-critically ill survivors, patients with demand ischemia had a longer median LOS [4, (3–7) days] than those without demand ischemia [4, (2–6) days] (p &lt; 0.001). However, the difference was not statistically significant after adjustment for covariates.

Conclusion/Relevance

Demand ischemia did not affect mortality in critically sick patients. In non-critically ill patients, however, demand ischemia was significantly associated with increased in-hospital mortality, likely due to the severity of the underlying acute illness. Measures aimed at mitigating risk factors that contribute to delirium and/or demand ischemia need to be explored.

The Levels of Lactate, Troponin, and N-Terminal Pro-B-Type Natriuretic Peptide Are Predictors of Mortality in Patients with Sepsis and Septic Shock: A Retrospective Cohort Study

Background

Serum lactate, troponin, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) have been proposed to be useful prognostic indicators in patients with sepsis and septic shock. This study aimed to evaluate the predictive ability of these biomarkers and assess how their prognostic utility may be improved by using them in combination.

Material/Methods

A retrospective review of the medical records of 1242 patients with sepsis and septic shock who were admitted to the Richmond University Medical Center between June 1, 2018, and June 1, 2019, was carried out; 427 patients met the study criteria and were included in the study. The primary outcome measures included 30-day mortality, APACHE II scores, length of hospital stay, and admission to the Medical Intensive Care Unit (MICU).

Results

High levels of lactate (>4 mmol/L), troponin (>0.45 ng/mL), and NT-proBNP (>8000 pg/mL) were independent predictors of 30-day mortality, with an adjusted odds ratio of mortality being 3.19 times, 2.13 times, and 2.5 times higher, respectively, compared with corresponding reference groups, at 95% confidence intervals. Elevated levels of lactate, troponin, and NT-proBNP were associated with 9.12 points, 7.70 points, and 8.88 points in higher APACHE II scores, respectively. Only elevated troponin levels were predictive of a longer length of hospital stay. In contrast, elevated lactate and troponin were associated with an increased chance of admission to the MICU.

Conclusions

Elevated levels of serum lactate, troponin, and NT-proBNP are independent predictors of mortality and higher APACHE II scores in patients with sepsis and septic shock.

Angiotensin II and Vasopressin for Vasodilatory Shock: A Critical Appraisal of Catecholamine-Sparing Strategies

Vasodilatory shock is a serious medical condition that increases the morbidity and mortality of perioperative and critically ill patients. Norepinephrine is an established first-line therapy for this condition, but at high doses, it may lead to diminishing returns. Oftentimes, secondary noncatecholamine agents are required in those whose hypotension persists. Angiotensin II and vasopressin are both noncatecholamine agents available for the treatment of hypotension in vasodilatory shock. They have distinct modes of action and unique pharmacologic properties when compared to norepinephrine. Angiotensin II and vasopressin have shown promise in certain subsets of the population, such as those with acute kidney injury, high Acute Physiology and Chronic Health Evaluation II scores, or those receiving cardiac surgery. Any benefit from these drugs must be weighed against the risks, as overall mortality has not been shown to decrease mortality in the general population. The aims of this narrative review are to provide insight into the historical use of noncatecholamine vasopressors and to compare and contrast their unique modes of action, physiologic rationale for administration, efficacy, and safety profiles.

Vasopressin and its analogues in shock states: a review

Activation of arginine–vasopressin is one of the hormonal responses to face vasodilation-related hypotension. Released from the post-pituitary gland, vasopressin induces vasoconstriction through the activation of V1a receptors located on vascular smooth muscle cells. Due to its non-selective receptor affinity arginine–vasopressin also activates V2 (located on renal tubular cells of collecting ducts) and V1b (located in the anterior pituitary and in the pancreas) receptors, thereby potentially promoting undesired side effects such as anti-diuresis, procoagulant properties due to release of the von Willebrand’s factor and platelet activation. Finally, it also cross-activates oxytocin receptors. During septic shock, vasopressin plasma levels were reported to be lower than expected, and a hypersensitivity to its vasopressor effect is reported in such situation. Terlipressin and selepressin are synthetic vasopressin analogues with a higher affinity for the V1 receptor, and, hence, potentially less side effects. In this narrative review, we present the current knowledge of the rationale, benefits and risks of vasopressin use in the setting of septic shock and vasoplegic shock following cardiac surgery. Clearly, vasopressin administration allows reducing norepinephrine requirements, but so far, no improvement of survival was reported and side effects are frequent, particularly ischaemic events. Finally, we will discuss the current indications for vasopressin and its agonists in the setting of septic shock, and the remaining unresolved questions.

Combination era, using combined vasopressors showed benefits in treating septic shock patients: a network meta-analysis of randomized controlled trials

Background

Septic shock is one of the major healthcare problems, affecting millions of people around the world every year. The object of this study is to find the best kind of regimen of vasopressors treatment in septic shock.

Methods

The PubMed, and the Web of Science were used to find the included studies. Stata 15.1 was performed to this systemic review and network meta-analysis.

Results

After searching and screening the articles, finally we included articles about 31 randomized controlled trials (RCTs), 11 arms (dopamine, dopexamine, epinephrine, norepinephrine, norepinephrine + dobutamine, norepinephrine + dopexamine, norepinephrine + epinephrine, norepinephrine + vasopressin, phenylephrine, terlipressin, vasopressin) and total 5,928 patients with septic shock. Compared with dopamine, the regimens (epinephrine, norepinephrine, norepinephrine + dobutamine, and vasopressin) have significantly lower 28-day mortality. Ranking the regimens in the order of estimated probabilities of each treatment by using the network meta-analysis for 28-day mortality, the result showed that norepinephrine + dopexamine was the best one (57.3%), followed by norepinephrine + epinephrine (14.8%), norepinephrine + dobutamine (10.9%), dopexamine (11.2%), terlipressin (9.8%), norepinephrine + vasopressin (2.4%), phenylephrine (1.2%), epinephrine (1.0%), vasopressin (0.5%), norepinephrine (0.0%), and dopamine (0.0%). In addition, for the results of arrhythmia and increased heart rate, the combination regimens groups did not showed inferiority to other single regimen groups.

Conclusions

Single dopamine had significantly higher 28d mortality. Combination regimens of vasopressors accounted for the best three therapeutic regimens. In treating patients with septic shock, using combining regimens probably gets more benefits.

Myocardial Injury in Patients With Sepsis and Its Association With Long-Term Outcome

BACKGROUND

Sepsis is frequently complicated by the release of cardiac troponin, but the clinical significance of this myocardial injury remains unclear. We studied the associations between troponin release during sepsis and 1-year outcomes.

METHODS AND RESULTS

We enrolled consecutive patients with sepsis in 2 Dutch intensive care units between 2011 and 2013. Subjects with a clinically apparent cause of troponin release were excluded. High-sensitivity cardiac troponin I (hs-cTnI) concentration in plasma was measured daily during the first 4 intensive care unit days, and multivariable Cox regression analysis was used to model its association with 1-year mortality while adjusting for confounding. In addition, we studied cardiovascular morbidity occurring during the first year after hospital discharge. Among 1258 patients presenting with sepsis, 1124 (89%) were eligible for study inclusion. Hs-cTnI concentrations were elevated in 673 (60%) subjects on day 1, and 755 (67%) ever had elevated levels in the first 4 days. Cox regression analysis revealed that high hs-cTnI concentrations were associated with increased death rates during the first 14 days (adjusted hazard ratio, 1.72; 95% confidence interval, 1.14-2.59 and hazard ratio, 1.70; 95% confidence interval, 1.10-2.62 for hs-cTnI concentrations of 100-500 and >500 ng/L, respectively) but not thereafter. Furthermore, elevated hs-cTnI levels were associated with the development of cardiovascular disease among 200 hospital survivors who were analyzed for this end point (adjusted subdistribution hazard ratio, 1.25; 95% confidence interval, 1.04-1.50).

CONCLUSIONS

Myocardial injury occurs in the majority of patients with sepsis and is independently associated with early-but not late-mortality, as well as postdischarge cardiovascular morbidity.

Sepsis-induced myocardial dysfunction

PURPOSE OF REVIEW

Sepsis leads to a complex intramyocardial inflammatory response that results in sepsis-induced myocardial dysfunction. Here, recent findings are reviewed in a physiologic context.

RECENT FINDINGS

Decreased systolic contractility during sepsis limits ventricular ejection and stroke volume. Initially, this effect is compensated for by increased diastolic filling during volume resuscitation. Reduced afterload due to arterial vasodilation also compensates so that cardiac output can be maintained or increased. Recent results recognize the importance of diastolic dysfunction, reduced ventricular diastolic compliance that impedes ventricular filling. Diastolic dysfunction becomes increasingly important as severity of septic shock increases. When impaired ventricular ejection is coupled with limited diastolic filling, stroke volume must decrease. Accordingly, diastolic dysfunction is more closely related to mortality than systolic dysfunction. Recent trials of beta-adrenergic agonists and levosimendan have been disappointing, while approaches to modulating the intramyocardial inflammatory response show promise.

SUMMARY

Sepsis-induced myocardial dysfunction is increasingly recognized as a major contributor to outcome of septic shock. Significant strides have been made in understanding the intramyocardial inflammatory response that causes myocardial dysfunction. A number of novel approaches show promise by modulating the intramyocardial inflammatory response.

Comparative efficacy of vasoactive medications in patients with septic shock: a network meta-analysis of randomized controlled trials

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.

New-Onset Heart Failure and Mortality in Hospital Survivors of Sepsis-Related Left Ventricular Dysfunction

BACKGROUND

The association between new-onset left ventricular (LV) dysfunction during sepsis with long-term heart failure outcomes is lesser understood.

METHODS

Retrospective cohort study of all adult patients with severe sepsis and septic shock between 2007 and 2014 who underwent echocardiography within 72 h of admission to the intensive care unit. Patients with prior heart failure, LV dysfunction, and structural heart disease were excluded. LV systolic dysfunction was defined as LV ejection fraction <50% and LV diastolic dysfunction as ≥grade II. Primary composite outcome included new hospitalization for acute decompensated heart failure and all-cause mortality at 2-year follow-up. Secondary outcomes included persistent LV dysfunction, and hospital mortality and length of stay.

RESULTS

During this 8-year period, 434 patients with 206 (48%) patients having LV dysfunction were included. The two groups had similar baseline characteristics, but those with LV dysfunction had worse function as demonstrated by worse LV ejection fraction, cardiac index, and LV diastolic dysfunction. In the 331 hospital survivors, new-onset acute decompensated heart failure hospitalization did not differ between the two cohorts (15% vs. 11%). The primary composite outcome was comparable at 2-year follow-up between the groups with and without LV dysfunction (P = 0.24). Persistent LV dysfunction was noted in 28% hospital survivors on follow-up echocardiography. Other secondary outcomes were similar between the two groups.

CONCLUSIONS

In patients with severe sepsis and septic shock, the presence of new-onset LV dysfunction did not increase the risk of long-term adverse heart failure outcomes.

Effect of Troponin I Elevation on Duration of Mechanical Ventilation and Length of Intensive Care Unit Stay in Patients With Sepsis

Background

Sepsis is a leading cause of mortality and morbidity. Recent studies suggest that troponin elevation is associated with increased mortality in sepsis patients. The purpose of this study is to determine the effect of troponin elevation on mechanical ventilation duration and intensive care unit (ICU) length of stay in patients with sepsis. Additionally, we investigated the association between troponin elevation and septic shock.

Methods

The study is a retrospective observational cohort study, conducted in a community teaching hospital between October 2015 and April 2018. All adult ICU patients with sepsis who required invasive mechanical ventilation were included. Primary outcomes were mechanical ventilation duration and ICU length of stay. Secondary outcomes were hospital length of stay, in-hospital mortality and association with septic shock.

Results

A total of 125 patients were included. Troponin was elevated in 36% (45/125) of the patients. Duration of mechanical ventilation in hours was longer for troponin-positive group (troponin positive: 55.6 h vs. troponin negative: 49.6 h, 95% CI 0.001 - 0.063, P = 0.032). ICU length of stay was similar (troponin positive: 4.6 days vs. troponin negative: 4.3 days, 95% CI 0.130 - 0.270). Septic shock had higher occurrence in elevated troponin group (troponin positive: 62.2% (28/45) vs. troponin negative: 43.8% (35/80), risk ratio (RR) 1.4, P = 0.04, 95% CI 1.015 - 1.99).

Conclusions

Troponin elevation was associated with longer duration of mechanical ventilation in patients admitted to ICU with sepsis. Troponin elevation was associated with higher risk for development of septic shock. No significant effect was observed in ICU length of stay and hospital length of stay.

Pathophysiology of Septic Shock

Fundamental features of septic shock are vasodilation, increased permeability, hypovolemia, and ventricular dysfunction. Vasodilation owing to increased nitric oxide and prostaglandins is treated with vasopressors (norepinephrine first). Increased permeability relates to several pathways (Slit/Robo4, vascular endothelial growth factor, angiopoietin 1 and 2/Tie2 pathway, sphingosine-1-phosphate, and heparin-binding protein), some of which are targets for therapies. Hypovolemia is common and crystalloid is recommended for fluid resuscitation. Cardiomyocyte-inflammatory interactions decrease contractility and dobutamine is recommended to increase cardiac output. There is benefit in decreasing heart rate in selected patients with esmolol. Ivabradine is a novel agent for heart rate reduction without decreasing contractility.

Use of vasopressin in the treatment of refractory septic shock

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.

Anesthesia for Patients with Concomitant Sepsis and Cardiac Dysfunction

Anesthesiologists faced with a patient with sepsis and concurrent cardiac dysfunction must be cognizant of the patient's cardiac status and cause of the cardiac problem to appropriately adapt physiologic and metabolic monitoring and anesthetic management. Anesthesia in such patients is challenging because the interaction of sepsis and cardiac dysfunction greatly complicates management. Intraoperative anesthesia management requires careful induction and maintenance of anesthesia; optimizing intravascular volume status; avoiding lung injury during mechanical ventilation; and close monitoring of arterial blood gases, serum lactate concentrations, and hematology renal and electrolyte parameters. Such patients have increased mortality because of their inability to adequately compensate for the cardiovascular changes caused by sepsis.

Adverse Drug Reactions in the Intensive Care Unit

Adverse drug reactions (ADRs) are undesirable effects of medications used in normal doses [1]. ADRs can occur during treatment in an intensive care unit (ICU) or result in ICU admissions. A meta-analysis of 4139 studies suggests the incidence of ADRs among hospitalized patients is 17% [2]. Because of underreporting and misdiagnosis, the incidence of ADRs may be much higher and has been reported to be as high as 36% [3]. Critically ill patients are at especially high risk because of medical complexity, numerous high-alert medications, complex and often challenging drug dosing and medication regimens, and opportunity for error related to the distractions of the ICU environment [4]. Table 1 summarizes the ADRs included in this chapter.

A review of sepsis-induced cardiomyopathy

Sepsis-induced cardiomyopathy is a reversible myocardial dysfunction that typically resolves in 7–10 days. It is characterized by left ventricular dilatation and depressed ejection fraction. However, many uncertainties exist regarding the mechanisms, characteristics, and treatments of this condition. Therefore, this review attempts to summarize our current knowledge of sepsis-induced cardiomyopathy.

Raised cardiac troponin in intensive care patients with sepsis, in the absence of angiographically documented coronary artery disease: A systematic review

Elevated cardiac troponin in the critically ill has been associated with increased hospital mortality. However, in critically ill patients with sepsis the results are heterogeneous and less easy to interpret. The objectives of this systematic review were to describe the pathophysiology, clinical relevance and prognostic significance of raised troponin in intensive care patients with sepsis. Articles were identified through a detailed MEDLINE search and additional references were retrieved from the selected studies. A growing body of clinical evidence suggests that although troponins are sensitive biomarkers with prognostic value, they are not independent predictors of mortality. However, vigilance for objective evidence of coronary artery disease is required and patients with atherosclerotic risk factors and elevated troponins may benefit from cardiac imaging. In patients with low pre-test probability for coronary artery disease and elevated troponins, therapy should target management of sepsis and optimisation of myocardial oxygen demand/supply balance.

Protocol for a randomised controlled trial of VAsopressin versus Noradrenaline as Initial therapy in Septic sHock (VANISH)

INTRODUCTION

Vasopressin is an alternative vasopressor in the management of septic shock. It spares catecholamine use but whether it improves outcome remains uncertain. Current evidence suggests that it may be most effective if used early and possibly in conjunction with corticosteroids. This trial will compare vasopressin to noradrenaline as initial vasopressor in the management of adult septic shock and investigate whether there is an interaction of vasopressin with corticosteroids.

METHODS AND ANALYSIS

This is a multicentre, factorial (2×2), randomised, double-blind, placebo-controlled trial. 412 patients will be recruited from multiple UK intensive care units and randomised to receive vasopressin (0-0.06 U/min) or noradrenaline (0-12 µg/min) as a continuous intravenous infusion as initial vasopressor therapy. If maximum infusion rates of this first study drug are reached, the patient will be treated with either hydrocortisone (initially 50 mg intravenous bolus six-hourly) or placebo, before additional open-label catecholamine vasopressors are prescribed. The primary outcome of the trial will be the difference in renal failure-free days between treatment groups. Secondary outcomes include need for renal replacement therapy, survival rates, other organ failures and resource utilisation.

ETHICS AND DISSEMINATION

The trial protocol and information sheets have received a favourable opinion from the Oxford A Research Ethics Committee (12/SC/0014). There is an independent Data Monitoring and Ethics Committee and independent membership of the Trial Steering Committee including patient and public involvement. The trial results will be published in peer-reviewed journals and presented at national and international scientific meetings.

TRIAL REGISTRATION NUMBER

ISRCTN 20769191 and EudraCT 2011-005363-24.

Cardiac arrest: should we consider norepinephrine instead of epinephrine?

A patient scheduled for a laparoscopic cholecystectomy had an anaphylactic shock during induction of anesthesia. After the injection of vecuronium, an unusual fall of arterial pressure occurred, with bradycardia, enlargement of the QRS complex, then a circulatory arrest. Chest compressions were initiated, while intravenous epinephrine 1 mg was administered. The cardiac rhythm turned into a ventricular fibrillation (VF). Despite continuous chest compressions with repeated boluses of epinephrine and several external electric shocks, the patient remained in VF. Because of obviously β-adrenergic adverse effects, epinephrine was replaced with norepinephrine. Return of spontaneous circulation was observed, with the recovering of sinusal activity. After staying for several weeks in intensive care unit because of multiorgan failure, the patient recovered without sequelae. Blood samples and cutaneous testing confirmed an allergy to vecuronium. This case report of a cardiac anaphylaxis with prolonged cardiac arrest illustrates the dual activity and adverse effects of epinephrine. Although vasoconstriction is mandated during cardiopulmonary resuscitation to provide an acceptable perfusion pressure to organs, β-adrenergic stimulation seems deleterious to the heart. Experimental studies have shown that blocking the β-adrenergic effects of epinephrine attenuates postresuscitation myocardial dysfunction or helps the return of spontaneous circulation after VF. Norepinephrine, a potent α-adrenergic drug nearly devoid of β-adrenergic properties, could be an interesting alternative to epinephrine. It can improve organ perfusion during cardiopulmonary resuscitation and could be more efficient than epinephrine in case of VF.

Early vasopressin reduces incidence of new onset arrhythmias

PURPOSE

The objective of this study was to determine the effect of early vs late vasopressin therapy on catecholamine dose and duration.

MATERIALS AND METHODS

We conducted a single-center, retrospective chart review of adult patients admitted to the medical intensive care unit between January 2010 and December 2011 with septic shock requiring catecholamine and vasopressin therapy. Patients were included in the early group if vasopressin was initiated within 6 hours and the late group if vasopressin was initiated between 6 and 48 hours of catecholamine(s).

RESULTS

Duration of catecholamine and vasopressin therapy was similar between the 35 patients in the early group and the 36 in the late group. Vasopressin therapy was associated with a decrease in catecholamine requirements in both groups. Early vasopressin was associated with fewer new onset arrhythmias (37.1% vs 62.9%, P<.001). There was no difference in mortality, hospital, or intensive care unit length of stay between the early and late group vasopressin groups (88.6% vs 88.9%, P=1; 14 vs 10 days, P=.48; 9 vs 7 days, P=.71, respectively).

CONCLUSIONS

Early initiation of vasopressin therapy in adult critically ill patients with septic shock was associated with no difference in total catecholamine requirements but decreased incidence of new onset arrhythmias.

Myocardial dysfunction in pediatric septic shock

OBJECTIVE

To evaluate the prevalence and significance of myocardial dysfunction in children with septic shock.

STUDY DESIGN

Thirty patients with septic shock were evaluated by transthoracic echocardiography within 24 hours of admission to a pediatric critical care unit. Transthoracic echocardiography evaluation included left ventricular (LV) size and function, mitral valve inflow velocities in early and late diastole, mitral valve annular velocities in systole and early and late diastole, and LV myocardial performance index. LV systolic dysfunction was defined as an ejection fraction or shortening fraction z-score <-2, and LV diastolic dysfunction was defined as a mitral valve inflow velocity/annular velocity in early diastole ratio z-score >2. Secondary outcomes included troponin I concentration, acute kidney injury, and 28-day mechanical ventilation-free duration.

RESULTS

Mortality for the 30 patients (mean age, 9.5 ± 7 years) was 7%. The prevalence of LV systolic and/or diastolic dysfunction was 53% (16 of 30). Eleven patients (37%) had systolic dysfunction, 10 (33%) had diastolic dysfunction, and 5 (17%) had both. Systolic and/or diastolic dysfunction was significantly associated with troponin I level (P = .007) and acute kidney injury (P = .02), but not with ventilation-free duration (P = .12). Kaplan-Meier analyses for pediatric critical care unit and hospital length of stay identified no differences between patients with and those without myocardial dysfunction.

CONCLUSION

Myocardial dysfunction occurs frequently in children with septic shock but might not affect hospital length of stay.

On sepsis, troponin and vasopressin: the bitter truth

One of the rationales for the use of vasopressin in septic shock has been its potential cardioprotective mechanisms. Lower heart rates, higher arterial pressures, and fewer norepinephrine doses during vasopressin therapy were hypothesized to protect the heart from myocardial ischemia. In a prospective sub-study of the VASST (Vasopressin in Septic Shock Trial) project, Mehta and colleagues specifically evaluated this hypothesis but failed to find lower cardiac biomarkers or fewer ischemic electrocardiogram changes in patients receiving vasopressin compared with subjects receiving norepinephrine alone. After recent evidence of a lacking survival benefit, the present study results further challenge the future role of vasopressin as a vasopressor in septic shock.