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Blankenship CR, Betthauser KD, Hencken LN, Maamari JA, Goetz J, Giacomino BD, Gibson GA. Clinical Response to Third-Line Angiotensin-II vs Epinephrine in Septic Shock: A Propensity-Matched Cohort Study. Ann Pharmacother 2024; 58:1003-1012. [PMID: 38303571 DOI: 10.1177/10600280231226132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND The appropriate third-line vasopressor in septic shock patients receiving norepinephrine and vasopressin is unknown. Angiotensin-II (AT-II) offers a unique mechanism of action to traditionally used vasopressors in septic shock. OBJECTIVE The objective of this study was to compare the clinical efficacy and safety of third-line AT-II to epinephrine in patients with septic shock. METHODS A single-center, retrospective cohort study of critically ill patients was performed between April 1, 2019 and July 31, 2022. Propensity-matched (2:1) analysis compared adults with septic shock who received third-line AT-II to controls who received epinephrine following norepinephrine and vasopressin. The primary outcome was clinical response 24 hours after third-line vasopressor initiation. Additional efficacy and safety outcomes were investigated. RESULTS Twenty-three AT-II patients were compared with 46 epinephrine patients. 47.8% of AT-II patients observed a clinical response at hour 24 compared with 28.3% of epinephrine patients (P = 0.12). In-hospital mortality (65.2% vs 73.9%, P = 0.45), cardiac arrhythmias (26.1% vs 26.1%, P = 0.21), and thromboembolism (4.3% vs 2.2%, P = 0.61) were not observed to be statistically different between groups. CONCLUSIONS AND RELEVANCE Administration of AT-II as a third-line vasopressor agent in septic shock patients was not associated with significantly improved clinical response at hour 24 compared with epinephrine. Although underpowered to detect meaningful differences, the clinical observations of this study warrant consideration and further investigation of AT-II as a third-line vasopressor in septic shock.
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Affiliation(s)
| | - Kevin D Betthauser
- Department of Pharmacy Practice, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Laura N Hencken
- Department of Pharmacy Practice, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Julie A Maamari
- Department of Pharmacy Practice, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Jenna Goetz
- Department of Pharmacy Practice, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Bria D Giacomino
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Gabrielle A Gibson
- Department of Pharmacy Practice, Barnes-Jewish Hospital, St. Louis, MO, USA
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Picod A, Garcia B, Van Lier D, Pickkers P, Herpain A, Mebazaa A, Azibani F. Impaired angiotensin II signaling in septic shock. Ann Intensive Care 2024; 14:89. [PMID: 38877367 PMCID: PMC11178728 DOI: 10.1186/s13613-024-01325-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 05/29/2024] [Indexed: 06/16/2024] Open
Abstract
Recent years have seen a resurgence of interest for the renin-angiotensin-aldosterone system in critically ill patients. Emerging data suggest that this vital homeostatic system, which plays a crucial role in maintaining systemic and renal hemodynamics during stressful conditions, is altered in septic shock, ultimately leading to impaired angiotensin II-angiotensin II type 1 receptor signaling. Indeed, available evidence from both experimental models and human studies indicates that alterations in the renin-angiotensin-aldosterone system during septic shock can occur at three distinct levels: 1. Impaired generation of angiotensin II, possibly attributable to defects in angiotensin-converting enzyme activity; 2. Enhanced degradation of angiotensin II by peptidases; and/or 3. Unavailability of angiotensin II type 1 receptor due to internalization or reduced synthesis. These alterations can occur either independently or in combination, ultimately leading to an uncoupling between the renin-angiotensin-aldosterone system input and downstream angiotensin II type 1 receptor signaling. It remains unclear whether exogenous angiotensin II infusion can adequately address all these mechanisms, and additional interventions may be required. These observations open a new avenue of research and offer the potential for novel therapeutic strategies to improve patient prognosis. In the near future, a deeper understanding of renin-angiotensin-aldosterone system alterations in septic shock should help to decipher patients' phenotypes and to implement targeted interventions.
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Affiliation(s)
- Adrien Picod
- INSERM, UMR-S 942 MASCOT-Université Paris-Cité, Paris, France.
| | - Bruno Garcia
- Department of Intensive Care Medicine, Centre Hospitalier Universitaire de Lille, Lille, France
- Experimental Laboratory of Intensive Care, Université Libre de Bruxelles, Brussels, Belgium
| | - Dirk Van Lier
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Antoine Herpain
- Experimental Laboratory of Intensive Care, Université Libre de Bruxelles, Brussels, Belgium
- Department of Intensive Care Medicine, St. Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Mebazaa
- INSERM, UMR-S 942 MASCOT-Université Paris-Cité, Paris, France
- Department of Anesthesiology, Burns and Critical Care, Hopitaux Saint-Louis-Lariboisière, AP-HP, Paris, France
| | - Feriel Azibani
- INSERM, UMR-S 942 MASCOT-Université Paris-Cité, Paris, France
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Ragoonanan D, Nickelsen P, Tran N, Allen B, Emborski R, Legare A, Villela A, Hampson L, Busey K, Shomo E, Broomfield A, Hailu K. Vasopressin Initiation as a Second-Line Vaso Pressor in Early Septic Shock (VISPSS). J Intensive Care Med 2024; 39:306-312. [PMID: 37715634 DOI: 10.1177/08850666231201364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
BACKGROUND Vasopressin is recommended as a second-line vasoactive agent for the management of septic shock; however, a paucity of data to guide its optimal use remains. The aim was to evaluate the effect of time-to vasopressin initiation and norepinephrine (NE) dose at vasopressin initiation on clinical outcomes in patients presenting with septic shock. METHODS This was a multi-centered, retrospective, observational study conducted in patients with septic shock. Patients were divided into 2 groups: patients initiated on vasopressin when NE-equivalent dose (NEE) < 0.25 mcg/kg/min or ≥ 0.25 mcg/kg/min. The primary outcome was time-to-vasopressor discontinuation (hours). Secondary outcomes included 28-day in-hospital mortality, intensive care unit (ICU) length of stay (LOS), fluid balance after 72 hours, and the change in NEE at 12 hours. RESULTS A total of 302 patients were included in this study. After propensity-score matching, 73 patients in each group were identified for analysis. There was no significant difference in the time-to-vasopressor discontinuation (hours) between the groups (88.8 [55-187.5] vs 86.7 [47-172]); p = 0.7815). Fluid balance (mL) at 72 hours was significantly lower when vasopressin was initiated at NEE < 0.25 mcg/kg/min (1769 [71-7287] vs 5762 [1463-8813]; p = 0.0077). A multivariable linear regression showed shorter time to shock resolution with earlier vasopressin initiation, defined as within 4 hours (p < 0.05). CONCLUSION In this propensity-score matched cohort, vasopressin initiation at NEE < 0.25 mcg/kg/min was not associated with shorter vasopressor duration. There was a lower fluid balance at 72 hours when vasopressin was initiated at lower NE doses.
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Affiliation(s)
- David Ragoonanan
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Paige Nickelsen
- Department of Pharmacy Services, University of California San Diego, San Diego, CA, USA
| | - Nicolas Tran
- Department of Pharmacy Services, Tampa General Hospital, Tampa, FL, USA
| | - Bryan Allen
- Department of Pharmacy Services, Ascension St. Vincent's, Jacksonville, FL, USA
| | - Rebecca Emborski
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Anit Legare
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Antonia Villela
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Lauryn Hampson
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Kirsten Busey
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Eileen Shomo
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Abby Broomfield
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Kirubel Hailu
- Department of Pharmacy Services, Ascension St. Vincent's, Jacksonville, FL, USA
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Coloretti I, Genovese A, Teixeira JP, Cherian A, Ferrer R, Landoni G, Leone M, Girardis M, Nielsen ND. Angiotensin ii therapy in refractory septic shock: which patient can benefit most? A narrative review. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:13. [PMID: 38383521 PMCID: PMC10882873 DOI: 10.1186/s44158-024-00150-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 02/12/2024] [Indexed: 02/23/2024]
Abstract
Patients with septic shock who experience refractory hypotension despite adequate fluid resuscitation and high-dose noradrenaline have high mortality rates. To improve outcomes, evidence-based guidelines recommend starting a second vasopressor, such as vasopressin, if noradrenaline doses exceed 0.5 µg/kg/min. Recently, promising results have been observed in treating refractory hypotension with angiotensin II, which has been shown to increase mean arterial pressure and has been associated with improved outcomes. This narrative review aims to provide an overview of the pathophysiology of the renin-angiotensin system and the role of endogenous angiotensin II in vasodilatory shock with a focus on how angiotensin II treatment impacts clinical outcomes and on identifying the population that may benefit most from its use.
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Affiliation(s)
- Irene Coloretti
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Via del Pozzo, Modena, 71. 41124, Italy.
| | - Andrea Genovese
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Via del Pozzo, Modena, 71. 41124, Italy
| | - J Pedro Teixeira
- Divisions of Nephrology and Pulmonary, Critical Care, and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Anusha Cherian
- Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantri Nagar, Pondicherry, India
| | - Ricard Ferrer
- Intensive Care Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Giovanni Landoni
- Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marc Leone
- Anesthesia and Intensive Care Medicine, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Massimo Girardis
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Via del Pozzo, Modena, 71. 41124, Italy
| | - Nathan D Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine & Section of Transfusion Medicine and Therapeutic Pathology, University of New Mexico School of Medicine, Albuquerque, NM, USA
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Bauer SR, Gellatly RM, Erstad BL. Precision fluid and vasoactive drug therapy for critically ill patients. Pharmacotherapy 2023; 43:1182-1193. [PMID: 36606689 PMCID: PMC10323046 DOI: 10.1002/phar.2763] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/03/2022] [Accepted: 10/30/2022] [Indexed: 01/07/2023]
Abstract
There are several clinical practice guidelines concerning the use of fluid and vasoactive drug therapies in critically ill adult patients, but the recommendations in these guidelines are often based on low-quality evidence. Further, some were compiled prior to the publication of landmark clinical trials, particularly in the comparison of balanced crystalloid and normal saline. An important consideration in the treatment of critically ill patients is the application of precision medicine to provide the most effective care to groups of patients most likely to benefit from the therapy. Although not currently widely integrated into these practice guidelines, the utility of precision medicine in critical illness is a recognized research priority for fluid and vasoactive therapy management. The purpose of this narrative review was to illustrate the evaluation and challenges of providing precision fluid and vasoactive therapies to adult critically ill patients. The review includes a discussion of important investigations published after the release of currently available clinical practice guidelines to provide insight into how recommendations and research priorities may change future guidelines and bedside care for critically ill patients.
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Affiliation(s)
- Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rochelle M Gellatly
- Pharmacy Department, Surrey Memorial Hospital, Surrey, British Columbia, Canada
| | - Brian L Erstad
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, Arizona, USA
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6
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García-Álvarez R, Arboleda-Salazar R. Vasopressin in Sepsis and Other Shock States: State of the Art. J Pers Med 2023; 13:1548. [PMID: 38003863 PMCID: PMC10672256 DOI: 10.3390/jpm13111548] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/19/2023] [Accepted: 10/27/2023] [Indexed: 11/26/2023] Open
Abstract
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.
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Affiliation(s)
- Raquel García-Álvarez
- Department of Anesthesiology and Surgical Intensive Care, University Hospital 12 de Octubre, 28022 Madrid, Spain
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7
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Tong X, Xue X, Duan C, Liu A. Early administration of multiple vasopressors is associated with better survival in patients with sepsis: a propensity score-weighted study. Eur J Med Res 2023; 28:249. [PMID: 37481578 PMCID: PMC10362716 DOI: 10.1186/s40001-023-01229-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/14/2023] [Indexed: 07/24/2023] Open
Abstract
BACKGROUND The association between the timing of administration of multiple vasopressors and patient outcomes has not been investigated. METHODS This study used data from the MIMIC-IV database. Patients with sepsis who were administered two or more vasopressors were included. The principal exposure was the last norepinephrine dose when adding a second vasopressor. The cohort was divided into early (last norepinephrine dose < 0.25 μg/kg/min) and normal (last norepinephrine dose ≥ 0.25 μg/kg/min) groups. The primary outcome was 28-day mortality. Multivariable Cox analyses, propensity score matching, stabilized inverse probability of treatment weighting (sIPTW), and restricted cubic spline (RCS) curves were used. RESULTS Overall, 1,437 patients who received multiple vasopressors were included. Patients in the early group had lower 28-day mortality (HR: 0.76; 95% CI: 0.65-0.89; p < 0.001) than those in the single group, with similar results in the propensity score-matched (HR: 0.80; 95% CI: 0.68-0.94; p = 0.006) and sIPTW (HR: 0.75; 95% CI: 0.63-0.88; p < 0.001) cohorts. RCS curves showed that the risk of 28-day mortality increased as the last norepinephrine dose increased. CONCLUSIONS The timing of secondary vasopressor administration is strongly associated with the outcomes of patients with sepsis.
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Affiliation(s)
- Xin Tong
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Xiaopeng Xue
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Chuanzhi Duan
- Department of Cerebrovascular Surgery, Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Zhujiang Hospital, Neurosurgery Center, Southern Medical University, Guangdong, China
- Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Guangdong, China
| | - Aihua Liu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.
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Carlos Sanchez E, Pinsky MR, Sinha S, Mishra RC, Lopa AJ, Chatterjee R. Fluids and Early Vasopressors in the Management of Septic Shock: Do We Have the Right Answers Yet? J Crit Care Med (Targu Mures) 2023; 9:138-147. [PMID: 37588181 PMCID: PMC10425929 DOI: 10.2478/jccm-2023-0022] [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: 06/12/2023] [Accepted: 07/22/2023] [Indexed: 08/18/2023] Open
Abstract
Septic shock is a common condition associated with hypotension and organ dysfunction. It is associated with high mortality rates of up to 60% despite the best recommended resuscitation strategies in international guidelines. Patients with septic shock generally have a Mean Arterial Pressure below 65 mmHg and hypotension is the most important determinant of mortality among this group of patients. The extent and duration of hypotension are important. The two initial options that we have are 1) administration of intravenous (IV) fluids and 2) vasopressors, The current recommendation of the Surviving Sepsis Campaign guidelines to administer 30 ml/kg fluid cannot be applied to all patients. Complications of fluid over-resuscitation further delay organ recovery, prolong ICU and hospital length of stay, and increase mortality. The only reason for administering intravenous fluids in a patient with circulatory shock is to increase the mean systemic filling pressure in a patient who is volume-responsive, such that cardiac output also increases. The use of vasopressors seems to be a more appropriate strategy, the very early administration of vasopressors, preferably during the first hour after diagnosis of septic shock, may have a multimodal action and potential advantages, leading to lower morbidity and mortality in the management of septic patients. Vasopressor therapy should be initiated as soon as possible in patients with septic shock.
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Affiliation(s)
- E. Carlos Sanchez
- Department of Critical Care Medicine, King Salman Hospital, Riyadh, Saudi Arabia
| | - Michael R. Pinsky
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sharmili Sinha
- Department of Critical Care Medicine, Apollo Hospitals, Bhubaneswar, India
| | - Rajesh Chandra Mishra
- Department of Critical Care Medicine, Ahmedabad Khyati Multi-speciality Hospitals, Ahmedabad, India Department of Critical Care Medicine, Ahmedabad Shaibya Comprehensive Care Clinic, Ahmedabad, India
| | - Ahsina Jahan Lopa
- ICU and Emergency Department, Shahabuddin Medical College Hospital, Dhaka, Bangladesh
| | - Ranajit Chatterjee
- Department of Critical Care Medicine, accident and emergency, Swami Dayanand Hospital Delhi, India
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Ning YL, Sun C, Xu XH, Li L, Ke YJ, Mai Y, Lin XF, Yang ZQ, Xian SX, Chen WT. Tendency of dynamic vasoactive and inotropic medications data as a robust predictor of mortality in patients with septic shock: An analysis of the MIMIC-IV database. Front Cardiovasc Med 2023; 10:1126888. [PMID: 37082452 PMCID: PMC10112491 DOI: 10.3389/fcvm.2023.1126888] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 02/13/2023] [Indexed: 03/09/2023] Open
Abstract
BackgroundSeptic shock patients fundamentally require delicate vasoactive and inotropic agent administration, which could be quantitatively and objectively evaluated by the vasoactive–inotropic score (VIS); however, whether the dynamic trends of high-time-resolution VIS alter the clinical outcomes remains unclear. Thus, this study proposes the term VIS Reduction Rate (VRR) to generalise the tendency of dynamic VIS, to explore the association of VRR and mortality for patients with septic shock.MethodsWe applied dynamic and static VIS data to predict ICU mortality by two models: the long short-term memory (LSTM) deep learning model, and the extreme gradient boosting (XGBoost), respectively. The specific target cohort was extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database by the sophisticated structured query language (SQL). Enrolled patients were divided into four groups by VRR value: ≥50%, 0 ~ 50%, −50% ~ 0, and < −50%. Statistical approaches included pairwise propensity score matching (PSM), Cox proportional hazards regression, and two doubly robust estimation models to ensure the robustness of the results. The primary and secondary outcomes were ICU mortality and in-hospital mortality, respectively.ResultsVRR simplifies the dosing trends of vasoactive and inotropic agents represented by dynamic VIS data while requiring fewer data. In total, 8,887 septic shock patients were included. Compared with the VRR ≥50% group, the 0 ~ 50%, −50% ~ 0, and < −50% groups had significantly higher ICU mortality [hazard ratio (HR) 1.32, 95% confidence interval (CI) 1.17–1.50, p < 0.001; HR 1.79, 95% CI 1.44–2.22, p < 0.001; HR 2.07, 95% CI 1.61–2.66, p < 0.001, respectively] and in-hospital mortality [HR 1.43, 95% CI 1.28–1.60, p < 0.001; HR 1.75, 95% CI 1.45–2.11, p < 0.001; HR 2.00, 95% CI 1.61–2.49, p < 0.001, respectively]. Similar findings were observed in two doubly robust estimation models.ConclusionThe trends of dynamic VIS in ICU might help intensivists to stratify the prognosis of adult patients with septic shock. A lower decline of VIS was remarkably associated with higher ICU and in-hospital mortality among septic shock patients receiving vasoactive–inotropic therapy for more than 24 h.
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Affiliation(s)
- Yi-Le Ning
- Department of Pulmonary and Critical Care Medicine (PCCM), Bao’an District Hospital of Chinese Medicine, Shenzhen, China
- The First Clinical School, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ce Sun
- Department of Critical Care Medicine, Meizhou Hospital of Chinese Medicine, Meizhou, China
| | - Xiang-Hui Xu
- The First Clinical School, Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Critical Care Medicine, Bao’an District Hospital of Chinese Medicine, Shenzhen, China
| | - Li Li
- Department of Pulmonary and Critical Care Medicine (PCCM), The First People’s Hospital of Kashgar Prefecture, Kashgar, China
| | - Yan-Ji Ke
- Department of Critical Care Medicine, The Fourth People’s Hospital of Foshan, Foshan, China
| | - Ye Mai
- Department of Critical Care Medicine, Chinese Medicine Hospital of Hainan Province, Haikou, China
| | - Xin-Feng Lin
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- *Correspondence: Xin-Feng Lin,
| | - Zhong-Qi Yang
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Zhong-Qi Yang,
| | - Shao-Xiang Xian
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Shao-Xiang Xian,
| | - Wei-Tao Chen
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Wei-Tao Chen,
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10
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Semedi BP, Rehatta NM, Soetjipto S, Nugraha J, Mahyuddin MH, Arnindita JN, Wairooy NAP. How Effective is Angiotensin II in Decreasing Mortality of Vasodilatory Shock? A Systematic Review. Open Access Emerg Med 2023; 15:1-11. [PMID: 36636460 PMCID: PMC9830054 DOI: 10.2147/oaem.s391167] [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: 09/25/2022] [Accepted: 12/20/2022] [Indexed: 01/05/2023] Open
Abstract
Background Patients with severe vasodilation accompanied by refractory hypotension despite high doses of vasopressors were associated with a high mortality rate. The Ang-2 for the Treatment of High-Output Shock (ATHOS) 3 trial demonstrated that angiotensin 2 (Ang-2) could effectively increase MAP and blood pressure in vasodilatory shock patients. This systematic review aims to summarize the impact of Ang-2 for the treatment of vasodilatory shock on clinical outcomes, including length of stay, MAP level (before and after), and mortality also Ang-2 dose needed. Methods A systematic search in PubMed, Sage, ScienceDirect, Scopus and Gray literature was conducted to obtain studies about the use of Ang-2 in vasodilatory shock patients. Results In all of the studies that we obtained, there were different results regarding mortality in patients with vasodilatory shock with Ang-2. Mortality was significantly lower when Ang-2 was administered to patients with elevated renin. The initial dose of Ang-2 can be started at 10-20 ng/kg/min, but there is no agreement on the maximum dose. Ang-2 may be considered a third-line vasopressor if the targeted MAP has not been achieved after administration of norepinephrine >200 ng/kg/min for more than 6 hours. Although not statistically significant, the use of Ang-2 can reduce the length of stay in the ICU and in the hospital when compared to patients without Ang-2 therapy, in addition to reducing the dose of vasopressor. Conclusion Overall, the use of Ang-2 has potential to be a regimen for patients with vasodilatory shock. Further study is needed to obtain more data.
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Affiliation(s)
- Bambang Pujo Semedi
- Doctoral Program of Medical Science, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, 60132, Indonesia,Department of Anesthesiology and Reanimation, Medical Faculty of Medicine, Universitas Airlangga—Dr Soetomo General Hospital, Surabaya, East Java, 60132, Indonesia
| | - Nancy Margarita Rehatta
- Department of Anesthesiology and Reanimation, Medical Faculty of Medicine, Universitas Airlangga—Dr Soetomo General Hospital, Surabaya, East Java, 60132, Indonesia,Correspondence: Nancy Margarita Rehatta, Email
| | - Soetjipto Soetjipto
- Department of Medical Biochemistry, Medical Faculty of Universitas Airlangga, Surabaya, East Java, 60132, Indonesia
| | - Jusak Nugraha
- Department of Clinical Pathology, Medical Faculty of Universitas Airlangga, Surabaya, East Java, 60132, Indonesia
| | | | | | - Nabilah A P Wairooy
- Medical Faculty Universitas Airlangga, Surabaya, East Java, 60132, Indonesia
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11
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De Backer D, Cecconi M, Chew MS, Hajjar L, Monnet X, Ospina-Tascón GA, Ostermann M, Pinsky MR, Vincent JL. A plea for personalization of the hemodynamic management of septic shock. Crit Care 2022; 26:372. [PMID: 36457089 PMCID: PMC9714237 DOI: 10.1186/s13054-022-04255-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/25/2022] [Indexed: 12/02/2022] Open
Abstract
Although guidelines provide excellent expert guidance for managing patients with septic shock, they leave room for personalization according to patients' condition. Hemodynamic monitoring depends on the evolution phase: salvage, optimization, stabilization, and de-escalation. Initially during the salvage phase, monitoring to identify shock etiology and severity should include arterial pressure and lactate measurements together with clinical examination, particularly skin mottling and capillary refill time. Low diastolic blood pressure may trigger vasopressor initiation. At this stage, echocardiography may be useful to identify significant cardiac dysfunction. During the optimization phase, echocardiographic monitoring should be pursued and completed by the assessment of tissue perfusion through central or mixed-venous oxygen saturation, lactate, and carbon dioxide veno-arterial gradient. Transpulmonary thermodilution and the pulmonary artery catheter should be considered in the most severe patients. Fluid therapy also depends on shock phases. While administered liberally during the resuscitation phase, fluid responsiveness should be assessed during the optimization phase. During stabilization, fluid infusion should be minimized. In the de-escalation phase, safe fluid withdrawal could be achieved by ensuring tissue perfusion is preserved. Norepinephrine is recommended as first-line vasopressor therapy, while vasopressin may be preferred in some patients. Essential questions remain regarding optimal vasopressor selection, combination therapy, and the most effective and safest escalation. Serum renin and the angiotensin I/II ratio may identify patients who benefit most from angiotensin II. The optimal therapeutic strategy for shock requiring high-dose vasopressors is scant. In all cases, vasopressor therapy should be individualized, based on clinical evaluation and blood flow measurements to avoid excessive vasoconstriction. Inotropes should be considered in patients with decreased cardiac contractility associated with impaired tissue perfusion. Based on pharmacologic properties, we suggest as the first test a limited dose of dobutamine, to add enoximone or milrinone in the second line and substitute or add levosimendan if inefficient. Regarding adjunctive therapies, while hydrocortisone is nowadays advised in patients receiving high doses of vasopressors, patients responding to corticosteroids may be identified in the future by the analysis of selected cytokines or specific transcriptomic endotypes. To conclude, although some general rules apply for shock management, a personalized approach should be considered for hemodynamic monitoring and support.
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Affiliation(s)
- Daniel De Backer
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Boulevard du Triomphe 201, 1160 Brussels, Belgium
| | - Maurizio Cecconi
- grid.417728.f0000 0004 1756 8807Humanitas Clinical and Research Center – IRCCS, Rozzano, MI Italy ,grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI Italy
| | - Michelle S. Chew
- grid.5640.70000 0001 2162 9922Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ludhmila Hajjar
- grid.11899.380000 0004 1937 0722Departamento de Cardiopneumologia, InCor, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Xavier Monnet
- grid.460789.40000 0004 4910 6535AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 Rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Gustavo A. Ospina-Tascón
- grid.477264.4Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia ,grid.440787.80000 0000 9702 069XTranslational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Marlies Ostermann
- grid.420545.20000 0004 0489 3985Department of Intensive Care, King’s College London, Guy’s & St Thomas’ Hospital, London, UK
| | - Michael R. Pinsky
- grid.21925.3d0000 0004 1936 9000Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Dept of Intensive Care, Erasme Univ Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Carà GA, Pasin L, Alborino E, Zarbock A, Bellomo R, Landoni G. Angiotensin II - A Brief Review and Role in Severe SARS-COV-2 Sepsis. J Cardiothorac Vasc Anesth 2022; 36:4496-4500. [PMID: 35995637 PMCID: PMC9304073 DOI: 10.1053/j.jvca.2022.07.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 07/09/2022] [Accepted: 07/18/2022] [Indexed: 11/16/2022]
Abstract
The renin-angiotensin-aldosterone system (RAAS), whose major vasopressor effector is angiotensin II (ATII), has multiple activities and regulates sodium-water homeostasis and fluid and blood pressure homeostasis. RAAS plays a crucial role in cardiocirculatory shock because it counteracts hypotension and hypovolemia by activating different physiologic responses. Based on the encouraging results of the ATHOS-3 trial, the US Food and Drug Administration and the European Medicines Agency approved the use of ATII for catecholamine-resistant vasodilatory shock. More recently, ATII was used for the compassionate treatment of critically ill patients with COVID-19. Beyond its vasopressor properties, ATII was hypothesized to have antiviral activity because it induces internalization and degradation of angiotensin-converting enzyme 2 receptors used by SARS-Cov-2 to infect cells. Overall, the use of ATII in patients with COVID-19 showed promising results because its administration was associated with the achievement and maintenance of target mean arterial pressure, increased PaO2/FIO2 ratio, and decreased FIO2. The aim of this narrative review is to summarize the available knowledge on the use of ATII in patients with COVID-19.
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Affiliation(s)
- Gianmarco A Carà
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Laura Pasin
- Department of Anesthesia and Intensive Care, Azienda Ospedale-Università di Padova, Padova, Italy
| | - Ettore Alborino
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Rinaldo Bellomo
- Data Analytics Research and Evaluation (DARE) Centre, The University of Melbourne at Austin Health, Melbourne, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia; Department of Critical Care, School of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
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13
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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: 1] [Impact Index Per Article: 0.5] [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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Andaluz-Ojeda D, Cantón-Bulnes M, Pey Richter C, Garnacho-Montero J. Fármacos vasoactivos en el tratamiento del shock séptico. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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15
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Andaluz-Ojeda D, Cantón-Bulnes ML, Pey Richter C, Garnacho-Montero J. [Vasoactive drugs in the treatment of septic shock]. Med Intensiva 2022; 46 Suppl 1:26-37. [PMID: 38341258 DOI: 10.1016/j.medine.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/03/2022] [Indexed: 02/12/2024]
Abstract
Septic shock is a high mortality complication frequently associated with sepsis. Early initiation of vasopressor treatment, even before completion of initial fluid resuscitation, is a determining factor in prognosis. In this sense, norepinephrine continues to be the drug of first choice, although there is increasing evidence of benefit combining it with other non-adrenergic drugs, such as vasopressin, instead of escalating norepinephrine doses. The pathophysiology of septic shock is multifactorial, and sometimes is associated with a situation of myocardial dysfunction that contributes to hemodynamic instability. It is essential to identify this situation since it worsens the prognosis and may benefit from combined treatment with inotropic drugs. There are novel vasoactive agents under study, more selective than the classic ones that in a next future could help to design more individualized and precise treatments. In the present work, the current knowledge about vasoactive drugs and their use in the management of septic shock is summarized according to the most recent scientific evidence.
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Affiliation(s)
- D Andaluz-Ojeda
- Servicio de Medicina Intensiva, Hospital Universitario HM Sanchinarro. Hospitales Madrid, Madrid, España.
| | - M L Cantón-Bulnes
- Unidad Clínica de Cuidados Intensivos. Hospital Universitario Virgen Macarena, Sevilla, España
| | - C Pey Richter
- Servicio de Medicina Intensiva, Hospital Universitario HM Sanchinarro. Hospitales Madrid, Madrid, España
| | - J Garnacho-Montero
- Unidad Clínica de Cuidados Intensivos. Hospital Universitario Virgen Macarena, Sevilla, España
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16
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Affiliation(s)
- A Jha
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - G Zilahi
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - A Rhodes
- St George's University Hospitals NHS Foundation Trust, London, UK
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17
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Abstract
The aim of this study was to assess the efficacy and safety of various resuscitation fluids in septic shock by adopting a network meta-analysis (NMA). Randomized controlled trials (RCTs) comparing resuscitation fluids in septic shock were carried out by retrieving electronic databases. NMAs of 28-day mortality, 90-day mortality, incidence of acute kidney injury (AKI), and the need for renal replacement therapy (RRT) were conducted using the STATA 15.0 software. Probability-based ranking and surface under cumulative ranking (SUCRA) were performed to identify the optimal resuscitation fluid. Inconsistencies were evaluated by node-splitting analysis and a loop-specific approach. Furthermore, publication bias was analyzed by funnel plots. A total of 13 RCTs were enrolled in the analysis. The NMA results revealed that no significant differences were detected in the outcomes of 28-day mortality and 90-day mortality among various resuscitation fluids. The SUCRAs (the first indicates the best) of 28-day mortality showed that the hypertonic sodium chloride/hydroxyethyl starch 40 solution ranked the highest (93.8%), followed by the balanced solution (BS) (69.6%), and albumin (61.9%). On the other hand, the SUCRAs of 90-day mortality revealed that gelatin (GEL) ranked the highest (75.1%), followed by BS (55.1%), and NS (52.4%). The NMA results of AKI demonstrated that high-molecular-weight hydroxyethyl starch (H-HES) was associated with increased risk of AKI in comparison with GEL, BS, and L-HES. The SUCRAs of AKI showed that GEL ranked the highest (74.4%), followed by NS (64.9%), and BS (58.3%). In addition, the NMA results of RRT revealed that H-HES was associated with an increased need for RRT in comparison with BS and NS, and L-HES was associated with increased need of RRT in comparison with BS. The SUCRAs of RRT revealed that NS ranked the highest (91.6%), followed by BS (74.4%) and L-HES (36.1%). No significant inconsistencies were shown by the node-splitting analysis and no publication bias was demonstrated in the funnel plots. In conclusion, BS was determined as the preferred resuscitation fluid for septic shock. Moreover, the use of GEL requires further evaluation. H-HES was associated with a significant risk of AKI and RRT, whereas L-HES with an increased need for RRT compared with BS. Thus, both resuscitation fluids should be avoided for septic shock.
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Gulati A, Jain D, Agrawal NR, Rahate P, Choudhuri R, Das S, Dhibar DP, Prabhu M, Haveri S, Agarwal R, Lavhale MS. Resuscitative Effect of Centhaquine (Lyfaquin ®) in Hypovolemic Shock Patients: A Randomized, Multicentric, Controlled Trial. Adv Ther 2021; 38:3223-3265. [PMID: 33970455 PMCID: PMC8189997 DOI: 10.1007/s12325-021-01760-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 04/22/2021] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Centhaquine (Lyfaquin®) showed significant efficacy as a resuscitative agent in animal models of haemorrhagic shock. Its safety and tolerability were confirmed in healthy human volunteers. In this study, our primary objective was to determine the safety, and the secondary objective was to assess the efficacy of centhaquine in patients with hypovolemic shock. METHODS A prospective, multicentre, randomized phase II study was conducted in male and female patients aged 18-70 years with hypovolemic shock having systolic BP ≤ 90 mmHg. Patients were randomized in a 1:1 ratio to either the control or centhaquine group. The control group received 100 ml of normal saline infusion over 1 h, while the centhaquine group received 0.01 mg/kg of centhaquine in 100 ml normal saline infusion over 1 h. Every patient received standard of care (SOC) and was followed for 28 days. RESULTS Fifty patients were included, and 45 completed the trial: 22 in the control group and 23 in the centhaquine group. The demographics of patients in both groups were comparable. No adverse event related to centhaquine was recorded in the 28-day observation period. The baseline, Injury Scoring System score, haemoglobin, and haematocrit were similar in both groups. However, 91% of the patients in the centhaquine group needed major surgery, whereas only 68% in the control group (p = 0.0526). Twenty-eight-day all-cause mortality was 0/23 in the centhaquine group and 2/22 in the control group. The percent time in ICU and ventilator support was less in the centhaquine group than in the control group. The total amount of vasopressors needed in the first 48 h of resuscitation was lower in the centhaquine group than in the control group (3.12 ± 2.18 vs. 9.39 ± 4.28 mg). An increase in systolic and diastolic BP from baseline through 48 h was more marked in the centhaquine group than in the control group. Compared with the control group, blood lactate level was lower by 1.75 ± 1.07 mmol/l in the centhaquine group on day 3 of resuscitation. Improvements in base deficit, multiple organ dysfunction syndrome (MODS) score and adult respiratory distress syndrome (ARDS) were greater in the centhaquine group than in the control group. CONCLUSION When added to SOC, centhaquine is a well-tolerated and effective resuscitative agent. It improves the clinical outcome of patients with hypovolemic shock. TRIAL REGISTRATION ClinicalTrials.gov identifier number: NCT04056065.
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Affiliation(s)
- Anil Gulati
- Professor Emeritus, Midwestern University, Downers Grove, IL USA
| | - Dinesh Jain
- Department of Medicine, Dayanand Medical College & Hospital, Civil Lines, Tagore Nagar, Ludhiana, Punjab 141001 India
| | - Nilesh Radheshyam Agrawal
- Department of Neurology, New Era Hospital, Near Jalaram Mandir, Queta Colony, Telephone Exchange Chowk, Central Avenue Road, Nagpur, Maharashtra 440008 India
| | - Prashant Rahate
- Seven Star Hospital Jagnade Square, KDK College Road, Nagpur, Maharashtra 440009 India
| | - Rajat Choudhuri
- Department of Anaesthesiology, Institute of Post-Graduate Medical Education and Research and SSKM Hospital, 244 A.J.C. Bose Road, Kolkata, West Bengal 700020 India
| | - Soumen Das
- Department of Surgery, Institute of Post-Graduate Medical Education and Research and SSKM Hospital, 244 A.J.C. Bose Road, Kolkata, West Bengal 700020 India
| | - Deba Prasad Dhibar
- Department of Internal Medicine, Nehru Hospital, Post-Graduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160 012 India
| | - Madhav Prabhu
- Department of Medicine, KLE’s Dr. Prabhakar Kore Hospital and Medical Research Centre, Nehru Nagar, Belgaum, Karnataka 590010 India
| | - Sameer Haveri
- Department of Orthopaedics, KLE’s Dr. Prabhakar Kore Hospital and Medical Research Centre, Nehru Nagar, Belgaum, Karnataka 590010 India
| | - Rohit Agarwal
- Department of Anaesthesiology, ORIANA Hospital, Plot No.: 6, 7, 8 Ravindrapuri Bhelpur, Varanasi, Uttar Pradesh 221005 India
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19
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Abstract
PURPOSE OF REVIEW The current article reviews recent findings on the monitoring and hemodynamic support of septic shock patients. RECENT FINDINGS The ultimate goal of hemodynamic resuscitation is to restore tissue oxygenation. A multimodal approach combining global and regional markers of tissue hypoxia seems appropriate to guide resuscitation. Several multicenter clinical trials have provided evidence against an aggressive fluid resuscitation strategy. Fluid administration should be personalized and based on the evidence of fluid responsiveness. Dynamic indices have proven to be highly predictive of responsiveness. Recent data suggest that balanced crystalloids may be associated with less renal failure. When fluid therapy is insufficient, a multimode approach with different types of vasopressors has been suggested as an initial approach. Dobutamine remains the firs inotropic option in patients with persistent hypotension and decrease ventricular systolic function. Calcium sensitizer and phosphodiesterase inhibitors may be considered, but evidence is still limited. Veno-arterial extracorporeal membrane oxygenation may be considered in selected unresponsive patients, particularly with myocardial depression, and in a highly experienced center. SUMMARY Resuscitation should be personalized and based on global and regional markers of tissue hypoxia as well as the fluid responsiveness indices. The beneficial effect of multimode approach with different types of vasopressors, remains to be determined.
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Jasiński T, Stefaniak J. COVID-19 and haemodynamic failure: a point of view on mechanisms and treatment. Anaesthesiol Intensive Ther 2020; 52:409-417. [PMID: 33327700 PMCID: PMC10183984 DOI: 10.5114/ait.2020.101813] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 11/29/2020] [Indexed: 11/17/2022] Open
Abstract
The SARS-CoV-2-related disease has an undoubted impact on the healthcare system. In the treatment of severe COVID-19 cases, the main focus is on respiratory failure. However, available data suggest an important contribution of haemodynamic impairment in the course of this disease. SARS-CoV-2 may affect the circulatory system in various ways that are universal for septic conditions. Nonetheless, unique features of this pathogen, e.g. direct insult leading to myocarditis and renin-angiotensin-aldosterone axis dysregulation, must be taken into account. Although current recommendations on COVID-19 resemble previous septic shock guidelines, special attention to haemodynamic monitoring and treatment is necessary. Regarding treatment, one must take into account the potential profound hypovolaemia of severe COVID-19 patients. Pharmacological cardiovascular support should follow existing guidelines and practice. Interesting concepts of decatecholaminisation and the effect of vasopressors on pulmonary circulation are also presented in this review on COVID-19-related haemodynamic failure.
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Affiliation(s)
- Tomasz Jasiński
- Department of Anaesthesiology and Intensive Therapy, Medical University of Gdansk, Poland
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21
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Wieruszewski PM, Wittwer ED, Kashani KB, Brown DR, Butler SO, Clark AM, Cooper CJ, Davison DL, Gajic O, Gunnerson KJ, Tendler R, Mara KC, Barreto EF. Angiotensin II Infusion for Shock: A Multicenter Study of Postmarketing Use. Chest 2020; 159:596-605. [PMID: 32882250 DOI: 10.1016/j.chest.2020.08.2074] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 08/11/2020] [Accepted: 08/20/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Vasodilatory shock refractory to catecholamine vasopressors and arginine vasopressin is highly morbid and responsible for significant mortality. Synthetic angiotensin II is a potent vasoconstrictor that may be suitable for use in these patients. RESEARCH QUESTION What is the safety and effectiveness of angiotensin II and what variables are associated with a favorable hemodynamic response? STUDY DESIGN AND METHODS We performed a multicenter, retrospective study at five tertiary medical centers in the United States. The primary end point of hemodynamic responsiveness to angiotensin II was defined as attainment of mean arterial pressure (MAP) of ≥ 65 mm Hg with a stable or reduced total vasopressor dosage 3 h after drug initiation. RESULTS Of 270 included patients, 181 (67%) demonstrated hemodynamic responsiveness to angiotensin II. Responders showed a greater increase in MAP (+10.3 mm Hg vs +1.6 mm Hg, P < .001) and reduction in vasopressor dosage (-0.20 μg/kg/min vs +0.04 μg/kg/min; P < .001) compared with nonresponders at 3 h. Variables associated with favorable hemodynamic response included lower lactate concentration (OR 1.11; 95% CI, 1.05-1.17, P < .001) and receipt of vasopressin (OR, 6.05; 95% CI, 1.98-18.6; P = .002). In severity-adjusted multivariate analysis, hemodynamic responsiveness to angiotensin II was associated with reduced likelihood of 30-day mortality (hazard ratio, 0.50; 95% CI, 0.35-0.71; P < .001). Arrhythmias occurred in 28 patients (10%) and VTE was identified in 4 patients. INTERPRETATION In postmarketing use for vasopressor-refractory shock, 67% of angiotensin II recipients demonstrated a favorable hemodynamic response. Patients with lower lactate concentrations and those receiving vasopressin were more likely to respond to angiotensin II. Patients who responded to angiotensin II experienced reduced mortality.
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Affiliation(s)
- Patrick M Wieruszewski
- Department of Pharmacy, Mayo Clinic, Rochester, MN; Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN
| | - Erica D Wittwer
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Kianoush B Kashani
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Daniel R Brown
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | | | - Angela M Clark
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI
| | - Craig J Cooper
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL
| | - Danielle L Davison
- Departments of Anesthesiology and Critical Care Medicine, George Washington University, Washington, DC
| | - Ognjen Gajic
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Kyle J Gunnerson
- Departments of Emergency Medicine, Anesthesiology, and Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | | | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN; Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
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22
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Russell JA, Gordon AC, Williams MD, Boyd JH, Walley KR, Kissoon N. Vasopressor Therapy in the Intensive Care Unit. Semin Respir Crit Care Med 2020; 42:59-77. [PMID: 32820475 DOI: 10.1055/s-0040-1710320] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
After fluid administration for vasodilatory shock, vasopressors are commonly infused. Causes of vasodilatory shock include septic shock, post-cardiovascular surgery, post-acute myocardial infarction, postsurgery, other causes of an intense systemic inflammatory response, and drug -associated anaphylaxis. Therapeutic vasopressors are hormones that activate receptors-adrenergic: α1, α2, β1, β2; angiotensin II: AG1, AG2; vasopressin: AVPR1a, AVPR1B, AVPR2; dopamine: DA1, DA2. Vasopressor choice and dose vary widely because of patient and physician practice heterogeneity. Vasopressor adverse effects are excessive vasoconstriction causing organ ischemia/infarction, hyperglycemia, hyperlactatemia, tachycardia, and tachyarrhythmias. To date, no randomized controlled trial (RCT) of vasopressors has shown a decreased 28-day mortality rate. There is a need for evidence regarding alternative vasopressors as first-line vasopressors. We emphasize that vasopressors should be administered simultaneously with fluid replacement to prevent and decrease duration of hypotension in shock with vasodilation. Norepinephrine is the first-choice vasopressor in septic and vasodilatory shock. Interventions that decrease norepinephrine dose (vasopressin, angiotensin II) have not decreased 28-day mortality significantly. In patients not responsive to norepinephrine, vasopressin or epinephrine may be added. Angiotensin II may be useful for rapid resuscitation of profoundly hypotensive patients. Inotropic agent(s) (e.g., dobutamine) may be needed if vasopressors decrease ventricular contractility. Dopamine has fallen to almost no-use recommendation because of adverse effects; angiotensin II is available clinically; there are potent vasopressors with scant literature (e.g., methylene blue); and the novel V1a agonist selepressin missed on its pivotal RCT primary outcome. In pediatric septic shock, vasopressors, epinephrine, and norepinephrine are recommended equally because there is no clear evidence that supports the use of one vasoactive agent. Dopamine is recommended when epinephrine or norepinephrine is not available. New strategies include perhaps patients will be started on several vasopressors with complementary mechanisms of action, patients may be selected for particular vasopressors according to predictive biomarkers, and novel vasopressors may emerge with fewer adverse effects.
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Affiliation(s)
- James A Russell
- Department of Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anthony C Gordon
- Department of Surgery and Cancer, Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, United Kingdom.,Department of Surgery and Cancer, Intensive Care Unit, Imperial College Healthcare NHS Trust, St Mary's Hospital, London, United Kingdom
| | - Mark D Williams
- Department of Medicine, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - John H Boyd
- Department of Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Keith R Walley
- Department of Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Niranjan Kissoon
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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23
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Evora PRB. Broad Spectrum Vasopressors Support Sparing Strategies in Vasodilatory Shock Beyond the Vascular Receptors. Chest 2020; 157:471-472. [PMID: 32033650 DOI: 10.1016/j.chest.2019.08.2211] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 08/26/2019] [Indexed: 01/23/2023] Open
Affiliation(s)
- Paulo Roberto B Evora
- Department of Surgery and Anatomy (Division of Cardiothoracic Surgery), Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil.
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24
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Montrucchio G, Brazzi L. Is it time for a stewardship approach to vasopressors in refractory septic shock? Minerva Anestesiol 2020; 86:482-484. [DOI: 10.23736/s0375-9393.20.14527-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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25
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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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26
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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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27
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Ortoleva J, Cobey FC. Comment on "Vasoplegic syndrome following cardiothoracic surgery-review of pathophysiology and update of treatment options". Crit Care 2020; 24:138. [PMID: 32264932 PMCID: PMC7140332 DOI: 10.1186/s13054-020-02854-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 03/26/2020] [Indexed: 11/21/2022] Open
Affiliation(s)
- Jamel Ortoleva
- Tufts Medical Center Department of Anesthesiology and Perioperative Medicine, Boston, USA.
| | - Frederick C Cobey
- Tufts Medical Center Department of Anesthesiology and Perioperative Medicine, Boston, USA
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28
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Heavner MS, McCurdy MT, Mazzeffi MA, Galvagno SM, Tanaka KA, Chow JH. Angiotensin II and Vasopressin for Vasodilatory Shock: A Critical Appraisal of Catecholamine-Sparing Strategies. J Intensive Care Med 2020; 36:635-645. [DOI: 10.1177/0885066620911601] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
| | - Michael T. McCurdy
- University of Maryland School of Medicine, Department of Medicine, Baltimore, MD, USA
| | - Michael A. Mazzeffi
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD, USA
| | - Samuel M. Galvagno
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD, USA
| | - Kenichi A. Tanaka
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD, USA
| | - Jonathan H. Chow
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD, USA
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29
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Wallis MC, Chow JH, Winters ME, McCurdy MT. Angiotensin II for the emergency physician. Emerg Med J 2020; 37:717-721. [PMID: 32075849 DOI: 10.1136/emermed-2019-209062] [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: 08/27/2019] [Revised: 01/23/2020] [Accepted: 01/25/2020] [Indexed: 11/04/2022]
Abstract
Refractory hypotension is one of the most common and difficult clinical problems faced by acute care clinicians, and it poses a particularly large problem to the emergency physician when a patient in undifferentiated shock arrives in the department. Angiotensin II (Ang-2) has been previously used as a vasopressor to combat shock; the feasibility of its clinical use has been reinvigorated after approval of a human synthetic formulation of the medication by the US Food and Drug Administration in 2017 and the European Medicines Agency in 2019. A thorough literature search was completed, and in this review, we discuss the discovery and development of Ang-2, its complex mechanisms of vasoconstriction, its potential adverse effects and its potential role in clinical practice for emergency physicians.
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Affiliation(s)
- Marianne C Wallis
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jonathan H Chow
- Department of Anesthesia, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michael E Winters
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michael T McCurdy
- Division of Pulmonary and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
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30
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Shah R, Wenger RK, Patel PA, Davis S, Ha B, Feinman JW, Patel S, Pulton D, Weiss SJ, Restrepo-Cardenas J, Aljure OD, Vasquez CR, Augoustides JG. Severe Vasoplegic Shock During Coronary Artery Bypass Surgery: Therapeutic challenges and Dilemmas in Hemodynamic Rescue. J Cardiothorac Vasc Anesth 2020; 34:1341-1347. [PMID: 32146101 DOI: 10.1053/j.jvca.2020.01.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 01/28/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Ronak Shah
- Department of Anesthesiology and Critical Care, Cardiovascular and Thoracic Section, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Robert K Wenger
- Department of Surgery, Division of Cardiac Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Prakash A Patel
- Department of Anesthesiology and Critical Care, Cardiovascular and Thoracic Section, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Scott Davis
- Department of Anesthesiology, Chester County Hospital, University of Pennsylvania, Philadelphia, PA
| | - Bao Ha
- Department of Anesthesiology and Critical Care, Cardiovascular and Thoracic Section, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jared W Feinman
- Department of Anesthesiology and Critical Care, Cardiovascular and Thoracic Section, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Saumil Patel
- Department of Anesthesiology and Critical Care, Cardiovascular and Thoracic Section, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Danielle Pulton
- Department of Anesthesiology and Critical Care, Cardiovascular and Thoracic Section, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stuart J Weiss
- Department of Anesthesiology and Critical Care, Cardiovascular and Thoracic Section, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Oscar D Aljure
- Department of Anesthesiology, Miller School of Medicine, University of Miami, Miami, FL
| | - Charles R Vasquez
- Department of Surgery, Division of Cardiac Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Department of Anesthesiology and Critical Care, Cardiovascular and Thoracic Section, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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31
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Caraballo C, Jaimes F. Organ Dysfunction in Sepsis: An Ominous Trajectory From Infection To Death. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2019; 92:629-640. [PMID: 31866778 PMCID: PMC6913810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Sepsis is a highly complex and lethal syndrome with highly heterogeneous clinical manifestations that makes it difficult to detect and treat. It is also one of the major and most urgent global public health challenges. More than 30 million people are diagnosed with sepsis each year, with 5 million attributable deaths and long-term sequalae among survivors. The current international consensus defines sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to an infection. Over the past decades substantial research has increased the understanding of its pathophysiology. The immune response induces a severe macro and microcirculatory dysfunction that leads to a profound global hypoperfusion, injuring multiple organs. Consequently, patients with sepsis might present dysfunction of virtually any system, regardless of the site of infection. The organs more frequently affected are kidneys, liver, lungs, heart, central nervous system, and hematologic system. This multiple organ failure is the hallmark of sepsis and determines patients' course from infection to recovery or death. There are tools to assess the severity of the disease that can also help to guide treatment, like the Sequential Organ Failure Assessment (SOFA) score. However, sepsis disease process is vastly heterogeneous, which could explain why interventions targeted to directly intervene its mechanisms have shown unsuccessful results and predicting outcomes with accuracy is still elusive. Thus, it is required to implement strong public health strategies and leverage novel technologies in research to improve outcomes and mitigate the burden of sepsis and septic shock worldwide.
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Affiliation(s)
- César Caraballo
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
| | - Fabián Jaimes
- Academic Group of Clinical Epidemiology, School of Medicine, University of Antioquia, Medellín, Colombia,Department of Internal Medicine, School of Medicine, University of Antioquia, Medellín, Colombia,Research Direction, San Vicente Foundation University Hospital, Medellín, Colombia,To whom all correspondence should be addressed: Dr. Fabián Jaimes, Hospital San Vicente Fundación, Calle 64 # 51 D-154, Medellín, Antioquia, Colombia; Tel: +57 (4) 2192433,
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32
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Coleman PJ, Nissen AP, Kim DE, Ainsworth CR, McCurdy MT, Mazzeffi MA, Chow JH. Angiotensin II in Decompensated Cirrhosis Complicated by Septic Shock. Semin Cardiothorac Vasc Anesth 2019; 24:266-272. [PMID: 31540560 DOI: 10.1177/1089253219877876] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
This case describes the first reported use of human-derived synthetic angiotensin II (Ang-2) in a patient with decompensated cirrhosis and septic shock. The patient presented in vasodilatory shock from Enterobacter cloacae bacteremia with a Sequential Organ Failure Assessment Score of 14 and a Model for End-Stage Liver Disease score of 36. This case is significant because liver failure was an exclusion criterion in the Angiotensin II for the Treatment of Vasodilatory Shock (ATHOS-3) trial, but the liver produces angiotensinogen, which is key precursor to Ang-2 in the renin-angiotensin-aldosterone system. Resuscitation with Ang-2 is a potentially beneficial medication when conventional vasopressors have failed to control mean arterial pressure in this population.
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Affiliation(s)
| | | | - Daniel E Kim
- US Army Institute of Surgical Research, Fort Sam Houston, TX, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | | | | | - Jonathan H Chow
- University of Maryland School of Medicine, Baltimore, MD, USA
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