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Fernandes M, Lorenzo AD, Tibiriçá E. The Usefulness of Microcirculatory Assessment After Cardiac Surgery: Illustrative Case Report. Braz J Cardiovasc Surg 2024; 39:e20230383. [PMID: 39248437 PMCID: PMC11382545 DOI: 10.21470/1678-9741-2023-0383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024] Open
Abstract
Cardiac surgery causes a series of disturbances in human physiology. The correction of systemic hemodynamic variables is frequently ineffective in improving microcirculatory perfusion and delivering oxygen to the tissues. We present the case of a 52-year-old male submitted to mitral valve replacement (metallic valve) and subaortic membrane resection. Sublingual microcirculatory density and perfusion were evaluated using a handheld CytoCam camera before surgery and in the early postoperative period. In this case, systemic hemodynamic variables were compromised despite an actual improvement in the microcirculatory parameters in comparison to the preoperative evaluation, possibly due to the correction of the structural cardiac defects.
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Affiliation(s)
- Marcos Fernandes
- Instituto Nacional de Cardiologia, Ministry of Health, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Andrea De Lorenzo
- Instituto Nacional de Cardiologia, Ministry of Health, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Eduardo Tibiriçá
- Instituto Nacional de Cardiologia, Ministry of Health, Rio de Janeiro, Rio de Janeiro, Brazil
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Chiscano-Camón L, Ruiz-Sanmartin A, Bajaña I, Bastidas J, Lopez-Martinez R, Franco-Jarava C, Gonzalez JJ, Larrosa N, Riera J, Nuvials-Casals X, Ruiz-Rodríguez JC, Ferrer R. Current perspectives in the management of sepsis and septic shock. Front Med (Lausanne) 2024; 11:1431791. [PMID: 39211340 PMCID: PMC11358069 DOI: 10.3389/fmed.2024.1431791] [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: 05/12/2024] [Accepted: 07/24/2024] [Indexed: 09/04/2024] Open
Abstract
Within patients with sepsis, there exists significant heterogeneity, and while all patients should receive conventional therapy, there are subgroups of patients who may benefit from specific therapies, often referred to as rescue therapies. Therefore, the identification of these specific patient subgroups is crucial and lays the groundwork for the application of precision medicine based on the development of targeted interventions. Over the years, efforts have been made to categorize sepsis into different subtypes based on clinical characteristics, biomarkers, or underlying mechanisms. For example, sepsis can be stratified into different phenotypes based on the predominant dysregulated host response. These phenotypes can range from hyperinflammatory states to immunosuppressive states and even mixed phenotypes. Each phenotype may require different therapeutic approaches to improve patient outcomes. Rescue strategies for septic shock may encompass various interventions, such as immunomodulatory therapies, extracorporeal support (e.g., ECMO), or therapies targeted at specific molecular or cellular pathways involved in the pathophysiology of sepsis. In recent years, there has been growing interest in precision medicine approaches to sepsis and phenotype identification. Precision medicine aims to tailor treatments to each individual patient based on their unique characteristics and disease mechanisms.
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Affiliation(s)
- Luis Chiscano-Camón
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Adolf Ruiz-Sanmartin
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Ivan Bajaña
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juliana Bastidas
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Rocio Lopez-Martinez
- Immunology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Clara Franco-Jarava
- Immunology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juan José Gonzalez
- Microbiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Nieves Larrosa
- Microbiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Jordi Riera
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Xavier Nuvials-Casals
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juan Carlos Ruiz-Rodríguez
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
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Ooms M, Winnand P, Heitzer M, Katz MS, Peters F, Bickenbach J, Hölzle F, Modabber A. Does the Anastomosis Recipient Vessel Have an Influence on Free Flap Perfusion in Microvascular Head and Neck Reconstruction-A Retrospective Analysis of 338 Cases with Comparison of Flap Perfusion between Different Arterial and Venous Recipient Vessels in Radial Free Forearm Flaps, Anterolateral Thigh Flaps, and Fibula Free Flaps. J Clin Med 2024; 13:2763. [PMID: 38792305 PMCID: PMC11122445 DOI: 10.3390/jcm13102763] [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: 04/07/2024] [Revised: 04/29/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Flap perfusion is a prerequisite for microvascular free flap survival and a parameter routinely used for flap monitoring. The aim of this study was to investigate the influence of the anastomosis recipient vessel on flap perfusion. Methods: Flap perfusion was retrospectively analyzed in 338 patients who underwent head and neck reconstruction with microvascular free flaps between 2011 and 2020. The Oxygen-to-see tissue oxygen analysis system measurements for intraoperative and postoperative flap blood flow, hemoglobin concentration, and hemoglobin oxygen saturation at 8 and 2 mm tissue depths were compared between arterial anastomosis recipient vessels (external carotid artery [ECA], facial artery [FAA], lingual artery [LIA], and superior thyroid artery [STA]) and venous anastomosis recipient vessels (internal jugular vein [IJV], combination of IJV and IJV branches, IJV branches, and external jugular vein). Results: The postoperative hemoglobin concentration at 2 mm tissue depth differed significantly between arterial anastomosis recipient vessels (ECA, 41.0 arbitrary units [AU]; FAA, 59.0 AU; LIA, 51.5 AU; STA, 59.0 AU; p = 0.029). This difference did not persist in the multivariable testing (p = 0.342). No other differences in flap blood flow, hemoglobin concentration, or hemoglobin oxygen saturation were observed between the arterial and venous anastomosis recipient vessels (p > 0.05 for all). Conclusions: The arterial and venous recipient vessels used for anastomosis did not influence microvascular free flap perfusion. This underlines the capability of the studied recipient vessels to adequately perfuse free flaps, may explain the observed indifferent flap survival rates between commonly used anastomosis recipient vessels, and implies that the recipient vessel is not a confounding variable for flap monitoring with the Oxygen-to-see tissue oxygen analysis system. Further prospective studies are needed to confirm the findings.
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Affiliation(s)
- Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Philipp Winnand
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Marie Sophie Katz
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Florian Peters
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Johannes Bickenbach
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
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Werdan K, Nuding S, Kühnert D, Kolthoum R, Schott A, Quitter F, Wienke A, Sedding D. Treatment of patients with multiple organ dysfunction syndrome (MODS) with an electromagnetic field coupled to biorhythmically defined impulse configuration: the MicrocircMODS study. Clin Res Cardiol 2024; 113:260-275. [PMID: 37717230 PMCID: PMC10850207 DOI: 10.1007/s00392-023-02293-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 08/21/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND To potentially improve impaired vasomotion of patients with multiple organ dysfunction syndrome (MODS), we tested whether an electromagnetic field of low flux density coupled with a biorhythmically defined impulse configuration (Physical Vascular Therapy BEMER®, PVT), in addition to standard care, is safe and feasible and might improve disturbed microcirculatory blood flow and thereby improve global haemodynamics. METHODS In a prospective, monocentric, one-arm pilot study, 10 MODS patients (APACHE II score 20-35) were included. Patients were treated, in addition to standard care, for 4 days with PVT (3 treatment periods of 8 min each day; day 1: field intensity 10.5 μT; day 2:14 μT, day 3:17.5 μT; day 4:21.0 μT). Primary endpoint was the effect of PVT on sublingual microcirculatory perfusion, documented by microvascular flow index (MFI). Patient safety, adverse events, and outcomes were documented. RESULTS An increase in MFI by approximately 25% paralleled 4-day PVT, with the increase starting immediately after the first PVT and lasting over the total 4-day treatment period. Concerning global haemodynamics (secondary endpoints), halving vasopressor use within 24 h, and haemodynamic stabilisation paralleled 4-day PVT with an increase in cardiac index, stroke volume index, and cardiac power index by 30%-50%. No adverse events (AEs) or serious adverse events (SAEs) were classified as causally related to the medical product (PVT) or study. Three patients died within 28 days and one patient between 28 and 180 days. CONCLUSION PVT treatment was feasible and safe and could be performed without obstruction of standard patient care. An increase in microcirculatory blood flow, a rapid reduction in vasopressor use, and an improvement in global haemodynamics paralleled PVT treatment. Findings of this pilot study allowed forming a concept for a randomized trial for further proof.
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Affiliation(s)
- Karl Werdan
- Department of Internal Medicine III, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06097, Halle (Saale), Germany.
| | - Sebastian Nuding
- Department of Internal Medicine III, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06097, Halle (Saale), Germany
- Hospital St. Elisabeth and St. Barbara, 06110, Halle (Saale), Germany
| | - Diethelm Kühnert
- Department of Internal Medicine III, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06097, Halle (Saale), Germany
- , 04838, Zschepplin, Germany
| | - Ramzi Kolthoum
- Department of Internal Medicine III, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06097, Halle (Saale), Germany
| | - Artjom Schott
- Department of Internal Medicine III, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06097, Halle (Saale), Germany
| | | | - Andreas Wienke
- Institute of Medical Epidemiology, Biometry and Computer Science, Martin-Luther-University Halle-Wittenberg, Magdeburger Strasse 8, 06112, Halle (Saale), Germany
| | - Daniel Sedding
- Department of Internal Medicine III, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, 06097, Halle (Saale), Germany
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Wang C, Wang X, Zhang H, Liu D, Zhang C. Effect of Norepinephrine on Peripheral Perfusion Index and Its Association With the Prognosis of Patients With Sepsis. J Intensive Care Med 2024; 39:21-27. [PMID: 37431214 DOI: 10.1177/08850666231187333] [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: 07/12/2023]
Abstract
Background: To evaluate whether the use of norepinephrine during the management of patients with sepsis affects the perfusion index (PI) and patient outcomes. Methods: We retrospectively studied patients with septic shock between January 2014 and December 2018 who had undergone Pulse index Continuous Cardiac Output-Plus cardiac output monitoring and received norepinephrine during the management. We collected data regarding basic clinical characteristics. Hemodynamic parameters, including lactate, PI, and norepinephrine dose at T0 and 24 h after Pulse index Continuous Cardiac Output catheterization (T24) were obtained. Results: The PI of the nonsurvivor group (n = 44) was significantly lower than that of the survivor group (n = 144) at T24, and the lactate level of the nonsurvivor group was significantly higher than that of the survivor group. The multiple logistic regression analysis suggested that the norepinephrine dose and PI were the most independent risk and protective factors, respectively, for intensive care unit mortality. The area under the curve for a poor prognosis was 0.847 (95% confidence interval, 0.782-0.912). The optimal cutoff value of the PI at T24 to predict intensive care unit mortality was 0.6, with a sensitivity of 77.1% and a specificity of 80%. Based on this optimal cutoff value, we divided patients into groups with PI ≥ 0.6 (n = 125) and PI < 0.6 (n = 59). The lactate level of the PI < 0.6 group was higher than that of the PI ≥ 0.6 group at T24. The PI < 0.6 group showed a significantly higher sublingual dose of norepinephrine indicators than the PI ≥ 0.6 group. The PI showed a strong negative correlation with norepinephrine dose (r = -0.344, P < .001) and lactate (r = -0.291, P < .001). Conclusions: A higher PI is a protective factor, and a higher dose of norepinephrine is a risk factor for the prognosis of critically ill patients with septic shock. A lower PI was associated with a higher dose of norepinephrine.
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Affiliation(s)
- Cui Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Hongmin Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Chengyuan Zhang
- Department of Respiratory and Critical Care Medicine, Feidong County Hospital of Traditional Chinese Medicine, Hefei, China
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Ooms M, Winnand P, Heitzer M, Peters F, Sophie Katz M, Bickenbach J, Hölzle F, Modabber A. Free Flap Perfusion in Microvascular Head and Neck Reconstruction: Influence of the Number of Ischemia Intervals and Ischemia Duration-A Retrospective Study. J Otolaryngol Head Neck Surg 2024; 53:19160216241265089. [PMID: 39077923 PMCID: PMC11289802 DOI: 10.1177/19160216241265089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/27/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND In microvascular head and neck reconstruction, ischemia of the free flap tissue is inevitable during microsurgical anastomosis and may affect microvascular free flap perfusion, which is a prerequisite for flap viability and a parameter commonly used for flap monitoring. The aim of this study was to investigate the influence of the number of ischemia intervals and ischemia duration on flap perfusion. METHODS Intraoperative and postoperative flap blood flow, hemoglobin concentration, and hemoglobin oxygen saturation at 2 and 8 mm tissue depths, as measured with the O2C tissue oxygen analysis system, were retrospectively analyzed for 330 patients who underwent microvascular head and neck reconstruction between 2011 and 2020. Perfusion values were compared between patients without (control patients) and with a second ischemia interval (early or late) and examined with regard to ischemia duration. RESULTS Intraoperative and postoperative flap blood flow at 8 mm tissue depth were lower in patients with early second ischemia intervals than in control patients [102.0 arbitrary units (AU) vs 122.0 AU, P = .030; 107.0 AU vs 128.0 AU, P = .023]. Both differences persisted in multivariable analysis. Intraoperative and postoperative flap blood flow at 8 mm tissue depth correlated weakly negatively with ischemia duration in control patients (r = -.145, P = .020; r = -.124, P = .048). Both associations did not persist in multivariable analysis. CONCLUSIONS The observed decrease in microvascular flap blood flow after early second ischemia intervals may reflect ischemia-related vascular flap tissue damage and should be considered as a confounding variable in flap perfusion monitoring.
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Affiliation(s)
- Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Philipp Winnand
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Florian Peters
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Marie Sophie Katz
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Johannes Bickenbach
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Aachen, Germany
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7
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Pruna A, Bonaccorso A, Belletti A, Turi S, Di Prima AL, D'amico F, Zangrillo A, Kotani Y, Landoni G. Methylene Blue Reduces Mortality in Critically Ill and Perioperative Patients: A Meta-Analysis of Randomized Trials. J Cardiothorac Vasc Anesth 2024; 38:268-274. [PMID: 37880041 DOI: 10.1053/j.jvca.2023.09.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 08/26/2023] [Accepted: 09/26/2023] [Indexed: 10/27/2023]
Abstract
Vasodilatory hypotension is common in critically ill and perioperative patients, and is associated with adverse outcomes. As a nitric oxide production inhibitor, methylene blue (MB) exerts its vasoconstrictor property and is an adjuvant for catecholamine-refractory vasodilatory shock. However, the effects of MB on clinically relevant outcomes remain unclear. Therefore, the authors performed a meta-analysis of randomized trials on MB in critically ill and perioperative patients. The authors searched through databases for randomized trials on MB in critically ill and perioperative patients, which yielded 11 studies consisting of 556 patients. The primary outcome was mortality at the longest follow-up. Secondary outcomes included hemodynamic parameters and organ dysfunction (PROSPERO: CRD42023409243). Nine out of the 11 included randomized trials reported mortality, which was significantly lower in the MB group (risk ratio, 0.60 [95% CI 0.43-0.84] p = 0.003), with findings confirmed in septic shock and cardiac surgery subgroups. The authors found reduced lengths of stay in the intensive care unit (mean difference [MD], -0.9 days [95% CI -1.06 to -0.77] p < 0.001) and in the hospital (MD, -2.2 days [95% CI, -2.68 to -1.70] p < 0.001) in the MB group. MB was associated with increased mean arterial pressure (MD, 8.4 mmHg [95% CI 5.01-11.75] p < 0.001) and systemic vascular resistance (MD, 94.5 dyn/s/cm5 [95% CI 17.73-171.15] p = 0.02), with no difference in cardiac output (standardized MD, 0.16 [95% CI, -0.25 to 0.57] p = 0.45). This meta-analysis showed that MB reverses vasodilation in critically ill and perioperative patients and might improve survival. Further adequately powered randomized trials are needed to confirm these findings.
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Affiliation(s)
- Alessandro Pruna
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandra Bonaccorso
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Turi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ambra Licia Di Prima
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Filippo D'amico
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - 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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8
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Garcia B, Su F, Dewachter L, Wang Y, Li N, Remmelink M, Eycken MV, Khaldi A, Favory R, Herpain A, Moreau A, Moiroux-Sahraoui A, Manicone F, Annoni F, Shi L, Vincent JL, Creteur J, Taccone FS. Neutralization of extracellular histones by sodium-Β-O-methyl cellobioside sulfate in septic shock. Crit Care 2023; 27:458. [PMID: 38001494 PMCID: PMC10675855 DOI: 10.1186/s13054-023-04741-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Extracellular histones have been associated with severity and outcome in sepsis. The aim of the present study was to assess the effects of sodium-β-O-Methyl cellobioside sulfate (mCBS), a histone-neutralizing polyanion, on the severity and outcome of sepsis in an experimental model. METHODS This randomized placebo-controlled experimental study was performed in 24 mechanically ventilated female sheep. Sepsis was induced by fecal peritonitis. Animals were randomized to three groups: control, early treatment, and late treatment (n = 8 each). mCBS was given as a bolus (1 mg/kg) followed by a continuous infusion (1 mg/kg/h) just after sepsis induction in the early treatment group, and 4 h later in the late treatment group. Fluid administration and antimicrobial therapy were initiated 4 h T4 after feces injection, peritoneal lavage performed, and a norepinephrine infusion titrated to maintain mean arterial pressure (MAP) between 65-75 mmHg. The experiment was blinded and lasted maximum 24 h. RESULTS During the first 4 h, MAP remained > 65 mmHg in the early treatment group but decreased significantly in the others (p < 0.01 for interaction, median value at T4: (79 [70-90] mmHg for early treatment, 57 [70-90] mmHg for late treatment, and 55 [49-60] mmHg for the control group). mCBS-treated animals required significantly less norepinephrine to maintain MAP than controls (p < 0.01 for interaction) and had lower creatinine (p < 0.01), lactate (p < 0.01), and interleukin-6 (p < 0.01) levels, associated with reduced changes in H3.1 nucleosome levels (p = 0.02). Early treatment was associated with lower norepinephrine requirements than later treatment. Two control animals died; all the mCBS-treated animals survived. CONCLUSIONS Neutralization of extracellular histones with mCBS was associated with reduced norepinephrine requirements, improved tissue perfusion, less renal dysfunction, and lower circulating IL-6 in experimental septic shock and may represent a new therapeutic approach to be tested in clinical trials.
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Affiliation(s)
- Bruno Garcia
- Experimental Laboratory of the Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070, Brussels, Belgium
- Department of Intensive Care, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Fuhong Su
- Experimental Laboratory of the Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070, Brussels, Belgium
| | - Laurence Dewachter
- Laboratory of Physiology and Pharmacology, Université Libre de Bruxelles, Brussels, Belgium
| | - Yong Wang
- Grand Pharma (China) Co., Ltd, Wuhan, China
| | - Ning Li
- Grand Pharma (China) Co., Ltd, Wuhan, China
| | - Myriam Remmelink
- Pathology Laboratory, Erasme Hospital, Hôpitaux Universitaires de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Marie Van Eycken
- Pathology Laboratory, Erasme Hospital, Hôpitaux Universitaires de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Amina Khaldi
- Experimental Laboratory of the Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070, Brussels, Belgium
| | - Raphaël Favory
- Department of Intensive Care, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Antoine Herpain
- Experimental Laboratory of the Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070, Brussels, Belgium
| | - Anthony Moreau
- Experimental Laboratory of the Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070, Brussels, Belgium
- Department of Intensive Care, Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexander Moiroux-Sahraoui
- Experimental Laboratory of the Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070, Brussels, Belgium
| | - Francesca Manicone
- Experimental Laboratory of the Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070, Brussels, Belgium
| | - Filippo Annoni
- Experimental Laboratory of the Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070, Brussels, Belgium
- Department of Intensive Care, Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Lin Shi
- Grand Pharma (China) Co., Ltd, Wuhan, China
| | - Jean-Louis Vincent
- Experimental Laboratory of the Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070, Brussels, Belgium.
| | - Jacques Creteur
- Experimental Laboratory of the Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070, Brussels, Belgium
| | - Fabio S Taccone
- Experimental Laboratory of the Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070, Brussels, Belgium
- Department of Intensive Care, Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
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9
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Lukaszewski M. Dilemmas of Adopting Goal-Directed Perfusion in Extracorporeal Circulation: A Narrative Review. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:535-539. [PMID: 37997651 DOI: 10.1177/15569845231211904] [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: 11/25/2023]
Abstract
OBJECTIVE Extracorporeal circulation (ECC) is generally based on standards established in the last decade. In recent years, a concept of perfusion management during ECC, goal-directed perfusion (GDP), has emerged to create optimal conditions for oxygen delivery and extraction, initiated by Rannuci et al. The aim of the present work was to determine whether the ECC procedure can truly be optimized with the current state of knowledge and understanding of human physiology. METHODS Discussed articles from 2017 to 2022 were selected from the MEDLINE (PubMed) database using the keywords "cardiopulmonary bypass" AND "cardiac surgery" AND "oxygen delivery" with the conditions of "clinical trial" OR "randomized controlled trial." RESULTS The concept of GDP is an attempt to reproduce the physiological conditions of tissue respiration during ECC. Published articles, also due to their retrospective nature, are based on standards and recommendations that do not fully fit the field of physiological circulation. There are still insufficient tools to assess the relationship between volemia, perfusion pressure, and pump performance. Limitations include indications for vasoactive drugs. Methodology has rarely taken into account the period of starting and stopping the heart-lung machine, the most pronounced periods of circulatory destabilization with reduced oxygen delivery. CONCLUSIONS Problems associated with ECC such as acute kidney injury, liver failure, vasoplegic syndrome, and others must await its resolution. The use of advanced monitoring technology and data engineering may allow the development of baseline hemodynamic models, which may make the ECC procedure more physiologic and thus improve the safety of the procedure.
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Affiliation(s)
- Marceli Lukaszewski
- Department for Anaesthesiology and Intensive Care Therapy, Sokolowski Specialized Hospital Wałbrzych, Poland
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10
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Lin YY, Chang HA, Kao YH, Chuu CP, Chiang WF, Chang YC, Li YK, Chu CM, Chan JS, Hsiao PJ. Investigation of the underuse of adrenaline (epinephrine) and prognosis among patients with anaphylaxis at emergency department admission. Front Med (Lausanne) 2023; 10:1163817. [PMID: 37484849 PMCID: PMC10360193 DOI: 10.3389/fmed.2023.1163817] [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: 02/11/2023] [Accepted: 06/01/2023] [Indexed: 07/25/2023] Open
Abstract
Background Anaphylaxis is a potentially fatal condition; in severe cases of anaphylaxis, the cardiovascular system is often heavily involved. Adrenaline (epinephrine) is a cornerstone of the initial treatment of anaphylaxis. The use of epinephrine remains below expectations in clinical practice. Whether the underuse of epinephrine affects the prognosis of patients with anaphylaxis is still unclear. Materials and methods This retrospective study included patients with anaphylaxis between 2011 and 2020 who were admitted to an emergency department (ED) in Taiwan. All patients were divided into two groups based on the use of epinephrine (or not), and we compared the demographic characteristics, allergens, clinical manifestations, management, and patient outcomes. Results We reviewed the records of 314 subjects (216 males, 98 females; mean age: 52.78 ± 16.02 years) who visited our ED due to anaphylaxis; 107 (34.1%) and 207 (65.9%) patients were categorized into the epinephrine use group and the non-epinephrine use group, respectively. Arrival via ambulance (p = 0.019), hypotension (p = 0.002), airway compromise (p < 0.001) and altered consciousness (p < 0.001) were the deciding factors for epinephrine use among anaphylactic patients in the ED. The epinephrine use group had higher rates of other inotropic agent usage and fluid challenge. More than 90% of patients received bed rest, steroids, antihistamines, and monitoring. The epinephrine use group had a longer ED length of stay (387.64 ± 374.71 vs. 313.06 ± 238.99 min, p = 0.03) and a greater need of hospitalization. Among all severe symptoms, hypotension was the most tolerated decision factor for not using epinephrine. In this retrospective analysis, some patients with serious anaphylaxis did not experience adverse outcomes or death even without the use of epinephrine at ED admission. Emergent care focuses first on the airway, breathing, and circulation (ABC) and may compensate for the underusage of epinephrine. This could be the reason why epinephrine was underused among patients with anaphylaxis in the ED. Conclusion In summary, early ABC management continues to play an important role in treating patients with severe anaphylaxis, even when epinephrine is not immediately available in clinical scenarios.
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Affiliation(s)
- Yen-Yue Lin
- Department of Emergency, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
- Department of Emergency, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Department of Life Sciences, National Central University, Taoyuan, Taiwan
| | - Hsin-An Chang
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yung-Hsi Kao
- Department of Life Sciences, National Central University, Taoyuan, Taiwan
| | - Chih-Pin Chuu
- Institute of Cellular and System Medicine, National Health Research Institutes, Zhunan, Taiwan
- Graduate Program for Aging, China Medical University, Taichung, Taiwan
| | - Wen-Fang Chiang
- Division of Nephrology, Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ya-Chieh Chang
- Division of Nephrology, Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yuan-Kuei Li
- Division of Colorectal Surgery, Department of Surgery, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
- Department of Biomedical Sciences and Engineering, National Central University, Taoyuan, Taiwan
| | - Chi-Ming Chu
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
- Department of Public Health, School of Public Health, China Medical University, Taichung, Taiwan
| | - Jenq-Shyong Chan
- Division of Nephrology, Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Po-Jen Hsiao
- Department of Life Sciences, National Central University, Taoyuan, Taiwan
- Institute of Cellular and System Medicine, National Health Research Institutes, Zhunan, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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11
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Zhang T, Niu H, Liu Y, Cai L, Liu D, Zhao E, Li M, Liu W, Li J, Qiao P, Zheng W, Ren P, Wang Z. Dobutamine-induced alternations in cerebral blood flow of healthy adults: a 3D pseudocontinuous arterial spin labeling study. BMC Med 2023; 21:238. [PMID: 37400817 DOI: 10.1186/s12916-023-02928-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 06/08/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND It is unclear whether dobutamine, commonly used clinically in echocardiography and short-term congestive heart failure treatment for promoting increased myocardial contractility, affects brain microcirculatory behavior. Cerebral microcirculation plays an important role in ensuring adequate oxygen transport. Therefore, we investigated the effects of dobutamine on cerebral hemodynamics. METHODS Forty-eight healthy volunteers without cardiovascular or cerebrovascular disease underwent MRI to obtain cerebral blood flow (CBF) maps using 3D pseudocontinuous arterial spin labeling before and during the dobutamine stress test. Additionally, cerebrovascular morphology was obtained based on 3D-time-off-light (3D-TOF) magnetic resonance angiography (MRA). Electrocardiogram, heart rate (HR), respiration rate (RR), blood pressure, and blood oxygen were simultaneously recorded before and during dobutamine injection and during recovery (not during MRI). The anatomic features of the circle of Willis and the basilar artery (BA) diameter were assessed on MRA images by two radiologists with extensive neuroimaging experience. Binary logistic regression was used to test for the independent determinants of CBF changes. RESULTS HR, RR, systolic (SBP), and diastolic blood pressure (DBP) significantly increased after dobutamine infusion. Blood oxygen levels remained similar. Compared to the CBF in the resting state, the CBF values exhibited significantly lower CBF levels in both grey matter and white matter. Furthermore, compared with the CBF in the resting state, that in the stress state was decreased in the anterior circulation, mainly in the frontal lobe (voxel level P < 0.001, pixel level P < 0.05). Logistic regression showed that body mass index (BMI; odds ratio [OR] 5.80, 95% confidence interval [CI] 1.60-21.01, P = 0.008], resting SBP (OR 0.64, 95% CI 0.45-0.92, P = 0.014), and BA diameter (OR 11.04, 95% CI 1.05-116.53, P = 0.046) were significantly associated with frontal lobe CBF changes. CONCLUSIONS Dobutamine-induced stress significantly decreased CBF in the frontal lobe anterior circulation. Individuals with a high BMI and low SBP during the dobutamine stress test are more likely to have a stress-induced CBF decrease. Thus, attention should be paid to blood pressure, BMI, and cerebrovascular morphology of patients undergoing dobutamine stress echocardiography or those receiving intensive care or anesthesia.
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Affiliation(s)
- Tingting Zhang
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Haijun Niu
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Yawen Liu
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Linkun Cai
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Dong Liu
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Erwei Zhao
- National Space Science Center, Chinese Academy of Sciences, Beijing, China
| | - Min Li
- Clinical Epidemiology and EBM Unit, Beijing Friendship Hospital, Capital Medical University, Beijing Clinical Research Institute, Beijing, China
| | - Wenjuan Liu
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jing Li
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - PengGang Qiao
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wei Zheng
- National Space Science Center, Chinese Academy of Sciences, Beijing, China
| | - Pengling Ren
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
| | - Zhenchang Wang
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China.
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
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12
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Garcia B, Legrand M. Adjunctive vasopressors in distributive shock: How soon is early? Crit Care 2023; 27:210. [PMID: 37254175 DOI: 10.1186/s13054-023-04500-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 06/01/2023] Open
Affiliation(s)
- Bruno Garcia
- Department of Anesthesia & Peri-Operative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA.
- Department of Intensive Care, Centre Hospitalier Universitaire de Lille, Lille, France.
- Experimental Laboratory of Intensive Care, Université Libre de Bruxelles, Brussels, Belgium.
| | - Matthieu Legrand
- Department of Anesthesia & Peri-Operative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
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13
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Laou E, Papagiannakis N, Michou A, Ntalarizou N, Ragias D, Angelopoulou Z, Sessler DI, Chalkias A. Association between mean arterial pressure and sublingual microcirculation during major non-cardiac surgery: Post hoc analysis of a prospective cohort. Microcirculation 2023; 30:e12804. [PMID: 36905347 DOI: 10.1111/micc.12804] [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: 11/28/2022] [Revised: 02/13/2023] [Accepted: 03/07/2023] [Indexed: 03/12/2023]
Abstract
OBJECTIVE To test the hypothesis that there is an association between mean arterial pressure (MAP) and sublingual perfusion during major surgery, and perhaps an identifiable harm threshold. METHODS This post hoc analysis of a prospective cohort included patients who had elective major non-cardiac surgery with a duration of ≥2 h under general anesthesia. We assessed sublingual microcirculation every 30 min using SDF+ imaging and determined the De Backer score, Consensus Proportion of Perfused Vessels (Consensus PPV), and the Consensus PPV (small). Our primary outcome was the relationship between MAP and sublingual perfusion which was evaluated with linear mixed effects modeling. RESULTS A total of 100 patients were included, with MAP ranging between 65 mmHg and 120 mmHg during anesthesia and surgery. Over a range of intraoperative MAPs between 65 and 120 mmHg, there were no meaningful associations between blood pressure and various measures of sublingual perfusion. There were also no meaningful changes in microcirculatory flow over 4.5 h of surgery. CONCLUSIONS In patients having elective major non-cardiac surgery with general anesthesia, sublingual microcirculation is well maintained when MAP ranges between 65 and 120 mmHg. It remains possible that sublingual perfusion will be a useful marker of tissue perfusion when MAP is lower than 65 mmHg.
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Affiliation(s)
- Eleni Laou
- Department of Anesthesiology, Agia Sophia Children's Hospital, Athens, Greece
| | - Nikolaos Papagiannakis
- First Department of Neurology, Eginition University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasia Michou
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Nicoleta Ntalarizou
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Dimitrios Ragias
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | | | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Athanasios Chalkias
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, Larisa, Greece
- Outcomes Research Consortium, Cleveland, Ohio, USA
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14
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Impacts of vascular comorbidities on free flap perfusion in microvascular head and neck reconstruction. Eur Arch Otorhinolaryngol 2023; 280:3375-3382. [PMID: 36897365 DOI: 10.1007/s00405-023-07913-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 03/04/2023] [Indexed: 03/11/2023]
Abstract
PURPOSE Arterial hypertension (AHTN), type 2 diabetes mellitus (DM), and atherosclerotic vascular disease (ASVD) are common vascular comorbidities in patients undergoing reconstruction of the head and neck region with a microvascular free flap. These conditions may affect flap perfusion (microvascular blood flow and tissue oxygenation), which is a prerequisite for flap survival and thus reconstruction success. This study aimed to investigate the impacts of AHTN, DM, and ASVD on flap perfusion. METHODS Data from 308 patients who underwent successful reconstruction of the head and neck region with radial free forearm flaps, anterolateral thigh flaps, or fibula free flaps between 2011 and 2020 were retrospectively analyzed. Flap perfusion was measured intraoperatively and postoperatively with the O2C tissue oxygen analysis system. Flap blood flow, hemoglobin concentration, and hemoglobin oxygen saturation were compared between patients with and without AHTN, DM, and ASVD. RESULTS Intraoperative hemoglobin oxygen saturation and postoperative blood flow were lower in patients with ASVD than in patients without ASVD (63.3% vs. 69.5%, p = 0.046; 67.5 arbitrary units [AU] vs. 85.0 AU, p = 0.036; respectively). These differences did not persist in the multivariable analysis (all p > 0.05). No difference was found in intraoperative or postoperative blood flow or hemoglobin oxygen saturation between patients with and without AHTN or DM (all p > 0.05). CONCLUSION Perfusion of microvascular free flaps used for head and neck reconstruction is not impaired in patients with AHTN, DM, or ASVD. Unrestricted flap perfusion may contribute to the observed successful use of microvascular free flaps in patients with these comorbidities.
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15
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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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16
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Liang Q, Li L, Chen K, An S, Deng Z, Li J, Zhou S, Chen Z, Zeng Z, An S. Effect of Esmolol on Clinical Outcomes in Critically Ill Patients: Data from the MIMIC-IV Database. J Cardiovasc Pharmacol Ther 2023; 28:10742484231185985. [PMID: 37415421 DOI: 10.1177/10742484231185985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
BACKGROUND AND AIMS Esmolol is a common short-acting drug to control ventricular rate. This study aimed to evaluate the association between use of esmolol and mortality in critically ill patients. METHODS This is a retrospective cohort study from MIMIC-IV database containing adult patients with a heart rate of over 100 beats/min during the intensive care unit (ICU) stay. Multivariable Cox proportional hazard models and logistic regression were used to explore the association between esmolol and mortality and adjust confounders. A 1:1 nearest neighbor propensity score matching (PSM) was performed to minimize potential cofounding bias. The comparison for secondary outcomes was performed at different points of time using an independent t-test. RESULTS A total of 30,332 patients were reviewed and identified as critically ill. There was no significant difference in 28-day mortality between two groups before (HR = 0.90, 95% CI = 0.73-1.12, p = 0.343) and after PSM (HR = 0.84, 95% CI = 0.65-1.08, p = 0.167). Similar results were shown in 90-day mortality before (HR = 0.93, 95% CI = 0.75-1.14, p = 0.484) and after PSM (HR = 0.85, 95% CI = 0.67-1.09, p = 0.193). However, esmolol treatment was associated with higher requirement of vasopressor use before (HR = 2.89, 95% CI = 2.18-3.82, p < 0.001) and after PSM (HR = 2.66, 95% CI = 2.06-3.45, p < 0.001). Esmolol treatment statistically reduced diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rate (all p < 0.001) and increased fluid balance at 24 hours (p < 0.05) but did not significantly lower SBP (p = 0.721). Patients in esmolol group showed no significant difference in lactate levels and daily urine output when compared with those in non-esmolol group when adjusted for confounders (all p > 0.05). CONCLUSION Esmolol treatment was associated with reduced heart rate and lowered DBP and MAP, which may increase vasopressor use and fluid balance at the timepoint of 24 hours in critically ill patients during ICU stay. However, after adjusting for confounders, esmolol treatment was not associated with 28-day and 90-day mortality.
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Affiliation(s)
- Qihong Liang
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Biostatistics, School of Public Health (Guangdong Provincial Key Laboratory of Tropical Disease Research), Southern Medical University, Guangzhou, Guangdong, China
| | - Lulan Li
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Pathophysiology, Guangdong Provincial Key Lab of Shock and Microcirculation, Southern Medical University, Guangzhou, China
| | - Kerong Chen
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Sheng An
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhiya Deng
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jiaxin Li
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shiyu Zhou
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Biostatistics, School of Public Health (Guangdong Provincial Key Laboratory of Tropical Disease Research), Southern Medical University, Guangzhou, Guangdong, China
| | - Zhongqing Chen
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhenhua Zeng
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Pathophysiology, Guangdong Provincial Key Lab of Shock and Microcirculation, Southern Medical University, Guangzhou, China
| | - Shengli An
- Department of Biostatistics, School of Public Health (Guangdong Provincial Key Laboratory of Tropical Disease Research), Southern Medical University, Guangzhou, Guangdong, China
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Mostovaya O, Shiabiev I, Pysin D, Stanavaya A, Abashkin V, Shcharbin D, Padnya P, Stoikov I. PAMAM-Calix-Dendrimers: Second Generation Synthesis, Fluorescent Properties and Catecholamines Binding. Pharmaceutics 2022; 14:pharmaceutics14122748. [PMID: 36559243 PMCID: PMC9781744 DOI: 10.3390/pharmaceutics14122748] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/04/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
A convenient method for the synthesis of the second generation of PAMAM dendrimers based on a p-tert-butylthiacalix[4]arene core in cone, partial cone and 1,3-alternate conformations was developed. Unusual fluorescence of the obtained PAMAM-calix-dendrimers has been found and explained. The binding ability of the synthesized dendrimers toward catecholamines (dopamine, L-adrenaline and L-noradrenaline) was shown by UV-Vis, fluorescence, 1D and 2D NMR spectroscopy and the binding constants (logKa 3.85-4.74) calculated. As was shown, the PAMAM-calix-dendrimers bind catecholamines by the internal cavities. All the studied hormones were most efficiently bound by the dendrimers bearing a macrocyclic core in 1,3-alternate conformation. The size of the formed supramolecular systems of dendrimer/catecholamine was established by the DLS method. A decrease in hemolytic activity of the PAMAM-calix-dendrimers with an increase in the generation number of a dendrimer was shown for the dendrimers with a core in 1,3-alternate conformation. The prospects for the use of the synthesized dendrimers with the macrocyclic core as drug delivery agents were discussed.
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Affiliation(s)
- Olga Mostovaya
- A.M. Butlerov Chemical Institute, Kazan Federal University, 18 Kremlevskaya Street, Kazan 420008, Russia
- Correspondence: (O.M.); (I.S.); Tel.: +7-843-233-7241 (I.S.)
| | - Igor Shiabiev
- A.M. Butlerov Chemical Institute, Kazan Federal University, 18 Kremlevskaya Street, Kazan 420008, Russia
| | - Dmitry Pysin
- A.M. Butlerov Chemical Institute, Kazan Federal University, 18 Kremlevskaya Street, Kazan 420008, Russia
| | - Alesia Stanavaya
- Institute of Biophysics and Cell Engineering of NASB, 27 Akademicheskaya Street, 220072 Minsk, Belarus
| | - Viktar Abashkin
- Institute of Biophysics and Cell Engineering of NASB, 27 Akademicheskaya Street, 220072 Minsk, Belarus
| | - Dzmitry Shcharbin
- Institute of Biophysics and Cell Engineering of NASB, 27 Akademicheskaya Street, 220072 Minsk, Belarus
| | - Pavel Padnya
- A.M. Butlerov Chemical Institute, Kazan Federal University, 18 Kremlevskaya Street, Kazan 420008, Russia
| | - Ivan Stoikov
- A.M. Butlerov Chemical Institute, Kazan Federal University, 18 Kremlevskaya Street, Kazan 420008, Russia
- Federal Center for Toxicological, Radiation and Biological Safety, 2 Nauchny Gorodok Street, Kazan 420075, Russia
- Correspondence: (O.M.); (I.S.); Tel.: +7-843-233-7241 (I.S.)
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Ooms M, Puladi B, Winnand P, Heitzer M, Steiner T, Bickenbach J, Hölzle F, Modabber A. Perfusion of microvascular free flaps in head and neck reconstruction after prior neck dissection and irradiation. Int J Oral Maxillofac Surg 2022; 52:640-647. [PMID: 36253245 DOI: 10.1016/j.ijom.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 10/05/2022] [Accepted: 10/07/2022] [Indexed: 12/24/2022]
Abstract
Microvascular free flaps are frequently used for head and neck reconstruction after prior neck dissection (ND) and neck irradiation (RTX). The aim of this study was to investigate the influence of ND and RTX on flap perfusion as a critical factor for flap success. Overall, 392 patients reconstructed with a microvascular fasciocutaneous flap (FF) or perforator flap (PF) in the head and neck region between 2011 and 2020 were analysed retrospectively. Flap perfusion measured intraoperatively and postoperatively with the O2C tissue oxygen analysis system was compared between patients who had received neither ND nor RTX (controls), patients who had received ND but no RTX (ND group), and patients who had received both ND and RTX (ND+RTX group). Intraoperative and postoperative flap blood flow was decreased in FFs in ND group patients compared to controls (median 66.3 AU vs 86.0 AU, P = 0.023; median 73.5 AU vs 93.8 AU, P = 0.045, respectively). In the multivariable analysis, these differences showed a tendency to persist (P = 0.052 and P = 0.056). Flap success rates were similar in control patients, ND patients, and ND+RTX patients (98.7%, 94.0%, and 97.6%, respectively). Flap perfusion is not reduced in FFs and PFs in patients who have undergone ND or ND and RTX. This indicates that neck dissection and neck irradiation should not be contraindications for microvascular free flap reconstruction.
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Zhao CC, Zhai YJ, Hu ZJ, Huo Y, Li ZQ, Zhu GJ. Efficacy and safety of methylene blue in patients with vasodilatory shock: A systematic review and meta-analysis. Front Med (Lausanne) 2022; 9:950596. [PMID: 36237547 PMCID: PMC9552293 DOI: 10.3389/fmed.2022.950596] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/01/2022] [Indexed: 12/03/2022] Open
Abstract
Background The role of methylene blue (MB) in patients with vasodilatory shock is unclear. The purpose of this systematic review and meta-analysis was to evaluate the efficacy and safety of MB in patients with vasodilatory shock. Methods We searched MEDLINE at PubMed, Embase, Web of Science, Cochrane, CNKI, CBM and Wanfang Medical databases for all observational and intervention studies comparing the effect of MB vs. control in vasodilatory shock patients. This study was performed in accordance with the PRISMA statement. There were no language restrictions for inclusion. Results A total of 15 studies with 832 patients were included. Pooled data demonstrated that administration of MB along with vasopressors significantly reduced mortality [odds ratio (OR) 0.54, 95% confidence interval (CI) 0.34 to 0.85, P = 0.008; I 2 = 7%]. This benefit in mortality rate was also seen in a subgroup analysis including randomized controlled trials and quasi-randomized controlled trials. In addition, the vasopressor requirement was reduced in the MB group [mean difference (MD) -0.77, 95%CI -1.26 to -0.28, P = 0.002; I 2 = 80%]. Regarding hemodynamics, MB increased the mean arterial pressure, heart rate and peripheral vascular resistance. In respect to organ function, MB was associated with a lower incidence of renal failure, while in regards to oxygen metabolism, it was linked to reduced lactate levels. MB had no effect on the other outcomes and no serious side effects. Conclusions Concomitant administration of MB and vasopressors improved hemodynamics, decreased vasopressor requirements, reduced lactate levels, and improved survival in patients with vasodilatory shock. However, further studies are required to confirm these findings. Systematic review registration Identifier: CRD42021281847.
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Affiliation(s)
- Cong-Cong Zhao
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yu-Jia Zhai
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhen-Jie Hu
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yan Huo
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhi-Qiang Li
- Department of Intensive Care Unit, Affiliated Hospital of North China University of Science and Technology, Tangshan, China
| | - Gui-Jun Zhu
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
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20
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Chalkias A, Xenos M. Relationship of Effective Circulating Volume with Sublingual Red Blood Cell Velocity and Microvessel Pressure Difference: A Clinical Investigation and Computational Fluid Dynamics Modeling. J Clin Med 2022; 11:jcm11164885. [PMID: 36013124 PMCID: PMC9410298 DOI: 10.3390/jcm11164885] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/18/2022] Open
Abstract
The characteristics of physiologic hemodynamic coherence are not well-investigated. We examined the physiological relationship between circulating blood volume, sublingual microcirculatory perfusion, and tissue oxygenation in anesthetized individuals with steady-state physiology. We assessed the correlation of mean circulatory filling pressure analogue (Pmca) with sublingual microcirculatory perfusion and red blood cell (RBC) velocity using SDF+ imaging and a modified optical flow-based algorithm. We also reconstructed the 2D microvessels and applied computational fluid dynamics (CFD) to evaluate the correlation of Pmca and RBC velocity with the obtained pressure and velocity fields in microvessels from CFD (pressure difference, (Δp)). Twenty adults with a median age of 39.5 years (IQR 35.5−44.5) were included in the study. Sublingual velocity distributions were similar and followed a log-normal distribution. A constant Pmca value of 14 mmHg was observed in all individuals with sublingual RBC velocity 6−24 μm s−1, while a Pmca < 14 mmHg was observed in those with RBC velocity > 24 μm s−1. When Pmca ranged between 11 mmHg and 15 mmHg, Δp fluctuated between 0.02 Pa and 0.1 Pa. In conclusion, the intact regulatory mechanisms maintain a physiological coupling between systemic hemodynamics, sublingual microcirculatory perfusion, and tissue oxygenation when Pmca is 14 mmHg.
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Affiliation(s)
- Athanasios Chalkias
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
- Outcomes Research Consortium, Cleveland, OH 44195, USA
- Committee on Shock, Hellenic Society of Cardiopulmonary Resuscitation, 10434 Athens, Greece
- Correspondence:
| | - Michalis Xenos
- Section of Applied and Computational Mathematics, Department of Mathematics, University of Ioannina, 45110 Ioannina, Greece
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21
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Ooms M, Puladi B, Houschyar KS, Heitzer M, Rashad A, Bickenbach J, Hölzle F, Modabber A. Smoking and microvascular free flap perfusion in head and neck reconstruction: radial free forearm flaps and anterolateral thigh flaps. Sci Rep 2022; 12:13902. [PMID: 35974131 PMCID: PMC9381556 DOI: 10.1038/s41598-022-18216-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 08/08/2022] [Indexed: 11/09/2022] Open
Abstract
Head and neck reconstruction with microvascular free flaps is frequently performed in smokers. Smoking causes various alterations in the cardiovascular system. The aim of this study was to investigate the effects of smoking on flap perfusion as a critical factor for flap survival. A total of 370 patients reconstructed with a radial free forearm flap (RFFF) or anterolateral thigh flap (ALTF) in the head and neck region between 2011 and 2020 were retrospectively analyzed. Flap perfusion measurements with the O2C tissue oxygen analysis system were compared between nonsmokers, light smokers (< 20 pack-years), and heavy smokers (≥ 20 pack-years). The blood flow was intraoperatively equal in RFFFs (84.5 AU vs. 84.5 AU; p = 0.900) and increased in ALTFs (80.5 AU vs. 56.5 AU; p = 0.001) and postoperatively increased in RFFFs (114.0 AU vs. 86.0 AU; p = 0.035) and similar in ALTFs (70.5 AU vs. 71.0 AU; p = 0.856) in heavy smokers compared to nonsmokers. The flap survival rate was similar in nonsmokers, light smokers, and heavy smokers (97.3%, 98.4%, and 100.0%). Smoking partially increases rather than decreases microvascular free flap perfusion, which may contribute to similar flap survival rates in smokers and nonsmokers.
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Affiliation(s)
- Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Behrus Puladi
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Khosrow Siamak Houschyar
- Department of Dermatology and Allergology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ashkan Rashad
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Johannes Bickenbach
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
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22
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Akil A, Ziegeler S, Rehers S, Ernst EC, Fischer S. Blood purification therapy in patients with severe COVID-19 requiring veno-venous ECMO therapy: A retrospective study. Int J Artif Organs 2022; 45:615-622. [PMID: 35695200 DOI: 10.1177/03913988221103287] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Patients with severe manifestations of COVID-19 might exhibit characteristics of a sepsis-like syndrome that can progress to multiple organ failure and ultimately death. Underlying mechanism have been explored and suggest a profound dysregulation of the immune system associated with hyperinflammation, hemodynamic instability and respiratory failure. Besides standard intensive care treatment, approaches modulating the dysregulated immune response, such as CytoSorb hemoadsorption, have been used. However, data of ECMO-dependent patients in comparison to a control cohort remain scarce. METHODS Included were 26 critically ill COVID-19 patients requiring high-flow veno-venous extracorporeal membrane oxygenation (high-flow VV ECMO) therapy due to severe acute respiratory distress syndrome (ARDS), of whom 16 were additionally treated with an extracorporeal hemoadsorption device, and compared to a control group of 10 patients. Assessed were levels of inflammatory markers, vasopressor requirements, oxygenation parameters, as well as clinically relevant outcome variables. Data were prospectively recorded and retrospectively analyzed. RESULTS Treatment with the applied multimodal therapy approach resulted in a stabilization in hemodynamics, a control of the hyperinflammatory response as evidenced by a significant reduction in inflammatory mediators, as well as a marked improvement in lung function. No device related adverse events were observed while treatment appeared safe and feasible. CONCLUSION Treatment of a critically ill COVID-19 ARDS patients with combined VV ECMO support and hemoadsorption therapy led to a rapid and sustained hemodynamic stabilization, a control of the uncontrolled inflammatory response and an improvement in oxygenation. Given these signals pointing toward a patient-oriented benefit of extracorporeal hemoadsorption therapy in those patients, future controlled, randomized studies should focus on the investigation of the appropriate timing and dosing of this promising treatment modality.
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Affiliation(s)
- Ali Akil
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Stephan Ziegeler
- Department of Anesthesiology, Intensive Care Medicine and Pain Management, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Stephanie Rehers
- Department of Anesthesiology, Intensive Care Medicine and Pain Management, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Erik Christian Ernst
- Department of Respiratory Medicine and Pulmonary Rehabilitation, Karl-Hansen-Hospital, Bad Lippspringe, Germany
| | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
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Vollenweider R, Manettas AI, Häni N, de Bruin ED, Knols RH. Passive motion of the lower extremities in sedated and ventilated patients in the ICU - a systematic review of early effects and replicability of Interventions. PLoS One 2022; 17:e0267255. [PMID: 35552550 PMCID: PMC9098053 DOI: 10.1371/journal.pone.0267255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 04/05/2022] [Indexed: 01/02/2023] Open
Abstract
Early mobilization, which includes active / passive motion in bed along with mobilization out of bed, is recommended to prevent the development of intensive care unit acquired-weakness (ICU-AW) for patients with critical illness on the intensive care unit. To date, the impact of passive motion of the lower extremities in sedated and ventilated patients remains unclear. The aim of the study is to systematically review and summarize the currently available randomized controlled trials in English or German language on the impact of passive motion of the lower extremities in sedated and ventilated patients ≥ 18 years in the intensive care unit on musculature, inflammation and immune system and the development of intensive care unit-acquired weakness and to evaluate the replicability of interventions and the methodological quality of included studies. A systematic literature search was performed up to 20th February 2022 in the databases Medline, Embase, Cochrane Library, CINAHL and PEDro. The description of the intervention (TIDieR checklist) and the methodological quality (Downs and Black checklist) were assessed. Five studies were included in the qualitative syntheses. On average, the studies were rated with 6.8 out of 12 points according to the TIDieR checklist. For the methodological quality an average of 19.8 out of 27 points on the Downs and Black checklist was reported. The results of included studies indicated that muscle loss may be reduced by passive manual movement, passive cycling and passive motion on a continuous passive motion-unit. In addition, positive effects were reported on the reduction of nitrosative stress and the immune response. The impact on the development of ICU-AW remains unclear. In conclusion, passive movement show a slight tendency for beneficial changes on cellular level in sedated and ventilated patients in the ICU within the first days of admission, which may indicate a reduction of muscle wasting and could prevent the development of ICU-AW. Future randomized controlled trials should use larger samples, use complete intervention description, use a comparable set of outcome measures, use rigorous methodology and examine the effect of passive motion on the development of ICU-AW.
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Affiliation(s)
- Rahel Vollenweider
- Nursing and Allied Health Profession Office, Physiotherapy Occupational Therapy, University Hospital Zurich, Zurich, Switzerland
| | - Anastasios I. Manettas
- Nursing and Allied Health Profession Office, Physiotherapy Occupational Therapy, University Hospital Zurich, Zurich, Switzerland
| | - Nathalie Häni
- Nursing and Allied Health Profession Office, Physiotherapy Occupational Therapy, University Hospital Zurich, Zurich, Switzerland
| | - Eling D. de Bruin
- Department of Health Sciences and Technology, Institute of Human Movement Sciences and Sport, ETH Zurich, Zurich, Switzerland
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna, Sweden
- OST–Eastern Swiss University of Applied Sciences, Department of Health, St. Gallen, Switzerland
| | - Ruud H. Knols
- Department of Health Sciences and Technology, Institute of Human Movement Sciences and Sport, ETH Zurich, Zurich, Switzerland
- Directorate of Research and Education, Physiotherapy Occupational Therapy Research Center, University Hospital Zurich, Zurich, Switzerland
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Suzuki R, Uchino S, Sasabuchi Y, Kawarai Lefor A, Sanui M. Dopamine use and its consequences in the intensive care unit: a cohort study utilizing the Japanese Intensive care PAtient Database. Crit Care 2022; 26:90. [PMID: 35366934 PMCID: PMC8977005 DOI: 10.1186/s13054-022-03960-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 03/19/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Dopamine is used to treat patients with shock in intensive care units (ICU) throughout the world, despite recent evidence against its use. The aim of this study was to identify the latest practice of dopamine use in Japan and also to explore the consequences of dopamine use in a large Asian population.
Methods
The Japanese Intensive Care PAtient Database (JIPAD), the largest intensive care database in Japan, was utilized. Inclusion criteria included: 1) age 18 years or older, 2) admitted to the ICU for reasons other than procedures, 3) ICU length of stay of 24 h or more, and 4) treatment with either dopamine or noradrenaline within 24 h of admission. The primary outcome was in-hospital mortality. Multivariable regression analysis was performed, followed by a propensity score-matched analysis.
Results
Of the 132,354 case records, 14,594 records from 56 facilities were included in this analysis. Dopamine was administered to 4,653 patients and noradrenaline to 11,844. There was no statistically significant difference in facility characteristics between frequent dopamine users (N = 28) and infrequent users (N = 28). Patients receiving dopamine had more cardiovascular diagnosis codes (70% vs. 42%; p < 0.01), more post-elective surgery status (60% vs. 31%), and lower APACHE III scores compared to patients given noradrenaline alone (70.7 vs. 83.0; p < 0.01). Multivariable analysis showed an odds ratio for in-hospital mortality of 0.86 [95% CI: 0.71–1.04] in the dopamine ≤ 5 μg/kg/min group, 1.46 [95% CI: 1.18–1.82] in the 5–15 μg/kg/min group, and 3.30 [95% CI: 1.19–9.19] in the > 15 μg/kg/min group. In a 1:1 propensity score matching for dopamine use as a vasopressor (570 pairs), both in-hospital mortality and ICU mortality were significantly higher in the dopamine group compared to no dopamine group (22.5% vs. 17.4%, p = 0.038; 13.3% vs. 8.8%, p = 0.018), as well as ICU length of stay (mean 9.3 days vs. 7.4 days, p = 0.004).
Conclusion
Dopamine is still widely used in Japan. The results of this study suggest detrimental effects of dopamine use specifically at a high dose.
Trial registration Retrospectively registered upon approval of the Institutional Review Board and the administration office of JIPAD.
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Flinspach AN, Booke H, Zacharowski K, Balaban Ü, Herrmann E, Adam EH. Associated Factors of High Sedative Requirements within Patients with Moderate to Severe COVID-19 ARDS. J Clin Med 2022; 11:588. [PMID: 35160040 PMCID: PMC8837042 DOI: 10.3390/jcm11030588] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/16/2022] [Accepted: 01/19/2022] [Indexed: 02/04/2023] Open
Abstract
The coronavirus pandemic continues to challenge global healthcare. Severely affected patients are often in need of high doses of analgesics and sedatives. The latter was studied in critically ill coronavirus disease 2019 (COVID-19) patients in this prospective monocentric analysis. COVID-19 acute respiratory distress syndrome (ARDS) patients admitted between 1 April and 1 December 2020 were enrolled in the study. A statistical analysis of impeded sedation using mixed-effect linear regression models was performed. Overall, 114 patients were enrolled, requiring unusual high levels of sedatives. During 67.9% of the observation period, a combination of sedatives was required in addition to continuous analgesia. During ARDS therapy, 85.1% (n = 97) underwent prone positioning. Veno-venous extracorporeal membrane oxygenation (vv-ECMO) was required in 20.2% (n = 23) of all patients. vv-ECMO patients showed significantly higher sedation needs (p < 0.001). Patients with hepatic (p = 0.01) or renal (p = 0.01) dysfunction showed significantly lower sedation requirements. Except for patient age (p = 0.01), we could not find any significant influence of pre-existing conditions. Age, vv-ECMO therapy and additional organ failure could be demonstrated as factors influencing sedation needs. Young patients and those receiving vv-ECMO usually require increased sedation for intensive care therapy. However, further studies are needed to elucidate the causes and mechanisms of impeded sedation.
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Affiliation(s)
- Armin N. Flinspach
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe-University Frankfurt, 60590 Frankfurt/Main, Germany; (H.B.); (K.Z.); (E.H.A.)
| | - Hendrik Booke
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe-University Frankfurt, 60590 Frankfurt/Main, Germany; (H.B.); (K.Z.); (E.H.A.)
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe-University Frankfurt, 60590 Frankfurt/Main, Germany; (H.B.); (K.Z.); (E.H.A.)
| | - Ümniye Balaban
- Department of Biostatistics and Mathematical Modelling, Goethe-University Frankfurt, 60590 Frankfurt/Main, Germany; (Ü.B.); (E.H.)
| | - Eva Herrmann
- Department of Biostatistics and Mathematical Modelling, Goethe-University Frankfurt, 60590 Frankfurt/Main, Germany; (Ü.B.); (E.H.)
| | - Elisabeth H. Adam
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe-University Frankfurt, 60590 Frankfurt/Main, Germany; (H.B.); (K.Z.); (E.H.A.)
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Dietrich M, Özdemir B, Gruneberg D, Petersen C, Studier-Fischer A, von der Forst M, Schmitt FCF, Fiedler MO, Nickel F, Müller-Stich BP, Brenner T, Weigand MA, Uhle F, Schmidt K. Hyperspectral Imaging for the Evaluation of Microcirculatory Tissue Oxygenation and Perfusion Quality in Haemorrhagic Shock: A Porcine Study. Biomedicines 2021; 9:1829. [PMID: 34944645 PMCID: PMC8698916 DOI: 10.3390/biomedicines9121829] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 11/27/2021] [Accepted: 11/29/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The ultimate goal of haemodynamic therapy is to improve microcirculatory tissue and organ perfusion. Hyperspectral imaging (HSI) has the potential to enable noninvasive microcirculatory monitoring at bedside. METHODS HSI (Tivita® Tissue System) measurements of tissue oxygenation, haemoglobin, and water content in the skin (ear) and kidney were evaluated in a double-hit porcine model of major abdominal surgery and haemorrhagic shock. Animals of the control group (n = 7) did not receive any resuscitation regime. The interventional groups were treated exclusively with either crystalloid (n = 8) or continuous norepinephrine infusion (n = 7). RESULTS Haemorrhagic shock led to a drop in tissue oxygenation parameters in all groups. These correlated with established indirect markers of tissue oxygenation. Fluid therapy restored tissue oxygenation parameters. Skin and kidney measurements correlated well. High dose norepinephrine therapy deteriorated tissue oxygenation. Tissue water content increased both in the skin and the kidney in response to fluid therapy. CONCLUSIONS HSI detected dynamic changes in tissue oxygenation and perfusion quality during shock and was able to indicate resuscitation effectivity. The observed correlation between HSI skin and kidney measurements may offer an estimation of organ oxygenation impairment from skin monitoring. HSI microcirculatory monitoring could open up new opportunities for the guidance of haemodynamic management.
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Affiliation(s)
- Maximilian Dietrich
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.G.); (C.P.); (M.v.d.F.); (F.C.F.S.); (M.O.F.); (M.A.W.); (F.U.)
| | - Berkin Özdemir
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany; (B.Ö.); (A.S.-F.); (F.N.); (B.P.M.-S.)
| | - Daniel Gruneberg
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.G.); (C.P.); (M.v.d.F.); (F.C.F.S.); (M.O.F.); (M.A.W.); (F.U.)
| | - Clara Petersen
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.G.); (C.P.); (M.v.d.F.); (F.C.F.S.); (M.O.F.); (M.A.W.); (F.U.)
| | - Alexander Studier-Fischer
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany; (B.Ö.); (A.S.-F.); (F.N.); (B.P.M.-S.)
| | - Maik von der Forst
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.G.); (C.P.); (M.v.d.F.); (F.C.F.S.); (M.O.F.); (M.A.W.); (F.U.)
| | - Felix C. F. Schmitt
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.G.); (C.P.); (M.v.d.F.); (F.C.F.S.); (M.O.F.); (M.A.W.); (F.U.)
| | - Mascha O. Fiedler
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.G.); (C.P.); (M.v.d.F.); (F.C.F.S.); (M.O.F.); (M.A.W.); (F.U.)
| | - Felix Nickel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany; (B.Ö.); (A.S.-F.); (F.N.); (B.P.M.-S.)
| | - Beat Peter Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany; (B.Ö.); (A.S.-F.); (F.N.); (B.P.M.-S.)
| | - Thorsten Brenner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany; (T.B.); (K.S.)
| | - Markus A. Weigand
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.G.); (C.P.); (M.v.d.F.); (F.C.F.S.); (M.O.F.); (M.A.W.); (F.U.)
| | - Florian Uhle
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.G.); (C.P.); (M.v.d.F.); (F.C.F.S.); (M.O.F.); (M.A.W.); (F.U.)
| | - Karsten Schmidt
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany; (T.B.); (K.S.)
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27
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Petitjeans F, Geloen A, Pichot C, Leroy S, Ghignone M, Quintin L. Is the Sympathetic System Detrimental in the Setting of Septic Shock, with Antihypertensive Agents as a Counterintuitive Approach? A Clinical Proposition. J Clin Med 2021; 10:4569. [PMID: 34640590 PMCID: PMC8509206 DOI: 10.3390/jcm10194569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/05/2021] [Accepted: 09/07/2021] [Indexed: 12/14/2022] Open
Abstract
Mortality in the setting of septic shock varies between 20% and 100%. Refractory septic shock leads to early circulatory failure and carries the worst prognosis. The pathophysiology is poorly understood despite studies of the microcirculatory defects and the immuno-paralysis. The acute circulatory distress is treated with volume expansion, administration of vasopressors (usually noradrenaline: NA), and inotropes. Ventilation and anti-infectious strategy shall not be discussed here. When circulation is considered, the literature is segregated between interventions directed to the systemic circulation vs. interventions directed to the micro-circulation. Our thesis is that, after stabilization of the acute cardioventilatory distress, the prolonged sympathetic hyperactivity is detrimental in the setting of septic shock. Our hypothesis is that the sympathetic hyperactivity observed in septic shock being normalized towards baseline activity will improve the microcirculation by recoupling the capillaries and the systemic circulation. Therefore, counterintuitively, antihypertensive agents such as beta-blockers or alpha-2 adrenergic agonists (clonidine, dexmedetomidine) are useful. They would reduce the noradrenaline requirements. Adjuncts (vitamins, steroids, NO donors/inhibitors, etc.) proposed to normalize the sepsis-evoked vasodilation are not reviewed. This itemized approach (systemic vs. microcirculation) requires physiological and epidemiological studies to look for reduced mortality.
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Affiliation(s)
- Fabrice Petitjeans
- Critical Care, Hôpital d’Instruction des Armées Desgenettes, 69003 Lyon, France;
| | - Alain Geloen
- UMR Ecologie Microbienne Lyon (LEM), University of Lyon, 69100 Villeurbanne, France;
| | - Cyrille Pichot
- Critical Care, Hôpital Louis Pasteur, 39108 Dole, France;
| | | | - Marco Ghignone
- Critical Care, JF Kennedy Hospital North Campus, West Palm Beach, FL 33407, USA;
| | - Luc Quintin
- Critical Care, Hôpital d’Instruction des Armées Desgenettes, 69003 Lyon, France;
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M‘Pembele R, Roth S, Stroda A, Lurati Buse G, Sixt SU, Westenfeld R, Polzin A, Rellecke P, Tudorache I, Hollmann MW, Aubin H, Akhyari P, Lichtenberg A, Huhn R, Boeken U. Risk Factors for Acute Kidney Injury Requiring Renal Replacement Therapy after Orthotopic Heart Transplantation in Patients with Preserved Renal Function. J Clin Med 2021; 10:jcm10184117. [PMID: 34575227 PMCID: PMC8470552 DOI: 10.3390/jcm10184117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 09/06/2021] [Accepted: 09/09/2021] [Indexed: 12/26/2022] Open
Abstract
Acute kidney injury (AKI), requiring renal replacement therapy (RRT). is a serious complication after orthotopic heart transplantation (HTX). In patients with preexisting impaired renal function, postoperative AKI is unsurprising. However, even in patients with preserved renal function, AKI requiring RRT is frequent. Therefore, this study aimed to identify risk factors associated with postoperative AKI requiring RRT after HTX in this sub-cohort. This retrospective cohort study included patients ≥ 18 years of age with preserved renal function (defined as preoperative glomerular filtration rate ≥ 60 mL/min) who underwent HTX between 2010 and 2021. In total, 107 patients were included in the analysis (mean age 52 ± 12 years, 78.5% male, 45.8% AKI requiring RRT). Based on univariate logistic regression, use of extracorporeal membrane oxygenation, postoperative infection, levosimendan therapy, duration of norepinephrine (NE) therapy and maximum daily increase in tacrolimus plasma levels were chosen to be included into multivariate analysis. Duration of NE therapy and maximum daily increase in tacrolimus plasma levels remained as independent significant risk factors (NE: OR 1.01, 95%CI: 1.00–1.02, p = 0.005; increase in tacrolimus plasma level: OR 1.18, 95%CI: 1.01–1.37, p = 0.036). In conclusion, this study identified long NE therapy and maximum daily increase in tacrolimus plasma levels as risk factors for AKI requiring RRT in HTX patients with preserved renal function.
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Affiliation(s)
- René M‘Pembele
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, 40225 Duesseldorf, Germany; (R.M.); (S.R.); (A.S.); (G.L.B.); (S.U.S.); (R.H.)
| | - Sebastian Roth
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, 40225 Duesseldorf, Germany; (R.M.); (S.R.); (A.S.); (G.L.B.); (S.U.S.); (R.H.)
| | - Alexandra Stroda
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, 40225 Duesseldorf, Germany; (R.M.); (S.R.); (A.S.); (G.L.B.); (S.U.S.); (R.H.)
| | - Giovanna Lurati Buse
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, 40225 Duesseldorf, Germany; (R.M.); (S.R.); (A.S.); (G.L.B.); (S.U.S.); (R.H.)
| | - Stephan U. Sixt
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, 40225 Duesseldorf, Germany; (R.M.); (S.R.); (A.S.); (G.L.B.); (S.U.S.); (R.H.)
| | - Ralf Westenfeld
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, 40225 Duesseldorf, Germany; (R.W.); (A.P.)
| | - Amin Polzin
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, 40225 Duesseldorf, Germany; (R.W.); (A.P.)
| | - Philipp Rellecke
- Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, 40225 Duesseldorf, Germany; (P.R.); (I.T.); (H.A.); (P.A.); (U.B.)
| | - Igor Tudorache
- Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, 40225 Duesseldorf, Germany; (P.R.); (I.T.); (H.A.); (P.A.); (U.B.)
| | - Markus W. Hollmann
- Amsterdam University Medical Center (AUMC), Department of Anesthesiology, Location AMC, 1105 AZ Amsterdam, The Netherlands;
| | - Hug Aubin
- Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, 40225 Duesseldorf, Germany; (P.R.); (I.T.); (H.A.); (P.A.); (U.B.)
| | - Payam Akhyari
- Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, 40225 Duesseldorf, Germany; (P.R.); (I.T.); (H.A.); (P.A.); (U.B.)
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, 40225 Duesseldorf, Germany; (P.R.); (I.T.); (H.A.); (P.A.); (U.B.)
- Correspondence: ; Tel.: +49-2118118331
| | - Ragnar Huhn
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, 40225 Duesseldorf, Germany; (R.M.); (S.R.); (A.S.); (G.L.B.); (S.U.S.); (R.H.)
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, 40225 Duesseldorf, Germany; (P.R.); (I.T.); (H.A.); (P.A.); (U.B.)
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Valeanu L, Bubenek-Turconi SI, Ginghina C, Balan C. Hemodynamic Monitoring in Sepsis-A Conceptual Framework of Macro- and Microcirculatory Alterations. Diagnostics (Basel) 2021; 11:1559. [PMID: 34573901 PMCID: PMC8469937 DOI: 10.3390/diagnostics11091559] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/22/2021] [Accepted: 08/26/2021] [Indexed: 12/29/2022] Open
Abstract
Circulatory failure in sepsis is common and places a considerable burden on healthcare systems. It is associated with an increased likelihood of mortality, and timely recognition is a prerequisite to ensure optimum results. While there is consensus that aggressive source control, adequate antimicrobial therapy and hemodynamic management constitute crucial determinants of outcome, discussion remains about the best way to achieve each of these core principles. Sound cardiovascular support rests on tailored fluid resuscitation and vasopressor therapy. To this end, an overarching framework to improve cardiovascular dynamics has been a recurring theme in modern critical care. The object of this review is to examine the nature of one such framework that acknowledges the growing importance of adaptive hemodynamic support combining macro- and microhemodynamic variables to produce adequate tissue perfusion.
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Affiliation(s)
- Liana Valeanu
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (L.V.); (S.-I.B.-T.)
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Serban-Ion Bubenek-Turconi
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (L.V.); (S.-I.B.-T.)
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Carmen Ginghina
- 3rd Department of Cardiology, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania;
- Department of Cardiology, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Cosmin Balan
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (L.V.); (S.-I.B.-T.)
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Hawchar F, Rao C, Akil A, Mehta Y, Rugg C, Scheier J, Adamson H, Deliargyris E, Molnar Z. The Potential Role of Extracorporeal Cytokine Removal in Hemodynamic Stabilization in Hyperinflammatory Shock. Biomedicines 2021; 9:biomedicines9070768. [PMID: 34356830 PMCID: PMC8301410 DOI: 10.3390/biomedicines9070768] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/26/2021] [Accepted: 06/27/2021] [Indexed: 02/06/2023] Open
Abstract
Hemodynamic instability due to dysregulated host response is a life-threatening condition requiring vasopressors and vital organ support. Hemoadsorption with Cytosorb has proven to be effective in reducing cytokines and possibly in attenuating the devastating effects of the cytokine storm originating from the immune over-response to the initial insult. We reviewed the PubMed database to assess evidence of the impact of Cytosorb on norepinephrine needs in the critically ill. We further analyzed those studies including data on control cohorts in a comparative pooled analysis, defining a treatment effect as the standardized mean differences in relative reductions in vasopressor dosage at 24 h. The literature search returned 33 eligible studies. We found evidence of a significant reduction in norepinephrine requirement after treatment: median before, 0.55 (IQR: 0.39-0.90); after, 0.09 (0.00-0.25) μg/kg/min, p < 0.001. The pooled effect size at 24 h was large, though characterized by high heterogeneity. In light of the importance of a quick resolution of hemodynamic instability in the critically ill, further research is encouraged to enrich knowledge on the potentials of the therapy.
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Affiliation(s)
- Fatime Hawchar
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, 6 Semmelweis Str., H-6725 Szeged, Hungary;
| | - Cristina Rao
- Cytosorbents Europe GmbH, Müggelseedamm 131, 12587 Berlin, Germany; (C.R.); (J.S.); (H.A.)
| | - Ali Akil
- Department of Thoracic Surgery and Lung Support, Klinikum Ibbenbueren, Grosse Strasse 41, 49477 Ibbenbueren, Germany;
| | - Yatin Mehta
- Institute of Critical Care and Anesthesiology, Medanta the Medicity, CH Baktawar Singh Rd, Gurugram 122001, Haryana, India;
| | - Christopher Rugg
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria;
| | - Joerg Scheier
- Cytosorbents Europe GmbH, Müggelseedamm 131, 12587 Berlin, Germany; (C.R.); (J.S.); (H.A.)
| | - Harriet Adamson
- Cytosorbents Europe GmbH, Müggelseedamm 131, 12587 Berlin, Germany; (C.R.); (J.S.); (H.A.)
| | - Efthymios Deliargyris
- Cytosorbents Corporation, 7 Deer Park Drive Suite K, Monmouth Junction, NJ 08852, USA;
| | - Zsolt Molnar
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, 6 Semmelweis Str., H-6725 Szeged, Hungary;
- Institute for Translational Medicine, School of Medicine, University of Pécs, Szigeti Str. 12, H-7624 Pécs, Hungary
- Department of Anaesthesiology and Intensive Therapy and Pain Management, Poznan University for Medical Sciences, 61-701 Poznan, Poland
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary
- Correspondence:
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Mostovaya O, Padnya P, Shurpik D, Shiabiev I, Stoikov I. Novel lactide derivatives of p-tert-butylthiacalix[4]arene: Directed synthesis and molecular recognition of catecholamines. J Mol Liq 2021. [DOI: 10.1016/j.molliq.2020.114806] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Sabioni L, De Lorenzo A, Lamas C, Muccillo F, Castro-Faria-Neto HC, Estato V, Tibirica E. Systemic microvascular endothelial dysfunction and disease severity in COVID-19 patients: Evaluation by laser Doppler perfusion monitoring and cytokine/chemokine analysis. Microvasc Res 2021; 134:104119. [PMID: 33278457 PMCID: PMC7710468 DOI: 10.1016/j.mvr.2020.104119] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/25/2020] [Accepted: 11/28/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Microvascular dysfunction, serum cytokines and chemokines may play important roles in pathophysiology of coronavirus disease 2019 (COVID-19), especially in severe cases. METHODS Patients with COVID-19 underwent non-invasive evaluation of systemic endothelium-dependent microvascular reactivity - using laser Doppler perfusion monitoring in the skin of the forearm - coupled to local thermal hyperemia. Maximal microvascular vasodilatation (44 °C thermal plateau phase) was used as endpoint. A multiplex biometric immunoassay was used to assess a panel of 48 serum cytokines and chemokines. Severe COVID-19 (S-COVID) was defined according to WHO criteria, while all other cases of COVID-19 were considered mild to moderate (M-COVID). A group of healthy individuals who tested negative for SARS-CoV-2 served as a control group and was also evaluated with LDPM. RESULTS Thirty-two patients with COVID-19 (25% S-COVID) and 14 controls were included. Basal microvascular flow was similar between M-COVID and controls (P = 0.69) but was higher in S-COVID than in controls (P = 0.005) and M-COVID patients (P = 0.01). The peak microvascular vasodilator response was markedly decreased in both patient groups (M-COVID, P = 0.001; S-COVID, P < 0.0001) compared to the healthy group. The percent increases in microvascular flow were markedly reduced in both patient groups (M-COVID, P < 0.0001; S-COVID, P < 0.0001) compared to controls. Patients with S-COVID had markedly higher concentrations of dissimilar proinflammatory cytokines and chemokines, compared to patients with M-COVID. CONCLUSIONS In patients with COVID-19, especially with S-COVID, endothelium-dependent microvascular vasodilator responses are reduced, while serum cytokines and chemokines involved in the regulation of vascular function and inflammation are increased.
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Affiliation(s)
- Letícia Sabioni
- Instituto Nacional de Cardiologia, Ministério da Saúde, Rio de Janeiro, Brazil
| | - Andrea De Lorenzo
- Instituto Nacional de Cardiologia, Ministério da Saúde, Rio de Janeiro, Brazil
| | - Cristiane Lamas
- Instituto Nacional de Cardiologia, Ministério da Saúde, Rio de Janeiro, Brazil
| | - Fabiana Muccillo
- Instituto Nacional de Cardiologia, Ministério da Saúde, Rio de Janeiro, Brazil
| | - Hugo Caire Castro-Faria-Neto
- Laboratório de Imunofarmacologia, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Vanessa Estato
- Laboratório de Imunofarmacologia, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Eduardo Tibirica
- Instituto Nacional de Cardiologia, Ministério da Saúde, Rio de Janeiro, Brazil.
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De Backer D, Vincent JL. Noninvasive Monitoring in the Intensive Care Unit. Semin Respir Crit Care Med 2020; 42:40-46. [PMID: 33065744 DOI: 10.1055/s-0040-1718387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
There has been considerable development in the field of noninvasive hemodynamic monitoring in recent years. Multiple devices have been proposed to assess blood pressure, cardiac output, and tissue perfusion. All have their own advantages and disadvantages and selection should be based on individual patient requirements and disease severity and adjusted according to ongoing patient evolution.
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Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, CHIREC Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
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Puntillo F, Giglio M, Pasqualucci A, Brienza N, Paladini A, Varrassi G. Vasopressor-Sparing Action of Methylene Blue in Severe Sepsis and Shock: A Narrative Review. Adv Ther 2020; 37:3692-3706. [PMID: 32705530 PMCID: PMC7444404 DOI: 10.1007/s12325-020-01422-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Indexed: 12/15/2022]
Abstract
Shock is a serious acute circulatory failure leading to inadequate oxygen delivery to the cells. Its treatment is mainly based on circulating fluid optimization, and vasopressors to provide an adequate mean arterial pressure and microcirculatory flow. Norepinephrine is the drug of choice, but high dosages may be responsible for several side effects, including increased myocardial oxygen consumption, dysrhythmias, and peripheral and organ ischemia. Moreover, some patients are “non-responders” to first-line norepinephrine treatment. Hence, other drugs have been proposed to reach and maintain the hemodynamic target. In general, they are described as catecholamine-sparing agents. Among others, the most used are vasopressin, corticosteroids, and angiotensin II. Methylene blue (MB) represents a further option, even though its use is still a topic of controversy. This review article tries to summarize what is known and unknown about the actions of MB in patients in shock. It reduces excessive production of nitric oxide via blockade of guanylate cyclase in shock states. At present, it appears the MB provides positive results in septic shock, if administered early. Further randomized controlled trials are warranted regarding its use to provide more precise indications to physicians involved in the treatment of such patients.
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Affiliation(s)
- Filomena Puntillo
- Department of Interdisciplinary Medicine, University of Bari "Aldo Moro", 70124, Bari, Italy
| | - Mariateresa Giglio
- Anesthesia, Intensive Care and Pain Unit, Policlinico Hospital, 70124, Bari, Italy
| | - Alberto Pasqualucci
- Department of Surgical and Biomedical Science, University of Perugia, 06100, Perugia, Italy
- Rashid Hospital, Trauma and Emergency Center, Dubai Health Authority, Dubai, UAE
| | - Nicola Brienza
- Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", 70124, Bari, Italy
| | | | - Giustino Varrassi
- Paolo Procacci Foundation, Via Tacito 7, 00193, Rome, Italy.
- World Institute of Pain, Winston-Salem, NC, USA.
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Guarracino F, Bertini P, Pinsky MR. Management of cardiovascular insufficiency in ICU: the BEAT approach. Minerva Anestesiol 2020; 87:476-480. [PMID: 32755093 DOI: 10.23736/s0375-9393.20.14613-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A large number of patients admitted to ICU display hemodynamic deterioration at some time during their stay. The management of acute hemodynamic derangement of any cause can be difficult and has to be accomplished quickly and correctly as delayed and inappropriate resuscitation treatments carry increased mortality. Cardiovascular insufficiency shows end-organ hypoperfusion-associated dysfunction, thus decreasing level of consciousness, falling urine output, ileus, new onset tachypnea and the presence of skin mottling are important clinical clues to cardiovascular deterioration and should be promptly looked for and if detected alert the bedside clinician that further assessment and potentially treatment is necessary. Although measures of serum lactate are useful to document the presence of tissue hypoperfusion, they are non-specific in defining its etiology. In a patient with acute hemodynamic instability, we propose a step-by-step approach as follows: 1) rapid initial ultrasound assessment of heart function; 2) pathophysiological understanding of heart and circulation interaction; 3) functional hemodynamic monitoring; and 4) treatment. We named such approach BEAT, which stands for: browse the heart, measure the elastances, assess volume status, and treat. Combining bedside echocardiography, including the evaluation of the interaction between the heart and the circulation, with FHM offers the opportunity to personalize the hemodynamic management to the specific requirements.
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Affiliation(s)
- Fabio Guarracino
- Unit of Cardiothoracic, Vascular Anesthesia and Intensive Care, Department of Anesthesia and Critical Care Medicine, University Hospital of Pisa, Pisa, Italy -
| | - Pietro Bertini
- Unit of Cardiothoracic, Vascular Anesthesia and Intensive Care, Department of Anesthesia and Critical Care Medicine, University Hospital of Pisa, Pisa, Italy
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Mauriat P, Bojan M, Soulie S, Foulgoc H, Tafer N, Ouattara A. Impact of the perioperative inotropic support in grown-up congenital heart patients undergoing cardiac surgery: a propensity score adjusted analysis. Ann Intensive Care 2020; 10:91. [PMID: 32648069 PMCID: PMC7344035 DOI: 10.1186/s13613-020-00709-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 06/30/2020] [Indexed: 12/30/2022] Open
Abstract
Background Grown-up congenital heart (GUCH) patients represent a growing population with a high morbidity risk when undergoing reparative surgery. A main preoperative feature is right ventricular failure, which represents a risk factor for postoperative low cardiac output syndrome. Levosimendan has a potentially beneficial effect. This retrospective study included consecutive GUCH patients with surgeries in a tertiary cardiothoracic centre between 01-01-2013 and 01-10-2017, to test the hypothesis that the postoperative use of levosimendan might be associated with shorter time of mechanical ventilation, when compared with the use of milrinone. To adjust for bias related to the probability of treatment assignment, it uses the inverse propensity score weighting methodology. Results Overall 363 patients had GUCH surgeries during the study period, their mean age was 31.39 ± 15.31 years, 87 patients were eligible for analysis in the Levosimendan group and 117 in the Milrinone group. The propensity score used pre- and intraoperative variables and resulted in a good balance between covariates. The Levosimendan group included patients with higher preoperative risk scores, a higher prevalence of left and right ventricular failure, who required more often the addition of epinephrine, renal replacement therapy, prolonged mechanical ventilation and intensive care stay. However, after propensity score weighting, patients in the Levosimendan group had shorter durations of mechanical ventilation (average treatment effect − 37.59 h IQR [− 138.85 to − 19.13], p = 0.01) and intensive care stay (average treatment effect − 3.11 days IQR [− 10.03 to − 1.48], p = 0.009). The number of days of additional epinephrine support was shorter and the vasoactive inotropic scores lower. Conclusion We report a beneficial effect in terms of duration of mechanical ventilation and intensive care stay, and on inotropic requirements of the use of levosimendan following GUCH surgeries. The use of levosimendan in this setting requires validation at a larger scale.
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Affiliation(s)
- Philippe Mauriat
- Department of Anaesthesia and Critical Care, University of Bordeaux, Haut-Levêque Hospital, Avenue Magellan, 33000, Pessac, France.
| | - Mirela Bojan
- Department of Anaesthesia, Congenital Cardiac Unit, Marie-Lannelongue Hospital, Paris-Sud University, 133 Avenue de la Résistance, 92350, Le Plessis-Robinson, France
| | - Sylvie Soulie
- Department of Anesthesia and Critical Care, Louis Pradel Hospital, University of Lyon, 59 Boulevard Pinel, 69500, Bron, France
| | - Hélène Foulgoc
- Department of Anaesthesia and Critical Care, University of Bordeaux, Haut-Levêque Hospital, Avenue Magellan, 33000, Pessac, France
| | - Nadir Tafer
- Department of Anaesthesia and Critical Care, University of Bordeaux, Haut-Levêque Hospital, Avenue Magellan, 33000, Pessac, France
| | - Alexandre Ouattara
- Department of Anaesthesia and Critical Care, University of Bordeaux, Haut-Levêque Hospital, Avenue Magellan, 33000, Pessac, France.,Biology of Cardiovascular Diseases, University of Bordeaux, INSERM, UMR 1034, 33600, Pessac, France
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Gefen A, Creehan S, Black J. Critical biomechanical and clinical insights concerning tissue protection when positioning patients in the operating room: A scoping review. Int Wound J 2020; 17:1405-1423. [PMID: 32496025 DOI: 10.1111/iwj.13408] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/10/2020] [Accepted: 05/11/2020] [Indexed: 12/30/2022] Open
Abstract
An optimal position of the patient during operation may require a compromise between the best position for surgical access and the position a patient and his or her tissues can tolerate without sustaining injury. This scoping review analysed the existing, contemporary evidence regarding surgical positioning-related tissue damage risks, from both biomechanical and clinical perspectives, focusing on the challenges in preventing tissue damage in the constraining operating room environment, which does not allow repositioning and limits the use of dynamic or thick and soft support surfaces. Deep and multidisciplinary aetiological understanding is required for effective prevention of intraoperatively acquired tissue damage, primarily including pressure ulcers (injuries) and neural injuries. Lack of such understanding typically leads to misconceptions and increased risk to patients. This article therefore provides a comprehensive aetiological description concerning the types of potential tissue damage, vulnerable anatomical locations, the risk factors specific to the operative setting (eg, the effects of anaesthetics and instruments), the complex interactions between the tissue damage risk and the pathophysiology of the surgery itself (eg, the inflammatory response to the surgical incisions), risk assessments for surgical patients and their limitations, and available (including emerging) technologies for positioning. The present multidisciplinary and integrated approach, which holistically joins the bioengineering and clinical perspectives, is unique to this work and has not been taken before. Close collaboration between bioengineers and clinicians, such as demonstrated here, is required to revisit the design of operating tables, support surfaces for surgery, surgical instruments for patient stabilisation, and for surgical access. Each type of equipment and its combined use should be evaluated and improved where needed with regard to the two major threats to tissue health in the operative setting: pressure ulcers and neural damage.
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Affiliation(s)
- Amit Gefen
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Sue Creehan
- Wound/Ostomy Program Team, VCU Health System, Richmond, Virginia, USA
| | - Joyce Black
- College of Nursing, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Early Mobilization of Patients Receiving Vasoactive Drugs in Critical Care Units: A Systematic Review. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2020. [DOI: 10.1097/jat.0000000000000140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gazmuri RJ, de Gomez CA. From a pressure-guided to a perfusion-centered resuscitation strategy in septic shock: Critical literature review and illustrative case. J Crit Care 2020; 56:294-304. [PMID: 31926637 DOI: 10.1016/j.jcrc.2019.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 07/28/2019] [Accepted: 11/13/2019] [Indexed: 01/15/2023]
Abstract
PURPOSE To support a paradigm shift in the management of septic shock from pressure-guided to perfusion-centered, expected to improve outcome while reducing adverse effects from vasopressor therapy and aggressive fluid resuscitation. MATERIAL AND METHODS Critical review of the literature cited in support of vasopressor use to achieve a predefined mean arterial pressure (MAP) of 65 mmHg and review of pertinent clinical trials and studies enabling deeper understanding of the hemodynamic pathophysiology supportive of a perfusion-centered approach, accompanied by an illustrative case. RESULTS Review of the literature cited by the Surviving Sepsis Campaign revealed lack of controlled clinical trials supporting outcome benefits from vasopressors. Additional literature review revealed adverse effects associated with vasopressors and worsened outcome in some studies. Vasopressors increase MAP primarily by peripheral vasoconstriction and in occasions by a modest increase in cardiac output when using norepinephrine. Thus, achieving the recommended MAP of 65 mmHg using vasopressors should not be presumed indicative that organ perfusion has been restored. It may instead create a false sense of hemodynamic stability hampering shock resolution. CONCLUSIONS We propose focusing the hemodynamic management of septic shock on reversing organ hypoperfusion instead of attaining a predefined MAP target as the key strategy for improving outcome.
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Affiliation(s)
- Raúl J Gazmuri
- Medicine, Physiology & Biophysics, Resuscitation Institute at Rosalind Franklin University of Medicine and Science, Critical Care Medicine and ICU, Captain James A. Lovell Federal Health Care Center, USA.
| | - Cristina Añez de Gomez
- Internal Medicine Physician, Northwestern Medical Group, Northwestern Medicine Lake Forrest Hospital, USA
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Monitoring tissue perfusion: a pilot clinical feasibility and safety study of a urethral photoplethysmography-derived perfusion device in high-risk patients. J Clin Monit Comput 2019; 34:961-969. [DOI: 10.1007/s10877-019-00414-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/25/2019] [Indexed: 10/25/2022]
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Kazune S, Caica A, Luksevics E, Volceka K, Grabovskis A. Impact of increased mean arterial pressure on skin microcirculatory oxygenation in vasopressor-requiring septic patients: an interventional study. Ann Intensive Care 2019; 9:97. [PMID: 31468202 PMCID: PMC6715757 DOI: 10.1186/s13613-019-0572-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 08/20/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Heterogeneity of microvascular blood flow leading to tissue hypoxia is a common finding in patients with septic shock. It may be related to suboptimal systemic perfusion pressure and lead to organ failure. Mapping of skin microcirculatory oxygen saturation and relative hemoglobin concentration using hyperspectral imaging allows to identify heterogeneity of perfusion and perform targeted measurement of oxygenation. We hypothesized that increasing mean arterial pressure would result in improved oxygenation in areas of the skin with most microvascular blood pooling. METHODS We included adult patients admitted to the intensive care unit within the previous 24 h with sepsis and receiving a noradrenaline infusion. Skin oxygen saturation was measured using hyperspectral imaging-based method at baseline and after the increase in mean arterial pressure by 20 mm Hg by titration of noradrenaline doses. The primary outcome was an increase in skin oxygen saturation depending upon disease severity. RESULTS We studied 30 patients with septic shock. Median skin oxygen saturation changed from 26.0 (24.5-27.0) % at baseline to 30.0 (29.0-31.0) % after increase in mean arterial pressure (p = 0.04). After adjustment for baseline saturation, patients with higher SOFA scores achieved higher oxygen saturation after the intervention (r2 = 0.21; p = 0.02). Skin oxygen saturation measured at higher pressure was found to be marginally predictive of mortality (OR: 1.10; 95% CI 1.00-1.23; p = 0.053). CONCLUSIONS Improvement of microcirculatory oxygenation can be achieved with an increase in mean arterial pressure in most patients. Response to study intervention is proportional to disease severity.
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Affiliation(s)
- Sigita Kazune
- Department of Anesthesiology, Hospital of Traumatology and Orthopedics, 22 Duntes Street, Riga, 1013, Latvia. .,Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, 1004, Latvia.
| | - Anastasija Caica
- Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, 1004, Latvia.,Department of Human and Animal Physiology, Faculty of Biology, University of Latvia, 1 Jelgavas Street, Riga, 1004, Latvia
| | - Einars Luksevics
- Clinic of Toxicology and Sepsis, Riga East University Hospital, 2 Hipokrata Street, Riga, 1038, Latvia
| | - Karina Volceka
- Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, 1004, Latvia.,Department of Human and Animal Physiology, Faculty of Biology, University of Latvia, 1 Jelgavas Street, Riga, 1004, Latvia
| | - Andris Grabovskis
- Laboratory of Biophotonics, Institute of Atomic Physics and Spectroscopy, University of Latvia, 3 Jelgavas Street, Riga, 1004, Latvia
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