Current use of inotropes in circulatory shock

Adjunctive Midodrine Therapy for Vasopressor-Dependent Shock in the ICU: A Systematic Review and Meta-Analysis

OBJECTIVES

To summarize the efficacy of midodrine as an adjunctive therapy in critically ill patients. Safety of midodrine was assessed as a secondary outcome.

DATA SOURCES

We performed a systematic review and meta-analysis using a peer-reviewed search strategy combining the themes of vasopressor-dependent shock, critical care, and midodrine and including MEDLINE, Ovid Embase, CINAHL, and Cochrane library databases until September 14, 2023.

STUDY SELECTION

We included studies if they: 1) included patients with vasopressor-dependent shock, 2) were performed in the ICU, 3) evaluated oral midodrine therapy compared with placebo or usual care, and 4) evaluated one of the outcomes of interest.

DATA EXTRACTION

We extracted data independently in duplicate using standardized data abstraction forms, which included the following specific variables: patient characteristics, age, sex, type of ICU, etiology of shock, number of patients, study inclusion and exclusion criteria, and geographical location. We also captured the type, dose, and duration of IV vasopressors, any cointervention used, and outcome data.

DATA SYNTHESIS

We identified seven randomized controlled trials (six included in the pooled analysis) and ten observational studies (four included in the pooled analysis) that met eligibility criteria. Adjunctive midodrine may decrease ICU length of stay (LOS) and there is low certainty of effect on hospital LOS. Midodrine may decrease IV vasopressor support duration, ICU mortality, and hospital mortality. Pooled observational data was based on very low certainty data for all outcomes of interest. The trial sequential analysis-informed required sample size was not met for ICU LOS or IV vasopressor duration and this contributed to Grading of Recommendations, Assessment, Development, and Evaluations assessments of imprecision for both outcomes.

CONCLUSIONS

Adjunctive midodrine may decrease ICU LOS, duration of IV vasopressor therapy, and mortality in critically ill patients. However, required sample sizes was not met to determine our outcomes of interest. Midodrine may increase risk of bradycardia. While midodrine may provide benefit for patient-centered outcomes, due to increased risk of adverse events, further large-scale studies are needed to inform and guide its routine use in the ICU.

Current Emergency Medical Service Vasoactive Use for the Management of Shock

OBJECTIVES

We sought to describe the indications for vasoactive medication administration, hemodynamic treatment targets, and specific agents used by various international emergency medical service (EMS) providers.

DESIGN AND SETTING

In March 2022, we sent an online survey comprising of 20 questions to Medical Directors of EMSs across Australia, the Asia Pacific region, and North America.

PATIENTS

A total of 108 EMS directors were emailed an invitation to participate.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Twenty-five EMS medical directors responded. Local site guidelines for vasoactive agent administration were available to 77.3% of providers. Epinephrine was commonly used as first-line vasoactive agent in 52% of questionnaire respondents, followed by norepinephrine (22%), dopamine (18%), and metaraminol (4%). Epinephrine was the most commonly used vasoactive agent across all forms of shock, with a higher proportion of utilization in cases of cardiogenic shock (58%) and patients suffering shock following cardiac arrest (56%).

CONCLUSIONS

International EMS vasoactive use in the management of shock is heterogeneous. Future randomized controlled trials should aim to elucidate optimal prehospital treatment strategies for shock, including the initiation, choice of agent, and monitoring of vasoactive medication.

Management of cardiogenic shock: state-of-the-art

The management of cardiogenic shock is an ongoing challenge. Despite all efforts and tremendous use of resources, mortality remains high. Whilst reversing the underlying cause, restoring/maintaining organ perfusion and function are cornerstones of management. The presence of comorbidities and preexisting organ dysfunction increases management complexity, aiming to integrate the needs of vital organs in each individual patient. This review provides a comprehensive overview of contemporary literature regarding the definition and classification of cardiogenic shock, its pathophysiology, diagnosis, laboratory evaluation, and monitoring. Further, we distill the latest evidence in pharmacologic therapy and the use of mechanical circulatory support including recently published randomized-controlled trials as well as future directions of research, integrating this within an international group of authors to provide a global perspective. Finally, we explore the need for individualization, especially in the face of neutral randomized trials which may be related to a dilution of a potential benefit of an intervention (i.e., average effect) in this heterogeneous clinical syndrome, including the use of novel biomarkers, artificial intelligence, and machine learning approaches to identify specific endotypes of cardiogenic shock (i.e., subclasses with distinct underlying biological/molecular mechanisms) to support a more personalized medicine beyond the syndromic approach of cardiogenic shock.

Hospitalized Advanced Heart Failure With Preserved vs Reduced Left Ventricular Ejection Fraction: A Global Perspective

BACKGROUND

Outcomes of hospitalized patients with heart failure (HF) and characteristics of advanced HF stage may vary across left ventricular ejection fraction (LVEF) and world regions.

OBJECTIVES

This study sought to analyze characteristics of hospitalized advanced HF patients across LVEF spectrum, world regions, and country income.

METHODS

Among 18,553 hospitalized patients with acute HF (7,902 new-onset HF and 10,651 decompensated chronic HF) enrolled in the global registry REPORT-HF (International Registry to Assess Medical Practice With Longitudinal Observation for Treatment of Heart Failure), we analyzed characteristics and outcomes of patients with advanced HF, defined as previously diagnosed HF; severe symptoms before current admission (NYHA functional class III/IV); and ≥1 HF-related hospitalization in the preceding 12 months, excluding the current. Differences among hospitalized advanced HF subgroups stratified by LVEF, world region, and country income were examined.

RESULTS

Among 6,999 patients with decompensated chronic HF and available previous NYHA functional class and HF hospitalization status, 3,397 (48.5%; 18.3% of the total population) had advanced HF. Of these, 44.5% had severely reduced (≤30%), 34.9% mildly/moderately reduced (31%-49%), and 20.7% preserved (≥50%) LVEF. Patients from Eastern Europe had the lowest 1-year mortality (23%), whereas those from Southeast Asia had the highest (37%). Patients from lower-middle-income countries were younger, with shorter HF duration and lower comorbidity prevalence, received fewer beta-blockers and HF-devices, and had higher 1-year mortality (34%) than upper-middle- (26%) or high-income countries (27%; P = 0.018). Adjusted 1-year mortality risk did not differ among LVEF subgroups (all P > 0.05), nor did 1-year HF hospitalization rate (P = 0.56).

CONCLUSIONS

Hospitalized patients with advanced HF and preserved LVEF had similarly adverse outcomes as those with reduced LVEF. Patients from lower-middle-income countries had less implementation of HF therapies and higher 1-year mortality.

Phosphodiesterase 3 inhibitors do not influence lactate kinetics and clinical outcomes in patients with septic shock: A multicentre cohort study

PURPOSE

We investigated the association between the administration of phosphodiesterase 3 inhibitors (PDE3i) and lactate kinetics, resolution of organ failure, ICU and hospital length of stay (LOS) and hospital mortality in a retrospective cohort of patients with septic shock and persistently elevated lactate concentrations.

MATERIAL AND METHODS

Patients with septic shock and two arterial lactate concentrations ≥4 mmol/L with at least 4 h between measurements were eligible. Clinical data of the first four days of admission were collected in an online database. For each patient, the area between the actual lactate concentrations and 2.2 mmol/L (AUClact2.2), was calculated for three days.

RESULTS

Data on 229 patients from 10 hospitals were collected, of whom 123 received PDE3i (54%). First, a linear multivariate model was developed to predict AUClact2.2 (R2 = 0.57). Adding PDE3i as a cofactor did not affect R2. Second, 60 patients receiving PDE3i at any time between days 0 and 2 were compared to 60 propensity matched no-PDE3i patients. Third, 30 patients who received PDE3i from ICU admission to day 3 were compared to 30 propensity-matched no-PDE3i patients. These analyses showed no differences in AUClact2.2, SOFA scores, ICU or hospital LOS or hospital mortality between treatment groups.

CONCLUSIONS

No association was found between the administration of PDE3i and lactate kinetics, resolution of organ failure, ICU or hospital LOS or hospital mortality.

ICU management of cardiogenic shock before mechanical support

PURPOSE OF REVIEW

Treatment of cardiogenic shock remains largely driven by expert consensus due to limited evidence from randomized controlled trials. In this review, we aim to summarize the approach to the management of patients with cardiogenic shock in the ICU prior to mechanical circulatory support (MCS).

RECENT FINDINGS

Main topics covered in this article include diagnosis, monitoring, initial management and key aspects of pharmacological therapy in the ICU for patients with cardiogenic shock.

SUMMARY

Despite efforts to improve therapy, short-term mortality in patients with cardiogenic shock is still reaching 40-50%. Early recognition and treatment of cardiogenic shock are crucial, including early revascularization of the culprit lesion with possible staged revascularization in acute myocardial infarction (AMI)-CS. Optimal volume management and vasoactive drugs titrated to restore arterial pressure and perfusion are the cornerstone of cardiogenic shock therapy. The choice of vasoactive drugs depends on the underlying cause and phenotype of cardiogenic shock. Their use should be limited to the shortest duration and lowest possible dose. According to recent observational evidence, assessment of the complete hemodynamic profile with a pulmonary artery catheter (PAC) was associated with improved outcomes and should be considered early in patients not responding to initial therapy or with unclear shock. A multidisciplinary shock team should be involved early in order to identify potential candidates for temporary and/or durable MCS.

Inotropic Agents: Are We Still in the Middle of Nowhere?

Inotropes are prescribed to enhance myocardial contractility while vasopressors serve to improve vascular tone. Although these medications remain a life-saving therapy in cardiovascular clinical scenarios with hemodynamic impairment, the paucity of evidence on these drugs makes the choice of the most appropriate vasoactive agent challenging. As such, deep knowledge of their pharmacological and hemodynamic effects becomes crucial to optimizing hemodynamic profile while reducing the potential adverse effects. Given this perspective, it is imperative for cardiologists to possess a comprehensive understanding of the underlying mechanisms governing these agents and to discern optimal strategies for their application across diverse clinical contexts. Thus, we briefly review these agents' pharmacological and hemodynamic properties and their reasonable clinical applications in cardiovascular settings. Critical interpretation of available data and the opportunities for future investigations are also highlighted.

Levosimendan and Dobutamin Attenuate LPS-Induced Inflammation in Microglia by Inhibiting the NF-κB Pathway and NLRP3 Inflammasome Activation via Nrf2/HO-1 Signalling

Hypovolemic shock is a circulatory failure, due to a loss in the effective circulating blood volume, that causes tissue hypoperfusion and hypoxia. This condition stimulates reactive oxygen species (ROS) and pro-inflammatory cytokine production in different organs and also in the central nervous system (CNS). Levosimendan, a cardioprotective inodilator, and dobutamine, a β1-adrenergic agonist, are commonly used for the treatment of hypovolemic shock, thanks to their anti-inflammatory and antioxidant effects. For this reason, we aimed at investigating levosimendan and dobutamine's neuroprotective effects in an "in vitro" model of lipopolysaccharide (LPS)-induced neuroinflammation. Human microglial cells (HMC3) were challenged with LPS (0.1 µg/mL) to induce an inflammatory phenotype and then treated with levosimendan (10 µM) or dobutamine (50 µM) for 24 h. Levosimendan and dobutamine significantly reduced the ROS levels and markedly increased Nrf2 and HO-1 protein expression in LPS-challenged cells. Levosimendan and dobutamine also decreased p-NF-κB expression and turned off the NLRP3 inflammasome together with its downstream signals, caspase-1 and IL-1β. Moreover, a reduction in TNF-α and IL-6 expression and an increase in IL-10 levels in LPS-stimulated HMC3 cells was observed following treatment. In conclusion, levosimendan and dobutamine attenuated LPS-induced neuroinflammation through NF-κB pathway inhibition and NLRP3 inflammasome activation via Nrf2/HO-1 signalling, suggesting that these drugs could represent a promising therapeutic approach for the treatment of neuroinflammation consequent to hypovolemic shock.

The Effects of Dobutamine in Septic Shock: An Updated Narrative Review of Clinical and Experimental Studies

The key objective in the hemodynamic treatment of septic shock is the optimization of tissue perfusion and oxygenation. This is usually achieved by the utilization of fluids, vasopressors, and inotropes. Dobutamine is the inotrope most commonly recommended and used for this purpose. Despite the fact that dobutamine was introduced almost half a century ago in the treatment of septic shock, and there is widespread use of the drug, several aspects of its pharmacodynamics remain poorly understood. In normal subjects, dobutamine increases contractility and lacks a direct effect on vascular tone. This results in augmented cardiac output and blood pressure, with reflex reduction in systemic vascular resistance. In septic shock, some experimental and clinical research suggest beneficial effects on systemic and regional perfusion. Nevertheless, other studies found heterogeneous and unpredictable effects with frequent side effects. In this narrative review, we discuss the pharmacodynamic characteristics of dobutamine and its physiologic actions in different settings, with special reference to septic shock. We discuss studies showing that dobutamine frequently induces tachycardia and vasodilation, without positive actions on contractility. Since untoward effects are often found and therapeutic benefits are occasional, its profile of efficacy and safety seems low. Therefore, we recommend that the use of dobutamine in septic shock should be cautious. Before a final decision about its prescription, efficacy, and tolerance should be evaluated throughout a short period with narrow monitoring of its wanted and side effects.

Percutaneous Mechanical Circulatory Support in Acute Heart Failure Complicated with Cardiogenic Shock

Despite advancements in algorithms concerning the management of cardiogenic shock, current guidelines still lack the adequate integration of mechanical circulatory support devices. In recent years, more and more devices have been developed to provide circulatory with or without respiratory support, when conservative treatment with inotropic agents and vasopressors has failed. Mechanical circulatory support can be contemplated for patients with severe, refractory, or acute-coronary-syndrome-related cardiogenic shock. Through this narrative review, we delve into the differences among the types of currently used devices by presenting their notable advantages and inconveniences. We address the technical issues emerging while choosing the best possible device, temporarily as a bridge to another treatment plan or as a destination therapy, in the optimal timing for each type of patient. We also highlight the diverse implantation and removal techniques to avoid major complications such as bleeding and limb ischemia. Ultimately, we hope to shed some light in the gaps of evidence and the importance of conducting further organized studies around the topic of mechanical circulatory support when dealing with such a high mortality rate.

Cardiac arrest, stony heart, and cardiopulmonary resuscitation: An updated revisit

The post-resuscitation period is recognized as the main predictor of cardiopulmonary resuscitation (CPR) outcomes. The first description of post-resuscitation syndrome and stony heart was published over 50 years ago. Major manifestations may include but are not limited to, persistent precipitating pathology, systemic ischemia/reperfusion response, post-cardiac arrest brain injury, and finally, post-cardiac arrest myocardial dysfunction (PAMD) after successful resuscitation. Why do some patients initially survive successful resuscitation, and others do not? Also, why does the myocardium response vary after resuscitation? These questions have kept scientists busy for several decades since the first successful resuscitation was described. By modifying the conventional modalities of resuscitation together with new promising agents, rescuers will be able to salvage the jeopardized post-resuscitation myocardium and prevent its progression to a dismal, stony heart. Community awareness and staff education are crucial for shortening the resuscitation time and improving short- and long-term outcomes. Awareness of these components before and early after the restoration of circulation will enhance the resuscitation outcomes. This review extensively addresses the underlying pathophysiology, management, and outcomes of post-resuscitation syndrome. The pattern, management, and outcome of PAMD and post-cardiac arrest shock are different based on many factors, including in-hospital cardiac arrest vs out-of-hospital cardiac arrest (OHCA), witnessed vs unwitnessed cardiac arrest, the underlying cause of arrest, the duration, and protocol used for CPR. Although restoring spontaneous circulation is a vital sign, it should not be the end of the game or lone primary outcome; it calls for better understanding and aggressive multi-disciplinary interventions and care. The development of stony heart post-CPR and OHCA remain the main challenges in emergency and critical care medicine.

Patient-, Clinician-, and Institution-level Variation in Inotrope Use for Cardiac Surgery: A Multicenter Observational Analysis

BACKGROUND

Conflicting evidence exists regarding the risks and benefits of inotropic therapies during cardiac surgery, and the extent of variation in clinical practice remains understudied. Therefore, the authors sought to quantify patient-, anesthesiologist-, and hospital-related contributions to variation in inotrope use.

METHODS

In this observational study, nonemergent adult cardiac surgeries using cardiopulmonary bypass were reviewed across a multicenter cohort of academic and community hospitals from 2014 to 2019. Patients who were moribund, receiving mechanical circulatory support, or receiving preoperative or home inotropes were excluded. The primary outcome was an inotrope infusion (epinephrine, dobutamine, milrinone, dopamine) administered for greater than 60 consecutive min intraoperatively or ongoing upon transport from the operating room. Institution-, clinician-, and patient-level variance components were studied.

RESULTS

Among 51,085 cases across 611 attending anesthesiologists and 29 hospitals, 27,033 (52.9%) cases received at least one intraoperative inotrope, including 21,796 (42.7%) epinephrine, 6,360 (12.4%) milrinone, 2,000 (3.9%) dobutamine, and 602 (1.2%) dopamine (non-mutually exclusive). Variation in inotrope use was 22.6% attributable to the institution, 6.8% attributable to the primary attending anesthesiologist, and 70.6% attributable to the patient. The adjusted median odds ratio for the same patient receiving inotropes was 1.73 between 2 randomly selected clinicians and 3.55 between 2 randomly selected institutions. Factors most strongly associated with increased likelihood of inotrope use were institutional medical school affiliation (adjusted odds ratio, 6.2; 95% CI, 1.39 to 27.8), heart failure (adjusted odds ratio, 2.60; 95% CI, 2.46 to 2.76), pulmonary circulation disorder (adjusted odds ratio, 1.72; 95% CI, 1.58 to 1.87), loop diuretic home medication (adjusted odds ratio, 1.55; 95% CI, 1.42 to 1.69), Black race (adjusted odds ratio, 1.49; 95% CI, 1.32 to 1.68), and digoxin home medication (adjusted odds ratio, 1.48; 95% CI, 1.18 to 1.86).

CONCLUSIONS

Variation in inotrope use during cardiac surgery is attributable to the institution and to the clinician, in addition to the patient. Variation across institutions and clinicians suggests a need for future quantitative and qualitative research to understand variation in inotrope use affecting outcomes and develop evidence-based, patient-centered inotrope therapies.

EDITOR’S PERSPECTIVE

Inflammatory mechanisms and intervention strategies for sepsis-induced myocardial dysfunction

Sepsis-induced myocardial dysfunction (SIMD) is the leading cause of death in patients with sepsis in the intensive care units. The main manifestations of SIMD are systolic and diastolic dysfunctions of the myocardium. Despite our initial understanding of the SIMD over the past three decades, the incidence and mortality of SIMD remain high. This may be attributed to the large degree of heterogeneity among the initiating factors, disease processes, and host states involved in SIMD. Previously, organ dysfunction caused by sepsis was thought to be an impairment brought about by an excessive inflammatory response. However, many recent studies have shown that SIMD is a consequence of a combination of factors shaped by the inflammatory responses between the pathogen and the host. In this article, we review the mechanisms of the inflammatory responses and potential novel therapeutic strategies in SIMD.

The medical treatment of cardiogenic shock

Cardiogenic shock (CS) is a leading cause of mortality worldwide. CS presentation and management in the current era have been widely depicted in epidemiological studies. Its treatment is codified and relies on medical care and extracorporeal life support (ECLS) in the bridge to recovery, chronic mechanical device therapy, or transplantation. Recent improvements have changed the landscape of CS. The present analysis aims to review current medical treatments of CS in light of recent literature, including addressing excitation-contraction coupling and specific physiology on applied hemodynamics. Inotropism, vasopressor use, and immunomodulation are discussed as pre-clinical and clinical studies have focused on new therapeutic options to improve patient outcomes. Certain underlying conditions of CS, such as hypertrophic or Takotsubo cardiomyopathy, warrant specifically tailored management that will be overviewed in this review.

The Sequential Organ Failure Assessment (SOFA) Score: has the time come for an update?

The Sequential Organ Failure Assessment (SOFA) score was developed more than 25 years ago to provide a simple method of assessing and monitoring organ dysfunction in critically ill patients. Changes in clinical practice over the last few decades, with new interventions and a greater focus on non-invasive monitoring systems, mean it is time to update the SOFA score. As a first step in this process, we propose some possible new variables that could be included in a SOFA 2.0. By so doing, we hope to stimulate debate and discussion to move toward a new, properly validated score that will be fit for modern practice.

Therapeutic Dilemmas in Mixed Septic-Cardiogenic Shock

Sepsis is an increasing cause of decompensation in patients with chronic heart failure with reduced or preserved ejection fraction. Sepsis and decompensated heart failure results in a mixed septic-cardiogenic shock that poses several therapeutic dilemmas: Rapid fluid resuscitation is the cornerstone of sepsis management, while loop diuretics are the main stay of decompensated heart failure treatment. Whether inotropic therapy with dobutamine or inodilators improves microvascular alterations remains unsettled in sepsis. When to resume loop diuretic therapy in patients with sepsis and decompensated heart failure is unclear. In the absence of relevant guidelines, we review vasopressor therapy, the timing and volume of fluid resuscitation, and the need for inotropic therapy in patients who, with sepsis and decompensated heart failure, present with a mixed septic-cardiogenic shock.

Pharmacological treatment of cardiogenic shock - A state of the art review

Cardiogenic shock is a clinical syndrome of impaired tissue perfusion caused by primary cardiac dysfunction and inadequate cardiac output. It represents one of the most lethal clinical conditions in intensive care medicine with mortality >40%. Management of different clinical presentations of cardiogenic shock includes guidance of cardiac preload, afterload, heart rate and contractility by differential pharmacological modulation of volume, systemic and pulmonary vascular resistance and cardiac output besides reversing the triggering cause. Data from large registries and randomized controlled trials on optimal diagnostic guidance as well as choice of pharmacological agents has accrued significantly in recent years. This state-of-the-art review summarizes the basic concepts of cardiogenic shock, the diagnostic work-up and currently available evidence and guideline recommendations on pharmacological treatment of cardiogenic shock.

Inotropes, vasopressors, and mechanical circulatory support for treatment of cardiogenic shock complicating myocardial infarction: a systematic review and network meta-analysis

PURPOSE

To compare the relative efficacy of supportive therapies (inotropes, vasopressors, and mechanical circulatory support [MCS]) for adult patients with cardiogenic shock complicating acute myocardial infarction.

SOURCE

We conducted a systematic review and network meta-analysis and searched six databases from inception to December 2021 for randomized clinical trials (RCTs). We evaluated inotropes, vasopressors, and MCS in separate networks. Two reviewers performed screening, full-text review, and extraction. We used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to rate the certainty in findings. The critical outcome of interest was 30-day all-cause mortality.

PRINCIPAL FINDINGS

We included 17 RCTs. Among inotropes (seven RCTs, 1,145 patients), levosimendan probably reduces mortality compared with placebo (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.33 to 0.87; moderate certainty), but primarily in lower severity shock. Milrinone (OR, 0.52; 95% CI, 0.19 to 1.39; low certainty) and dobutamine (OR, 0.67, 95% CI, 0.30 to 1.49; low certainty) may have no effect on mortality compared with placebo. With regard to MCS (eight RCTs, 856 patients), there may be no effect on mortality with an intra-aortic balloon pump (IABP) (OR, 0.94; 95% CI, 0.69 to 1.28; low certainty) or percutaneous MCS (pMCS) (OR, 0.96; 95% CI, 0.47 to 1.98; low certainty), compared with a strategy involving no MCS. Intra-aortic balloon pump use was associated with less major bleeding compared with pMCS. We found only two RCTs evaluating vasopressors, yielding insufficient data for meta-analysis.

CONCLUSION

The results of this systematic review and network meta-analysis indicate that levosimendan reduces mortality compared with placebo among patients with low severity cardiogenic shock. Intra-aortic balloon pump and pMCS had no effect on mortality compared with a strategy of no MCS, but pMCS was associated with higher rates of major bleeding.

STUDY REGISTRATION

Center for Open Science ( https://osf.io/ky2gr ); registered 10 November 2020.

Clinical and haemodynamic characteristics of preterm infants with early onset sepsis

AIM

Early onset sepsis (EOS) in preterm infants is associated with high morbidity and mortality. Improved characterisation of the haemodynamic presentation of EOS could lead to more effective and targeted treatments.

METHODS

We performed a retrospective observational study of preterm infants ≤32 week' gestation with EOS between 2010 and 2020 and gathered clinical, haemodynamic and echocardiographic data.

RESULTS

Of the 2198 admitted infants, 27 infants (median gestational age 28 weeks, median birthweight 1174 g) developed EOS with predominantly gram-negative pathogens and the overall mortality rate was 33.3%. Besides hypotension, clinical signs were non-specific, and over half of infants were normotensive in the first 72 h of life. Those with hypotension received more fluid resuscitation, inotropic support and had a higher mortality compared to the normotensive infants. Cardiac ultrasound was available in 18 infants and commonly revealed higher as expected cardiac output, pulmonary hypertension and diastolic dysfunction.

CONCLUSION

Preterm infants with EOS had a high mortality rate, especially when they progressed from sepsis to septic shock. Echocardiography revealed a normal haemodynamic pattern, or one suggestive of vasodilatation and warm shock physiology. Targeting this pathophysiology earlier might improve outcomes.

Midodrine therapy for vasopressor dependent shock in the intensive care unit: a protocol for a systematic review and meta-analysis

INTRODUCTION

Intensive care unit (ICU) lengths of stay are modified by ongoing need for haemodynamic support in critically ill patients. This is most commonly provided by intravenous vasopressor therapy. Midodrine has been used as an oral agent for haemodynamic support in patients with orthostatic hypotension or cirrhosis. However, its efficacy in treating shock in the ICU, particularly for patients weaning from intravenous vasopressors, remains uncertain. The objective of this systematic review is to determine the efficacy of midodrine in vasopressor dependent shock.

METHODS AND ANALYSIS

We will search Ovid MEDLINE, Ovid Embase, CINAHL and Cochrane Library for observational trials and randomised controlled trials evaluating midodrine in critically ill patients from inception to 21 April 2022. We will also review unpublished data and relevant conference abstracts. Outcomes will include ICU length of stay, duration of intravenous vasopressor support, ICU mortality, hospital mortality, hospital length of stay and rates of ICU readmission. Data will be analysed in aggregate, where appropriate. We will evaluate risk of bias using the modified Cochrane tool and certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluations methodology. We will perform trial sequential analysis for the outcome of ICU length of stay.

ETHICS AND DISSEMINATION

Ethics approval is not required as primary data will not be collected. Findings of this review will be disseminated through peer-related publication and will inform future clinical trials.

PROSPERO REGISTRATION NUMBER

CRD42021260375.

[Pharmaceutical therapy of infarct-related cardiogenic shock]

Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is a comparably seldom but fatal entity. The definition of cardiogenic shock - unlike e. g. septic shock - is not uniform. Immediate revascularization is central to the patient's prognosis in AMI-CS. Patients who continue to meet the criteria of shock despite revascularization should be hemodynamically phenotyped to allow guidance of personalized subsequent therapy. Antiplatelet medication is the cornerstone for maintaining myocardial (re)perfusion. In hypotension, norepinephrine should be used as the first-line vasopressor, depending on afterload and after compensation for possible hypovolemia. Dobutamine is recommended to increase inotropy, possibly augmented or substituted by calcium sensitizers such as levosimendan. PDE-III (phosphodiesterase enzyme type III)-inhibitors should be used with restraint in myocardial infarction. Dopamine is no longer recommended in Europe. A sasodilator may be an option in highly selected patients with AMI-CS. This review will provide a detailed updated overview on pharmacological treatment modalities and indications in individual patients.

Evolving Presentation of Cardiogenic Shock: A Review of the Medical Literature and Current Practices

Cardiogenic shock (CS) remains a leading cause of morbidity and mortality among patients with cardiovascular disease. In the past, acute myocardial infarction was the leading cause of CS. However, in recent years, other etiologies, such as decompensated chronic heart failure, arrhythmia, valvular disease, and post-cardiotomy, each with distinct hemodynamic profiles, have risen in prevalence. The number of treatment options, particularly with regard to device-mediated therapy has also increased. In this review, we sought to survey the medical literature and provide an update on current practices.

Non-Invasive Dynamic Reperfusion of Microvessels In Vivo Controlled by Optical Tweezers

Distributive shock is considered to be a condition of microvascular hypoperfusion, which can be fatal in severe cases. However, traditional therapeutic methods to restore the macro blood flow are difficult to accurately control the blood perfusion of microvessels, and the currently developed manipulation techniques are inevitably incompatible with biological systems. In our approach, infrared optical tweezers are used to dynamically control the microvascular reperfusion within subdermal capillaries in the pinna of mice. Furthermore, we estimate the effect of different optical trap positions on reperfusion at branch and investigate the effect of the laser power on reperfusion. The results demonstrate the ability of optical tweezers to control microvascular reperfusion. This strategy allows near-noninvasive reperfusion of the microvascular hypoperfusion in vivo. Hence, our work is expected to provide unprecedented insights into the treatment of distributive shock.

Shock: aetiology, pathophysiology and management

The term 'shock' is used to describe a complex, life-threatening clinical condition that arises from acute circulatory failure. Shock is a pathological state that results when the circulation is unable to deliver sufficient oxygen and nutrients to the cells and tissues. The resulting hypoxia, tissue hypoperfusion and cellular dysfunction can lead to multi-organ failure; if this is not treated in a timely and appropriate manner, it can lead to death. This article gives an introduction to shock with an overview of the condition and its physiological impact on patients. Focusing on the aetiology and underlying causes, discussion will highlight the different types, stages and general pathophysiology of shock, as well as providing a guide to treatment options and nursing interventions.

Single-dose of adrecizumab versus placebo in acute cardiogenic shock (ACCOST-HH): an investigator-initiated, randomised, double-blinded, placebo-controlled, multicentre trial

BACKGROUND

Cardiogenic shock has a high mortality on optimal therapy. Adrenomedullin is released during cardiogenic shock and is involved in its pathophysiological processes. This study assessed treatment with the humanised, monoclonal, non-neutralising, adrenomedullin antibody adrecizumab, increasing circulating concentrations of adrenomedullin in cardiogenic shock.

METHODS

In this investigator-initiated, placebo-controlled, double-blind, multicentre, randomised trial (ACCOST-HH), patients were recruited from four university hospitals in Germany. Patients were eligible if they were 18 years old or older and hospitalised for cardiogenic shock within the last 48 h. Exclusion criteria were resuscitation for longer than 60 min and cardiogenic shock due to sustained ventricular tachycardia or bradycardia. Adult patients in cardiogenic shock were randomly assigned (1:1) to intravenous adrecizumab (8 mg/kg bodyweight) or placebo using an internet-based software. A block randomisation procedure was applied with stratification by age (older vs younger than 65 years), sex (male vs female), and type of underlying cardiogenic shock (acute myocardial infarction vs other entities). Investigators, patients, and medical staff involved in patient care were masked to group assignment. The primary endpoint was number of days up to day 30 without the need for cardiovascular organ support, defined as vasopressor therapy, inotropes, or mechanical circulatory support (or both) assessed in the intention-to-treat population. Safety outcomes included therapy-emergent serious adverse events, severe adverse events, adverse events, suspected unexpected serious adverse reactions, study drug-related mortality, and total mortality. The trial was registered at ClinicalTrials.gov, NCT03989531, and EudraCT, 2018-002824-17, and is now complete.

FINDINGS

Between April 5, 2019, and Jan 13, 2021, 150 patients were enrolled: 77 (51%) were randomly assigned to adrecizumab and 73 (49%) to placebo. All patients received the allocated treatment. The number of days without the need for cardiovascular organ support was not different between patients receiving adrecizumab or placebo (12·37 days [95% CI 9·80-14·94] vs 14·05 [11·41-16·69]; adjusted mean difference -1·69 days [-5·37 to 2·00]; p=0·37). Serious adverse events occurred in 59 patients receiving adrecizumab and in 57 receiving placebo (odds ratio 0·92 [95% CI 0·43-1·98]; p=0·83). Mortality was not different between groups at 30 days (hazard ratio 0·99 [95% CI 0·60-1·65]; p=0·98) or 90 days (1·10 [0·68-1·77]; p=0·71).

INTERPRETATION

Adrecizumab was well tolerated in patients with cardiogenic shock but did not reduce the need for cardiovascular organ support or improve survival at days 30 and 90.

FUNDING

Adrenomed AG and University Hospital of Hamburg.

Combination of Prehospital NT-proBNP with qSOFA and NEWS to Predict Sepsis and Sepsis-Related Mortality

Background. The aim of this study was to assess the role of prehospital point-of-care N-terminal probrain natriuretic peptide to predict sepsis, septic shock, or in-hospital sepsis-related mortality. Methods. A prospective, emergency medical service-delivered, prognostic, cohort study of adults evacuated by ambulance and admitted to emergency department between January 2020 and May 2021. The discriminative power of the predictive variable was assessed through a prediction model trained using the derivation cohort and evaluated by the area under the curve of the receiver operating characteristic on the validation cohort. Results. A total of 1,360 patients were enrolled with medical disease in the study. The occurrence of sepsis, septic shock, and in-hospital sepsis-related mortality was 6.4% (67 cases), 4.2% (44 cases), and 6.1% (64 cases). Prehospital National Early Warning Score 2 had superior predictive validity than quick Sequential Organ Failure Assessment and N-terminal probrain natriuretic peptide for detecting sepsis and septic shock, but N-terminal probrain natriuretic peptide outperformed both scores in in-hospital sepsis-related mortality estimation. Application of N-terminal probrain natriuretic peptide to subgroups of the other two scores improved the identification of sepsis, septic shock, and sepsis-related mortality in the group of patients with low-risk scoring. Conclusions. The incorporation of N-terminal probrain natriuretic peptide in prehospital care combined with already existing scores could improve the identification of sepsis, septic shock, and sepsis-related mortality.

Inotropes and vasopressors are associated with increased short-term mortality but not long-term survival in critically ill patients

OBJECTIVE

Limited information is currently available on the impact of vasoactive medications in intensive care (ICU) and long-term outcomes. The main objective of our study was to describe the association between the use of inotropes and/or vasopressors and ICU mortality. Secondary objectives were to evaluate the association between the use of vasoactive drugs and in-hospital as well as 1-year all-cause mortality in ICU survivors.

METHODS

FROG-ICU was a prospective, observational, multi-centre cohort designed to investigate long-term mortality of critically ill adult patients. Cox proportional hazards models were used to evaluate the association between the use of inotropes and/or vasopressors and ICU mortality, as well as in-hospital and 1-year all-cause mortality in a propensity-score matched cohort.

RESULTS

The study included 2087 patients, 939 of whom received inotropes and/or vasopressors during the initial ICU stay. Patients treated with vasoactive medications were older and had a more severe clinical presentation. In a propensity score-matched cohort of 1201 patients, ICU mortality was higher in patients who received vasoactive medications (HR of 1.40 [1.10 - 1.78], p = 0.007). One thousand six hundred thirty-five patients survived the index ICU hospitalisation. There was no significant difference according to the use of inotropes and/or vasopressors in the propensity-score matched cohort on in-hospital mortality (HR of 0.94 [0.60 - 1.49], p = 0.808) as well as one-year all-cause mortality (HR 0.94 [0.71 - 1.24], p = 0.643).

CONCLUSION

Inotropic and/or vasopressor therapy is a strong predictor of in-ICU death. However, the use of inotropes and/or vasopressors during ICU admission was not associated with a worse prognosis after ICU discharge.

Current practice and evolving concepts in septic shock resuscitation

Clinical and pathophysiological understanding of septic shock has progressed exponentially in the previous decades, translating into a steady decrease in septic shock-related morbidity and mortality. Even though large randomized, controlled trials have addressed fundamental aspects of septic shock resuscitation, many questions still exist. In this review, we will describe the current standards of septic shock resuscitation, but the emphasis will be placed on evolving concepts in different domains such as clinical resuscitation targets, adequate use of fluids and vasoactive drugs, refractory shock, and the use of extracorporeal therapies. Multiple research opportunities remain open, and collaborative endeavors should be performed to fill in these gaps.

An international survey of adherence to Surviving Sepsis Campaign Guidelines 2016 regarding fluid resuscitation and vasopressors in the initial management of septic shock

BACKGROUND

Our survey aimed to evaluate adherence to Surviving Sepsis Campaign (SSC) Guidelines 2016 among intensive care practitioners and to identify issues that remain controversial or lack clarity.

METHODS

Members of the European Society of Intensive Care Medicine (ESICM) were surveyed using an anonymous web-based survey written by an international group of experts. The primary outcome measure was the rate of adherence to specific recommendations. Secondary outcomes were to describe areas of controversy and lack of data and to associate specific practices with clinician characteristics.

RESULTS

Overall 820 questionnaires were completed. The SCC recommendations 2016 most adhered to were the choice of norepinephrine as first-line vasoactive drug (96.5%), vasopressor prescription based on therapeutic goal rather than dose (83.4%), targeting a specific mean arterial blood pressure during vasopressor use (77.9%), monitoring of blood pressure invasively (62.8%) and adding vasopressin or epinephrine as a second vasoactive agent (83.4%). We identified an internal conflict with regards to parallel versus sequential administration of fluids and vasoactive drugs and regional differences in practice that may be related to drug availabilities.

CONCLUSION

The use of vasopressors and fluid use in septic shock is largely compliant with current guidelines but several controversies should be addressed in future guideline iterations.

Monitoring, management, and outcome of hypotension in Intensive Care Unit patients, an international survey of the European Society of Intensive Care Medicine

INTRODUCTION

Hypotension in the ICU is common, yet management is challenging and variable. Insight in management by ICU physicians and nurses may improve patient care and guide future hypotension treatment trials and guidelines.

METHODS

We conducted an international survey among ICU personnel to provide insight in monitoring, management, and perceived consequences of hypotension.

RESULTS

Out of 1464 respondents, 1197 (81.7%) were included (928 physicians (77.5%) and 269 nurses (22.5%)). The majority indicated that hypotension is underdiagnosed (55.4%) and largely preventable (58.8%). Nurses are primarily in charge of monitoring changes in blood pressure, physicians are in charge of hypotension treatment. Balanced crystalloids, dobutamine, norepinephrine, and Trendelenburg position were the most frequently reported fluid, inotrope, vasopressor, and positional maneuver used to treat hypotension. Reported complications believed to be related to hypotension were AKI and myocardial injury. Most ICUs do not have a specific hypotension treatment guideline or protocol (70.6%), but the majority would like to have one in the future (58.1%).

CONCLUSIONS

Both physicians and nurses report that hypotension in ICU patients is underdiagnosed, preventable, and believe that hypotension influences morbidity. Hypotension management is generally not protocolized, but the majority of respondents would like to have a specific hypotension management protocol.

Vasopressor and inotrope treatment for septic shock: An umbrella review of reviews

PURPOSE

To review the characteristics, findings and quality of systematic reviews (SRs) on the effect of any vasopressor/inotrope on outcomes in adult patients with sepsis compared with either no treatment, another vasopressor or inotrope or fluids.

MATERIALS AND METHODS

We systematically searched Cochrane Central Register of Controlled Trials, PubMed and Embase (January 1993-March 2021). Descriptive statistics were used.

RESULTS

Among the 28 SRs identified, mortality was the primary outcome in most (26/28) and mortality was usually (23/28) studied using randomised controlled trials (RCTs). Fifteen SRs focused exclusively on patients with sepsis or septic shock. Sepsis and septic shock were always grouped for the analysis. Publication bias was consistently low when studied. The most consistent findings were a survival advantage with norepinephrine versus dopamine, which disappeared in analyses restricted to 28-day mortality, and more arrhythmias with dopamine. However, these analyses were dominated by a single study. Only 2 SRs were judged to be of moderate-high quality. Lack of blinding and attrition bias may have affected the outcomes.

CONCLUSIONS

The quality of SRs on the effect of vasopressors/inotropes on the outcomes of adult patients with sepsis can be improved, but high-quality, multicenter, RCTs should be preferred to additional SRs on this topic.

[Pharmacological therapy of circulatory shock]

Circulatory shock requires treatment of the underlying pathology in addition to supportive pharmacological therapy that is guided by hemodynamic monitoring. Based on the evaluation of the patient's volume, perfusion and cardiac status, the following therapeutic goals should be achieved: (1) Normalization of the intra- and extravascular fluid volume. (2) Provision of sufficient perfusion pressure and organ perfusion. (3) Optimization of cardiac function including protecting an ischemic and exhausted myocardium from overload. The most important therapeutic substances are balanced electrolyte solutions and the vasopressor noradrenaline. Because there is little scientific evidence for the use of alternative drugs, these should only be given if there is a good pathophysiologic rationale and if their effect is continuously monitored and re-evaluated.

The medical treatment of cardiogenic shock: cardiovascular drugs

PURPOSE OF REVIEW

To discuss the use of vasopressors and inotropes in cardiogenic shock.

RECENT FINDINGS

The classic form or cardiogenic shock requires administration of inotropic and/or vasopressor agents to try to improve the impaired tissue perfusion. Among vasopressors various alpha-adrenergic agents, vasopressin derivatives and angiotensin can be used. The first-line therapy remains norepinephrine as it is associated with minimal adverse effects and appears to be associated by the best outcome in network meta-analyses. On the contrary, epinephrine is associated with an increased incidence of refractory shock and observational studies suggest an increased risk of death. Vasopressin may be an excellent alternative in tachycardiac patients or in the presence of pulmonary hypertension. Concerning inotropic agents, dobutamine is the first-line agent but levosimendan is an excellent alternative or additional agent in cases not responding to dobutamine. The impact on outcome of inotropic agents remains controversial.

SUMMARY

Recent studies have refined the position of the various vasopressor and inotropic agents. Norepinephrine is recommended as first-line vasopressor agent by various guidelines. Among inotropic agents, selection between the agents should be individualized and based on the hemodynamic response.

Inotropic therapies in heart failure and cardiogenic shock: an educational review

Reduced systolic function is central to the pathophysiology and clinical sequelae of acute decompensated heart failure (ADHF) with reduced ejection fraction and cardiogenic shock. These clinical entities are the final common pathway for marked deterioration of right or left ventricular function and can occur in multiple clinical presentations including severe ADHF, myocardial infarction, post-cardiac surgery, severe pulmonary hypertension, and advanced or end-stage chronic heart failure. Inotropic therapies improve ventricular systolic function and may be divided into three classes on the basis of their mechanism of action (calcitropes, mitotropes, and myotropes). Most currently available therapies for cardiogenic shock are calcitropes which can provide critical haemodynamic support, but also may increase myocardial oxygen demand, ischaemia, arrhythmia, and mortality. Emerging therapies to improve cardiac function such as mitotropes (e.g. perhexiline, SGLT2i) or myotropes (e.g. omecamtiv mecarbil) may provide useful alternatives in the future.

Clinical use of peripheral perfusion parameters in septic shock

PURPOSE OF REVIEW

Current goals of resuscitation in septic shock are mainly a fixed volume of fluids and vasopressors to correct hypotension and improve tissue perfusion indicated by decreasing lactate levels.

RECENT FINDINGS

Abnormal peripheral perfusion by objective and subjective parameters are associated with increased mortality in various phases of the treatment of critically ill patients including patients with septic shock. Ongoing resuscitation in septic shock patients with normal peripheral perfusion is not associated with improved outcome, rather with increased mortality. Mitigation of fluid resuscitation by using parameters of peripheral perfusion in septic shock seems to be safe.

SUMMARY

Septic shock patients with normal peripheral perfusion represent a different clinical phenotype of patients that might benefit from limited resuscitation efforts. Parameters of peripheral perfusion could be used to guide the individualization of patients with septic shock.