Inodilators in septic shock: should these be used?

Modifications of peripheral perfusion in patients with vasopressor-dependent septic shock treated with polymyxin B-direct hemoperfusion

Abnormal peripheral perfusion (PP) worsens the prognosis of patients with septic shock. Polymyxin B-direct hemoperfusion (PMX-DHP) increases blood pressure and reduces vasopressor doses. However, the modification of PP following administration of PMX-DHP in patients with vasopressor-dependent septic shock have not yet been elucidated. A retrospective exploratory observational study was conducted in patients with septic shock treated with PMX-DHP. Pulse-amplitude index (PAI), vasoactive inotropic score (VIS), and cumulative fluid balance data were extracted at PMX-DHP initiation (T0) and after 24 (T24) and 48 (T48) h. Changes in these data were analyzed in all patients and two subgroups (abnormal PP [PAI < 1] and normal PP [PAI ≥ 1]) based on the PAI at PMX-DHP initiation. Overall, 122 patients (abnormal PP group, n = 67; normal PP group, n = 55) were evaluated. Overall and in the abnormal PP group, PAI increased significantly at T24 and T48 compared with that at T0, with a significant decrease in VIS. Cumulative 24-h fluid balance after PMX-DHP initiation was significantly higher in the abnormal PP group. PMX-DHP may be an effective intervention to improve PP in patients with abnormal PP; however, caution should be exercised as fluid requirements may differ from that of patients with normal PP.

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.

The effect of HES130/0.4 sodium chloride solution on kidney function following early fluid resuscitation in shock patients

Background

Doctors often use a small dose of hydroxyethyl starch (HES) 130/0.4 sodium chloride solution in the emergency room; however, its effect on kidney function remains controversial. This study aimed to evaluate the effect of a small dose of HES130/0.4 sodium chloride solution on kidney function in shock patients during early fluid resuscitation.

Methods

This cohort study retrospectively analyzed the data of 129 shock patients requiring fluid resuscitation who had been admitted to the Emergency Department of the Affiliated Hospital of Nantong University from January 2019 to December 2020. Patients were divided into the observation group (n=40) and control group (n=89) according to the type of fluid resuscitation. In relation to the fluid resuscitation treatment, the observation group was treated with crystalloid solution, while the control group was treated with crystalloid and HES130/0.4 sodium chloride solution. To further explore the effect of a small dose of HES130/0.4 sodium chloride solution, the patients were further divided into the following 4 groups based on the specific fluid administered: (I) the HES(+), lactated Ringer's (LR)(+) group (n=85); (II) the HES(+), LR(-) group (n=4); (III) the HES(-), LR(+) group (n=31); and (IV) the HES(-), LR(-) group (n=9). The outcomes were in-hospital mortality and changes in creatinine (CR) level after fluid resuscitation.

Results

There were no significant differences in the in-hospital mortality rates between the observation and control groups (P=0.343). The CR levels of patients in the control and HES(+), LR(+) groups were reduced after fluid resuscitation (P=0.034; P=0.028). There was no significant change in patients' CR levels in the HES(+), LR(-) group after fluid resuscitation (P=0.999).

Conclusions

Administering a small dose of HES 130/0.4 sodium chloride in patients with shock does not appear to affect kidney function and in-hospital mortality; however, these findings should be considered exploratory, and further studies should be conducted to confirm these results.

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.

Levosimendan versus dobutamine for sepsis-induced cardiac dysfunction: a systematic review and meta-analysis

Levosimendan and dobutamine are extensively used to treat sepsis-associated cardiovascular failure in ICU. Nevertheless, the role and mechanism of levosimendan in patients with sepsis-induced cardiomyopathy remains unclear. Moreover, previous studies on whether levosimendan is superior to dobutamine are still controversial. More importantly, these studies did not take changes (before-after comparison to the baseline) in quantitative parameters such as ejection fraction into account with the baseline level. Here, we aimed to determine the pros and cons of the two medicines by assessing the changes in cardiac function and blood lactate, mortality, with the standardized mean difference used as a summary statistic. Relevant studies were obtained by a thorough and disciplined literature search in several notable academic databases, including Google Scholar, PubMed, Cochrane Library and Embase until November 2020. Outcomes included changes in cardiac function, lactic acid, mortality and length of hospital stay. A total of 6 randomized controlled trials were included in this study, including 192 patients. Compared with dobutamine, patients treated with levosimendan had a greater improvement of cardiac index (ΔCI) (random effects, SMD = 0.90 [0.20,1.60]; I2 = 76%, P < 0.01) and left ventricular stroke work index (ΔLVSWI) (random effects, SMD = 1.56 [0.90,2.21]; I2 = 65%, P = 0.04), a significant decrease of blood lactate (Δblood lactate) (random effects, MD =  - 0.79 [- 1.33, - 0.25]; I2 = 68%, P < 0.01) at 24-h after drug intervention, respectively. There was no significant difference between levosimendan and dobutamine on all-cause mortality in ICU (fixed effect, OR = 0.72 [0.39,1.33]; I2 = 0%, P = 0.99). We combine effect sizes related to different measurement parameters to evaluate cardiac function, which implied that septic patients with myocardial dysfunction might have a better improvement of cardiac function by levosimendan than dobutamine (random effects, SMD = 1.05 [0.69,1.41]; I2 = 67%, P < 0.01). This study suggested a significant improvement of CI, LVSWI, and decrease of blood lactate in septic patients with myocardial dysfunction in ICU after 24-h administration of levosimendan than dobutamine. However, the administration of levosimendan has neither an impact on mortality nor LVEF. Septic patients with myocardial dysfunction may partly benefit from levosimendan than dobutamine, mainly embodied in cardiac function improvement.