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Trifi A, Abdellatif S, Mehdi A, Messaoud L, Seghir E, Mrad N, Ben Khelil J, Ben Ismail K, Merhaben T, Fradj H, Mokline A, Messaadi AA, Khiari H, Garbaa Y, Borsali Falfoul N, Ennouri E, Toumi R, Boussarsar M, Jaoued O, Atrous S, Ghezala HB, Brahmi N, Trabelsi I, Ghadhoune H, Bradaii S, Bahloul M, Ammar R, Kaaniche FM. Early administration of norepinephrine in sepsis: Multicenter randomized clinical trial (EA-NE-S-TUN) study protocol. PLoS One 2024; 19:e0307407. [PMID: 39024364 PMCID: PMC11257256 DOI: 10.1371/journal.pone.0307407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 06/30/2024] [Indexed: 07/20/2024] Open
Abstract
One of the most important components of sepsis management is hemodynamic restoration. If the target mean arterial pressure (MAP) is not obtained, the first recommendation is for volume expansion, and the second is for norepinephrine (NE). We describe the methodology of a randomized multicenter trial aiming to assess the hypothesis that low-dose NE given early in adult patients with sepsis will provide better control of shock within 6 hours from therapy starting compared to standard care. This trial includes ICU septic patients in whom MAP decrease below 65 mmHg to be randomized into 2 groups: early NE-group versus standard care-group. The patient's attending clinician will determine how much volume expansion is necessary to meet the target of a MAP > 65 mm Hg. If this target not achieved, after at least 30 ml/kg and guided by the available indices of fluid responsiveness, NE will be used in a usual way. The latter must follow a consensual schedule elaborated by the investigating centers. Parameters to be taken at inclusion and at H6 are: lactates, cardiac ultrasound parameters (stroke volume (SV), cardiac output (CO), E/E' ratio), and P/F ratio. MAP and diuresis are recorded hourly. Our primary outcome is the shock control defined as a composite criterion (MAP > 65 mm Hg for 2 consecutive measurements and urinary output > 0.5 ml/kg/h for 2 consecutive hours) within 6 hours. Secondary outcomes: Decrease in serum lactate> 10% from baseline within 6 hours, the received fluid volume within 6 hours, variation of CO and E/E', and 28 days-Mortality. The study is ongoing and aims to include at least 100 patients per arm. This study is likely to contribute to support the indication of early initiation of NE with the aim to restrict fluid intake in septic patients. (ClinicalTrials.gov ID: NCT05836272).
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Affiliation(s)
- Ahlem Trifi
- Medical Intensive Care Unit (MICU), La Rabta Hospital, Tunis, Tunisia
| | - Sami Abdellatif
- Medical Intensive Care Unit (MICU), La Rabta Hospital, Tunis, Tunisia
| | - Asma Mehdi
- Medical Intensive Care Unit (MICU), La Rabta Hospital, Tunis, Tunisia
| | - Linda Messaoud
- Medical Intensive Care Unit (MICU), La Rabta Hospital, Tunis, Tunisia
| | - Eya Seghir
- Medical Intensive Care Unit (MICU), La Rabta Hospital, Tunis, Tunisia
| | - Nacef Mrad
- MICU, Abderrahmen Mami-hospital, Ariana, Tunisia
| | | | | | | | | | | | | | - Hyem Khiari
- Department of Epidemiological Medicine and Statistics, Salah Azaiez Institute of Tunis, Tunis, Tunisia
| | | | | | | | | | | | | | | | | | - Nozha Brahmi
- Urgent Medical Assistance Center, Tunis, Tunisia
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Ahn C, Yu G, Shin TG, Cho Y, Park S, Suh GY. Comparison of Early and Late Norepinephrine Administration in Patients With Septic Shock: A Systematic Review and Meta-analysis. Chest 2024:S0012-3692(24)04581-1. [PMID: 38972348 DOI: 10.1016/j.chest.2024.05.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 07/09/2024] Open
Abstract
BACKGROUND Vasopressor administration at an appropriate time is crucial, but the optimal timing remains controversial. RESEARCH QUESTION Does early vs late norepinephrine administration impact the prognosis of septic shock? STUDY DESIGN AND METHODS Searches were conducted in PubMed, EMBASE, the Cochrane Library, and KMbase databases. We included studies of adults with sepsis and categorized patients into an early and late norepinephrine group according to specific time points or differences in norepinephrine use protocols. The primary outcome was overall mortality. The secondary outcomes included length of stay in the ICU, days free from ventilator use, days free from renal replacement therapy, days free from vasopressor use, adverse events, and total fluid volume. RESULTS Twelve studies (four randomized controlled trials [RCTs] and eight observational studies) comprising 7,281 patients were analyzed. For overall mortality, no significant difference was found between the early norepinephrine group and late norepinephrine group in RCTs (OR, 0.70; 95% CI, 0.41-1.19) or observational studies (OR, 0.83; 95% CI, 0.54-1.29). In the two RCTs without a restrictive fluid strategy that prioritized vasopressors and lower IV fluid volumes, the early norepinephrine group showed significantly lower mortality than the late norepinephrine group (OR, 0.49; 95%, CI, 0.25-0.96). The early norepinephrine group demonstrated more mechanical ventilator-free days in observational studies (mean difference, 4.06; 95% CI, 2.82-5.30). The incidence of pulmonary edema was lower in the early norepinephrine group in the three RCTs that reported this outcome (OR, 0.43; 95% CI, 0.25-0.74). No differences were found in the other secondary outcomes. INTERPRETATION Overall mortality did not differ significantly between early and late norepinephrine administration for septic shock. However, early norepinephrine administration seemed to reduce pulmonary edema incidence, and mortality improvement was observed in studies without fluid restriction interventions, favoring early norepinephrine use.
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Affiliation(s)
- Chiwon Ahn
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul, South Korea
| | - Gina Yu
- Department of Emergency Medicine, University of Yonsei College of Medicine, Seoul, South Korea
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Youngsuk Cho
- Department of Emergency Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, South Korea
| | - Sunghoon Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Zhou X, Hu C, Pan J, Xu C, Xu Z, Pan T, Chen B. Dynamic arterial elastance as a predictor of arterial pressure response to norepinephrine weaning in mechanically ventilated patients with vasoplegic syndrome-a systematic review and meta-analysis. Front Cardiovasc Med 2024; 11:1350847. [PMID: 38390442 PMCID: PMC10881861 DOI: 10.3389/fcvm.2024.1350847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/29/2024] [Indexed: 02/24/2024] Open
Abstract
Introduction During the de-escalation phase of circulatory shock, norepinephrine weaning may induce diverse arterial pressure responses in patients with different vasomotor tones. Dynamic arterial elastance (Eadyn) has been extensively studied to predict the arterial pressure response to interventions. We conducted this meta-analysis to systematically assess the predictive performance of Eadyn for the mean arterial pressure (MAP) response to norepinephrine weaning in mechanically ventilated patients with vasoplegic syndrome. Materials and methods A systematic literature search was conducted on May 29, 2023 (updated on January 21, 2024), to identify relevant studies from electronic databases. The area under the hierarchical summary receiver operating characteristic curve (AUHSROC) was estimated as the primary measure of diagnostic accuracy because of the varied thresholds reported. Additionally, we observed the distribution of the cutoff values of Eadyn, while computing the optimal value and its corresponding 95% confidential interval (CI). Results A total of 5 prospective studies met eligibility, comprising 183 participants, of whom 67 (37%) were MAP responders. Eadyn possessed an excellent ability to predict the MAP response to norepinephrine weaning in patients with vasoplegic syndrome, with an AUHSROC of 0.93 (95% CI: 0.91-0.95), a pooled sensitivity of 0.94 (95% CI: 0.85-0.98), a pooled specificity of 0.73 (95% CI: 0.65-0.81), and a pooled diagnostic odds ratio of 32.4 (95% CI: 11.7-89.9). The cutoff values of Eadyn presented a nearly conically symmetrical distribution; the mean and median cutoff values were 0.89 (95% CI: 0.80-0.98) and 0.90 (95% CI: not estimable), respectively. Conclusions This meta-analysis with limited evidences demonstrates that Eadyn may be a reliable predictor of the MAP response to norepinephrine weaning in mechanically ventilated patients with vasoplegic syndrome. Systematic Review Registration PROSPERO CRD42023430362.
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Affiliation(s)
- Xiaoyang Zhou
- Department of Intensive Care Medicine, Ningbo No.2 Hospital, Ningbo, Zhejiang, China
| | - Caibao Hu
- Department of Intensive Care Medicine, Affiliated Zhejiang Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jianneng Pan
- Department of Intensive Care Medicine, Ningbo No.2 Hospital, Ningbo, Zhejiang, China
| | - Chang Xu
- Department of Intensive Care Medicine, Ningbo No.2 Hospital, Ningbo, Zhejiang, China
| | - Zhaojun Xu
- Department of Intensive Care Medicine, Ningbo No.2 Hospital, Ningbo, Zhejiang, China
| | - Tao Pan
- Department of Intensive Care Medicine, Ningbo No.2 Hospital, Ningbo, Zhejiang, China
| | - Bixin Chen
- Department of Intensive Care Medicine, Ningbo No.2 Hospital, Ningbo, Zhejiang, China
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Thoppil J, Mehta P, Bartels B, Sharma D, Farrar JD. Impact of norepinephrine on immunity and oxidative metabolism in sepsis. Front Immunol 2023; 14:1271098. [PMID: 38022663 PMCID: PMC10662053 DOI: 10.3389/fimmu.2023.1271098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Sepsis is a major health problem in the United States (US), constituting a leading contributor to mortality among critically ill patients. Despite advances in treatment the underlying pathophysiology of sepsis remains elusive. Reactive oxygen species (ROS) have a significant role in antimicrobial host defense and inflammation and its dysregulation leads to maladaptive responses because of excessive inflammation. There is growing evidence for crosstalk between the central nervous system and the immune system in response to infection. The hypothalamic-pituitary and adrenal axis and the sympathetic nervous system are the two major pathways that mediate this interaction. Epinephrine (Epi) and norepinephrine (NE), respectively are the effectors of these interactions. Upon stimulation, NE is released from sympathetic nerve terminals locally within lymphoid organs and activate adrenoreceptors expressed on immune cells. Similarly, epinephrine secreted from the adrenal gland which is released systemically also exerts influence on immune cells. However, understanding the specific impact of neuroimmunity is still in its infancy. In this review, we focus on the sympathetic nervous system, specifically the role the neurotransmitter norepinephrine has on immune cells. Norepinephrine has been shown to modulate immune cell responses leading to increased anti-inflammatory and blunting of pro-inflammatory effects. Furthermore, there is evidence to suggest that norepinephrine is involved in regulating oxidative metabolism in immune cells. This review attempts to summarize the known effects of norepinephrine on immune cell response and oxidative metabolism in response to infection.
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Affiliation(s)
- Joby Thoppil
- Department of Emergency Medicine, University of Texas, Southwestern Medical Center, Dallas, TX, United States
| | - Prayag Mehta
- Department of Emergency Medicine, University of Texas, Southwestern Medical Center, Dallas, TX, United States
| | - Brett Bartels
- Department of Emergency Medicine, University of Texas, Southwestern Medical Center, Dallas, TX, United States
| | - Drashya Sharma
- Department of Immunology, University of Texas (UT) Southwestern Medical Center, Dallas, TX, United States
| | - J. David Farrar
- Department of Immunology, University of Texas (UT) Southwestern Medical Center, Dallas, TX, United States
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Jouffroy R, Gilbert B, Tourtier JP, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye P. Prehospital pulse pressure and mortality of septic shock patients cared for by a mobile intensive care unit. BMC Emerg Med 2023; 23:97. [PMID: 37626302 PMCID: PMC10464421 DOI: 10.1186/s12873-023-00864-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Septic shock medical treatment relies on a bundle of care including antibiotic therapy and hemodynamic optimisation. Hemodynamic optimisation consists of fluid expansion and norepinephrine administration aiming to optimise cardiac output to reach a mean arterial pressure of 65mmHg. In the prehospital setting, direct cardiac output assessment is difficult because of the lack of invasive and non-invasive devices. This study aims to assess the relationship between 30-day mortality and (i) initial pulse pressure (iPP) as (ii) pulse pressure variation (dPP) during the prehospital stage among patients cared for SS by a prehospital mobile intensive care unit (MICU). METHODS From May 09th, 2016 to December 02nd, 2021, septic shock patients requiring MICU intervention were retrospectively analysed. iPP was calculated as the difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP) at the first contact between the patient and the MICU team prior to any treatment and, dPP as the difference between the final PP (the difference between SBP and DBP at the end of the prehospital stage) and iPP divided by prehospital duration. To consider cofounders, the propensity score method was used to assess the relationship between (i) iPP < 40mmHg, (ii) positive dPP and 30-day mortality. RESULTS Among the 530 patients analysed, pulmonary, digestive, and urinary infections were suspected among 43%, 25% and 17% patients, respectively. The 30-day overall mortality rate reached 31%. Cox regression analysis showed an association between 30-day mortality and (i) iPP < 40mmHg; aHR of 1.61 [1.03-2.51], and (ii) a positive dPP; aHR of 0.56 [0.36-0.88]. CONCLUSION The current study reports an association between 30-day mortality rate and iPP < 40mmHg and a positive dPP among septic shock patients cared for by a prehospital MICU. A negative dPP could be helpful to identify septic shock with higher risk of poor outcome despite prehospital hemodynamic optimization.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique Hôpitaux Paris and Paris Saclay University, 9 avenue Charles De Gaulle, Boulogne-Billancourt, 92100, France.
- Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux Paris, Paris, France.
- Centre de recherche en Epidémiologie et Santé des Populations - U1018 INSERM, Paris Saclay University, Villejuif, France.
- Institut de Recherche bioMédicale et d'Epidémiologie du Sport - EA7329, INSEP - Paris University, Paris, France.
- EA 7525 Université des Antilles, Fort de France, France.
| | - Basile Gilbert
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | | | - Emmanuel Bloch-Laine
- Emergency Department, Cochin Hospital, Paris, France
- Emergency Department, SMUR, Hôtel Dieu Hospital - Assistance Publique - Hôpitaux Paris, Paris, France
| | - Patrick Ecollan
- Intensive Care Unit, SMUR, Pitie Salpêtriere Hospital, 47 Boulevard de l'Hôpital, Paris - Assistance Publique - Hôpitaux Paris, Paris, 75013, France
| | - Josiane Boularan
- SAMU 31, Centre Hospitalier Intercommunal Castres-Mazamet, Castres, France
| | - Vincent Bounes
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | - Benoit Vivien
- Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux Paris, Paris, France
| | - Papa Gueye
- EA 7525 Université des Antilles, Fort de France, France
- SAMU 972, Centre Hospitalier Universitaire de Martinique, Fort-de-France Martinique, France
- EA 7525 University of the Antilles, Martinique, France
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Muniz-Santos R, Lucieri-Costa G, de Almeida MAP, Moraes-de-Souza I, Brito MADSM, Silva AR, Gonçalves-de-Albuquerque CF. Lipid oxidation dysregulation: an emerging player in the pathophysiology of sepsis. Front Immunol 2023; 14:1224335. [PMID: 37600769 PMCID: PMC10435884 DOI: 10.3389/fimmu.2023.1224335] [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: 05/17/2023] [Accepted: 06/30/2023] [Indexed: 08/22/2023] Open
Abstract
Sepsis is a life-threatening organ dysfunction caused by abnormal host response to infection. Millions of people are affected annually worldwide. Derangement of the inflammatory response is crucial in sepsis pathogenesis. However, metabolic, coagulation, and thermoregulatory alterations also occur in patients with sepsis. Fatty acid mobilization and oxidation changes may assume the role of a protagonist in sepsis pathogenesis. Lipid oxidation and free fatty acids (FFAs) are potentially valuable markers for sepsis diagnosis and prognosis. Herein, we discuss inflammatory and metabolic dysfunction during sepsis, focusing on fatty acid oxidation (FAO) alterations in the liver and muscle (skeletal and cardiac) and their implications in sepsis development.
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Affiliation(s)
- Renan Muniz-Santos
- Laboratory of Immunopharmacology, Department of Physiology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Giovanna Lucieri-Costa
- Laboratory of Immunopharmacology, Department of Physiology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Matheus Augusto P. de Almeida
- Neuroscience Graduate Program, Federal Fluminense University, Niteroi, Brazil
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Isabelle Moraes-de-Souza
- Laboratory of Immunopharmacology, Department of Physiology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Adriana Ribeiro Silva
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Cassiano Felippe Gonçalves-de-Albuquerque
- Laboratory of Immunopharmacology, Department of Physiology, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroscience Graduate Program, Federal Fluminense University, Niteroi, Brazil
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
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Ranjit S, Kissoon N, Argent A, Inwald D, Ventura AMC, Jaborinsky R, Sankar J, de Souza DC, Natraj R, De Oliveira CF, Samransamruajkit R, Jayashree M, Schlapbach LJ. Haemodynamic support for paediatric septic shock: a global perspective. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:588-598. [PMID: 37354910 DOI: 10.1016/s2352-4642(23)00103-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/19/2023] [Accepted: 04/19/2023] [Indexed: 06/26/2023]
Abstract
Septic shock is a leading cause of hospitalisation, morbidity, and mortality for children worldwide. In 2020, the paediatric Surviving Sepsis Campaign (SSC) issued evidence-based recommendations for clinicians caring for children with septic shock and sepsis-associated organ dysfunction based on the evidence available at the time. There are now more trials from multiple settings, including low-income and middle-income countries (LMICs), addressing optimal fluid choice and amount, selection and timing of vasoactive infusions, and optimal monitoring and therapeutic endpoints. In response to developments in adult critical care to trial personalised haemodynamic management algorithms, it is timely to critically reassess the current state of applying SSC guidelines in LMIC settings. In this Viewpoint, we briefly outline the challenges to improve sepsis care in LMICs and then discuss three key concepts that are relevant to management of children with septic shock around the world, especially in LMICs. These concepts include uncertainties surrounding the early recognition of paediatric septic shock, choices for initial haemodynamic support, and titration of ongoing resuscitation to therapeutic endpoints. Specifically, given the evolving understanding of clinical phenotypes, we focus on the controversies surrounding the concepts of early fluid resuscitation and vasoactive agent use, including insights gained from experience in LMICs and high-income countries. We outline the key components of sepsis management that are both globally relevant and translatable to low-resource settings, with a view to open the conversation to the large variety of treatment pathways, especially in LMICs. We emphasise the role of simple and easily available monitoring tools to apply the SSC guidelines and to tailor individualised support to the patient's cardiovascular physiology.
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Affiliation(s)
- Suchitra Ranjit
- Paediatric Intensive Care Unit, Apollo Children's Hospital, Chennai, India.
| | | | - Andrew Argent
- Department of Paediatrics and Child Health, University of Cape Town, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - David Inwald
- Addenbrooke's Hospital, University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andréa Maria Cordeiro Ventura
- Department of Pediatrics, Pediatric Intensive Care Unit, Hospital Universitário da Universidade de Sao Paulo, São Paulo, Brazil
| | - Roberto Jaborinsky
- Northeastern National University, Corrientes, Argentina; Latin American Society of Pediatric Intensive Care (LARed Network), Montevideo, Uruguay; SLACIP Sociedad Latinoamericana de Cuidados Intensivos Pediátricos, Monterrey, Mexico
| | - Jhuma Sankar
- Division of Pediatric Pulmonology and Critical Care, Department of Pediatrics, AIIMS, New Delhi, India
| | - Daniela Carla de Souza
- Department of Pediatrics, Pediatric Intensive Care Unit, Hospital Universitário da Universidade de Sao Paulo, São Paulo, Brazil; Latin American Sepsis Institute, São Paulo, Brazil
| | - Rajeswari Natraj
- Department of Paediatric Intensive Care, Apollo Children's Hospitals, Chennai, India
| | | | - Rujipat Samransamruajkit
- Division of Pediatric Critical Care, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Muralidharan Jayashree
- Pediatric Emergency and Intensive Care, Advanced Pediatrics Centre, PGIMER, Chandigarh, India
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care and Neonatology and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
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Tong X, Xue X, Duan C, Liu A. Early administration of multiple vasopressors is associated with better survival in patients with sepsis: a propensity score-weighted study. Eur J Med Res 2023; 28:249. [PMID: 37481578 PMCID: PMC10362716 DOI: 10.1186/s40001-023-01229-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/14/2023] [Indexed: 07/24/2023] Open
Abstract
BACKGROUND The association between the timing of administration of multiple vasopressors and patient outcomes has not been investigated. METHODS This study used data from the MIMIC-IV database. Patients with sepsis who were administered two or more vasopressors were included. The principal exposure was the last norepinephrine dose when adding a second vasopressor. The cohort was divided into early (last norepinephrine dose < 0.25 μg/kg/min) and normal (last norepinephrine dose ≥ 0.25 μg/kg/min) groups. The primary outcome was 28-day mortality. Multivariable Cox analyses, propensity score matching, stabilized inverse probability of treatment weighting (sIPTW), and restricted cubic spline (RCS) curves were used. RESULTS Overall, 1,437 patients who received multiple vasopressors were included. Patients in the early group had lower 28-day mortality (HR: 0.76; 95% CI: 0.65-0.89; p < 0.001) than those in the single group, with similar results in the propensity score-matched (HR: 0.80; 95% CI: 0.68-0.94; p = 0.006) and sIPTW (HR: 0.75; 95% CI: 0.63-0.88; p < 0.001) cohorts. RCS curves showed that the risk of 28-day mortality increased as the last norepinephrine dose increased. CONCLUSIONS The timing of secondary vasopressor administration is strongly associated with the outcomes of patients with sepsis.
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Affiliation(s)
- Xin Tong
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Xiaopeng Xue
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Chuanzhi Duan
- Department of Cerebrovascular Surgery, Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Zhujiang Hospital, Neurosurgery Center, Southern Medical University, Guangdong, China
- Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Guangdong, China
| | - Aihua Liu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.
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Carlos Sanchez E, Pinsky MR, Sinha S, Mishra RC, Lopa AJ, Chatterjee R. Fluids and Early Vasopressors in the Management of Septic Shock: Do We Have the Right Answers Yet? J Crit Care Med (Targu Mures) 2023; 9:138-147. [PMID: 37588181 PMCID: PMC10425929 DOI: 10.2478/jccm-2023-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/22/2023] [Indexed: 08/18/2023] Open
Abstract
Septic shock is a common condition associated with hypotension and organ dysfunction. It is associated with high mortality rates of up to 60% despite the best recommended resuscitation strategies in international guidelines. Patients with septic shock generally have a Mean Arterial Pressure below 65 mmHg and hypotension is the most important determinant of mortality among this group of patients. The extent and duration of hypotension are important. The two initial options that we have are 1) administration of intravenous (IV) fluids and 2) vasopressors, The current recommendation of the Surviving Sepsis Campaign guidelines to administer 30 ml/kg fluid cannot be applied to all patients. Complications of fluid over-resuscitation further delay organ recovery, prolong ICU and hospital length of stay, and increase mortality. The only reason for administering intravenous fluids in a patient with circulatory shock is to increase the mean systemic filling pressure in a patient who is volume-responsive, such that cardiac output also increases. The use of vasopressors seems to be a more appropriate strategy, the very early administration of vasopressors, preferably during the first hour after diagnosis of septic shock, may have a multimodal action and potential advantages, leading to lower morbidity and mortality in the management of septic patients. Vasopressor therapy should be initiated as soon as possible in patients with septic shock.
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Affiliation(s)
- E. Carlos Sanchez
- Department of Critical Care Medicine, King Salman Hospital, Riyadh, Saudi Arabia
| | - Michael R. Pinsky
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sharmili Sinha
- Department of Critical Care Medicine, Apollo Hospitals, Bhubaneswar, India
| | - Rajesh Chandra Mishra
- Department of Critical Care Medicine, Ahmedabad Khyati Multi-speciality Hospitals, Ahmedabad, India Department of Critical Care Medicine, Ahmedabad Shaibya Comprehensive Care Clinic, Ahmedabad, India
| | - Ahsina Jahan Lopa
- ICU and Emergency Department, Shahabuddin Medical College Hospital, Dhaka, Bangladesh
| | - Ranajit Chatterjee
- Department of Critical Care Medicine, accident and emergency, Swami Dayanand Hospital Delhi, India
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Arfaras-Melainis A, Ventoulis I, Polyzogopoulou E, Boultadakis A, Parissis J. The current and future status of inotropes in heart failure management. Expert Rev Cardiovasc Ther 2023; 21:573-585. [PMID: 37458248 DOI: 10.1080/14779072.2023.2237869] [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] [Received: 04/09/2023] [Revised: 07/08/2023] [Accepted: 07/14/2023] [Indexed: 07/25/2023]
Abstract
INTRODUCTION Heart failure (HF) is a complex syndrome with a wide range of presentations and acuity, ranging from outpatient care to inpatient management due to acute decompensated HF, cardiogenic shock or advanced HF. Frequently, the etiology of a patient's decompensation is diminished cardiac output and peripheral hypoperfusion. Consequently, there is a need for use of inotropes, agents that increase cardiac contractility, optimize hemodynamics and ensure adequate perfusion. AREAS COVERED Inotropes are divided into 3 major classes: beta agonists, phosphodiesterase III inhibitors and calcium sensitizers. Additionally, as data from prospective studies accumulates, novel agents are emerging, including omecamtiv mecarbil and istaroxime. The aim of this review is to summarize current data on the optimal use of inotropes and to provide an expert opinion regarding their current and future use in the management of HF. EXPERT OPINION The use of inotropes has long been linked to worsening mortality, tachyarrhythmias, increased myocardial oxygen consumption and ischemia. Therefore, individualized and evidence-based treatment plans for patients who require inotropic support are necessary. Also, better quality data on the use of existing inotropes is imperative, while the development of newer and safer agents will lead to more effective management of patients with HF in the future.
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Affiliation(s)
- Angelos Arfaras-Melainis
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ioannis Ventoulis
- Department of Occupational Therapy, University of Western Macedonia, Ptolemaida, Greece
| | - Effie Polyzogopoulou
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonios Boultadakis
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - John Parissis
- Emergency Department, Heart Failure Unit, Attikon University Hospital, Athens, Greece
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11
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Jouffroy R, Hajjar A, Gilbert B, Tourtier JP, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye PN. Prehospital norepinephrine administration reduces 30-day mortality among septic shock patients. BMC Infect Dis 2022; 22:345. [PMID: 35387608 PMCID: PMC8988327 DOI: 10.1186/s12879-022-07337-y] [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: 07/24/2021] [Accepted: 02/21/2022] [Indexed: 11/23/2022] Open
Abstract
Background Despite differences in time of sepsis recognition, recent studies support that early initiation of norepinephrine in patients with septic shock (SS) improves outcome without an increase in adverse effects. This study aims to investigate the relationship between 30-day mortality in patients with SS and prehospital norepinephrine infusion in order to reach a mean blood pressure (MAP) > 65 mmHg at the end of the prehospital stage. Methods From April 06th, 2016 to December 31th, 2020, patients with SS requiring prehospital Mobile Intensive Care Unit intervention (MICU) were retrospectively analysed. To consider cofounders, the propensity score method was used to assess the relationship between prehospital norepinephrine administration in order to reach a MAP > 65 mmHg at the end of the prehospital stage and 30-day mortality.
Results Four hundred and seventy-eight patients were retrospectively analysed, among which 309 patients (65%) were male. The mean age was 69 ± 15 years. Pulmonary, digestive, and urinary infections were suspected among 44%, 24% and 17% patients, respectively. One third of patients (n = 143) received prehospital norepinephrine administration with a median dose of 1.0 [0.5–2.0] mg h−1, among which 84 (69%) were alive and 38 (31%) were deceased on day 30 after hospital-admission. 30-day overall mortality was 30%. Cox regression analysis after the propensity score showed a significant association between prehospital norepinephrine administration and 30-day mortality, with an adjusted hazard ratio of 0.42 [0.25–0.70], p < 10–3. Multivariate logistic regression of IPTW retrieved a significant decrease of 30-day mortality among the prehospital norepinephrine group: ORa = 0.75 [0.70–0.79], p < 10–3.
Conclusion In this study, we report that prehospital norepinephrine infusion in order to reach a MAP > 65 mmHg at the end of the prehospital stage is associated with a decrease in 30-day mortality in patients with SS cared for by a MICU in the prehospital setting. Further prospective studies are needed to confirm that very early norepinephrine infusion decreases septic shock mortality.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique Hôpitaux Paris and Paris Saclay University, 9 avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France. .,Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique, Hôpitaux Paris, Paris, France. .,Centre de Recherche en Epidémiologie et Santé des Populations, U1018 INSERM, Paris Saclay University, Paris, France. .,Institut de Recherche bioMédicale et d'Epidémiologie du Sport, EA7329, INSEP, Paris University, Paris, France. .,EA 7525 Université des Antilles, Pointe-à-Pitre, France.
| | - Adèle Hajjar
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique Hôpitaux Paris and Paris Saclay University, 9 avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France
| | - Basile Gilbert
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | | | - Emmanuel Bloch-Laine
- Emergency Department, Cochin Hospital, Paris, France.,Emergency Department, SMUR, Hôtel Dieu Hospital, Assistance Publique, Hôpitaux Paris, Paris, France
| | - Patrick Ecollan
- Intensive Care Unit, SMUR, Pitie Salpêtriere Hospital, Assistance Publique, Hôpitaux Paris, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Josiane Boularan
- SAMU 31, Centre Hospitalier Intercommunal Castres-Mazamet, Castres, France
| | - Vincent Bounes
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | - Benoit Vivien
- Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique, Hôpitaux Paris, Paris, France
| | - Papa-Ngalgou Gueye
- EA 7525 Université des Antilles, Pointe-à-Pitre, France.,SAMU 972 University Hospital of Martinique, Fort-de-France, Martinique, France
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12
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Early initiation of norepinephrine in patients with septic shock: A propensity score-based analysis. Am J Emerg Med 2022; 54:287-296. [DOI: 10.1016/j.ajem.2022.01.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/22/2022] [Accepted: 01/27/2022] [Indexed: 12/20/2022] Open
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13
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Koutroulis I, Velez T, Wang T, Yohannes S, Galarraga JE, Morales JA, Freishtat RJ, Chamberlain JM. Pediatric sepsis phenotypes for enhanced therapeutics: An application of clustering to electronic health records. J Am Coll Emerg Physicians Open 2022; 3:e12660. [PMID: 35112102 PMCID: PMC8790108 DOI: 10.1002/emp2.12660] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 11/22/2021] [Accepted: 12/30/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE The heterogeneity of pediatric sepsis patients suggests the potential benefits of clustering analytics to derive phenotypes with distinct host response patterns that may help guide personalized therapeutics. We evaluate the relative performance of latent class analysis (LCA) and K-means, 2 commonly used clustering methods toward the derivation of clinically useful pediatric sepsis phenotypes. METHODS Data were extracted from anonymized medical records of 6446 pediatric patients that presented to 1 of 6 emergency departments (EDs) between 2013 and 2018 and were thereafter admitted. Using International Classification of Diseases (ICD)-9 and ICD-10 discharge codes, 151 patients were identified with a sepsis continuum diagnosis that included septicemia, sepsis, severe sepsis, and septic shock. Using feature sets used in related clustering studies, LCA and K-means algorithms were used to derive 4 distinct phenotypic pediatric sepsis segmentations. Each segmentation was evaluated for phenotypic homogeneity, separation, and clinical use. RESULTS Using the 2 feature sets, LCA clustering resulted in 2 similar segmentations of 4 clinically distinct phenotypes, while K-means clustering resulted in segmentations of 3 and 4 phenotypes. All 4 segmentations identified at least 1 high severity phenotype, but LCA-identified phenotypes reflected superior stratification, high entropy approaching 1 (eg, 0.994) indicating excellent separation between estimated phenotypes, and differential treatment/treatment response, and outcomes that were non-randomly distributed across phenotypes (P < 0.001). CONCLUSION Compared to K-means, which is commonly used in clustering studies, LCA appears to be a more robust, clinically useful statistical tool in analyzing a heterogeneous pediatric sepsis cohort toward informing targeted therapies. Additional prospective studies are needed to validate clinical utility of predictive models that target derived pediatric sepsis phenotypes in emergency department settings.
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Affiliation(s)
- Ioannis Koutroulis
- Emergency MedicineChildren's National Hospital/George Washington University School of Medicine and Health SciencesWashingtonDistrict of ColumbiaUSA
| | - Tom Velez
- Computer Technology AssociatesCardiffCaliforniaUSA
| | | | | | | | | | - Robert J. Freishtat
- Emergency MedicineChildren's National Hospital/George Washington University School of Medicine and Health SciencesWashingtonDistrict of ColumbiaUSA
| | - James M. Chamberlain
- Emergency MedicineChildren's National Hospital/George Washington University School of Medicine and Health SciencesWashingtonDistrict of ColumbiaUSA
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14
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Nugent K, Berdine G, Pena C. Does Fluid Administration Based on Fluid Responsiveness Tests such as Passive Leg Raising Improve Outcomes in Sepsis? Curr Cardiol Rev 2022; 18:18-23. [PMID: 35249497 PMCID: PMC9896423 DOI: 10.2174/1573403x18666220304202556] [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] [Received: 09/22/2021] [Revised: 01/06/2022] [Accepted: 01/24/2022] [Indexed: 11/22/2022] Open
Abstract
The management of sepsis requires the rapid administration of fluid to support blood pressure and tissue perfusion. Guidelines suggest that patients should receive 30 ml per kg of fluid over the first one to three hours of management. The next concern is to determine which patients need additional fluid. This introduces the concept of fluid responsiveness, defined by an increase in cardiac output following the administration of a fluid bolus. Dynamic tests, measuring cardiac output, identify fluid responders better than static tests. Passive leg raising tests provide an alternative approach to determine fluid responsiveness without administering fluid. However, one small randomized trial demonstrated that patients managed with frequent passive leg raising tests had a smaller net fluid balance at 72 hours and reduced requirements for renal replacement therapy and mechanical ventilation, but no change in mortality. A meta-analysis including 4 randomized control trials reported that resuscitation guided by fluid responsiveness does not improve mortality outcomes in patients with sepsis. Recent studies have demonstrated that the early administration of norepinephrine may improve outcomes in patients with sepsis. The concept of fluid responsiveness helps clinicians analyze the clinical status of patients, but this information must be integrated into the overall management of the patient. This review considers the use and benefit of fluid responsiveness tests to direct fluid administration in patients with sepsis.
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Affiliation(s)
- Kenneth Nugent
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock Texas, USA
| | - Gilbert Berdine
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock Texas, USA
| | - Camilo Pena
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock Texas, USA
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15
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Barlow B, Bissell BD. Evaluation of Evidence, Pharmacology, and Interplay of Fluid Resuscitation and Vasoactive Therapy in Sepsis and Septic Shock. Shock 2021; 56:484-492. [PMID: 33756502 DOI: 10.1097/shk.0000000000001783] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT We sought to review the pharmacology of vasoactive therapy and fluid administration in sepsis and septic shock, with specific insight into the physiologic interplay of these agents. A PubMed/MEDLINE search was conducted using the following terms (vasopressor OR vasoactive OR inotrope) AND (crystalloid OR colloid OR fluid) AND (sepsis) AND (shock OR septic shock) from 1965 to October 2020. A total of 1,022 citations were reviewed with only relevant clinical data extracted. While physiologic rationale provides a hypothetical foundation for interaction between fluid and vasopressor administration, few studies have sought to evaluate the clinical impact of this synergy. Current guidelines are not in alignment with the data available, which suggests a potential benefit from low-dose fluid administration and early vasopressor exposure. Future data must account for the impact of both of these pharmacotherapies when assessing clinical outcomes and should assess personalization of therapy based on the possible interaction.
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Affiliation(s)
- Brooke Barlow
- Department of Pharmacy, University of Kentucky, Lexington, Kentucky
- College of Pharmacy, Pharmacy Practice and Science, University of Kentucky, Lexington, Kentucky
| | - Brittany D Bissell
- Department of Pharmacy, University of Kentucky, Lexington, Kentucky
- College of Pharmacy, Pharmacy Practice and Science, University of Kentucky, Lexington, Kentucky
- College of Medicine, Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky, Lexington, Kentucky
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16
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The effect of norepinephrine on common carotid artery blood flow in septic shock patients. Sci Rep 2021; 11:16763. [PMID: 34408193 PMCID: PMC8373863 DOI: 10.1038/s41598-021-96082-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 08/04/2021] [Indexed: 11/17/2022] Open
Abstract
This study was designed to evaluate the hemodynamic effect of norepinephrine (NE) on the peak systolic velocity (PSV), diameter, and blood flow of the common carotid artery (CCA) using the point-of-care ultrasound (POCUS) in patients with septic shock. The study involved patients above 18 years old with septic shock. Arterial monitoring, carotid ultrasonography, and transthoracic echocardiography were performed before NE administration (T0). When the mean arterial pressure exceeded 65 mmHg after NE administration (T1), the measurement was repeated. Twenty-four patients (median age 67 [interquartile range: 54–77] years; 42% female) with septic shock were examined in this study. Before (T0) and after (T1) NE administration, the PSV (mean, standard deviation [SD]) changed from 85.3 (21.1) cm/s to 83.5 (23.5) cm/s (p = 0.417); this change was not significant. However, the diameter and blood flow of the CCA increased significantly from 0.6 (0.09) cm and 0.75 (0.27) L/min to 0.66 (0.09) cm and 0.85 (0.27) L/min, respectively (p < 0.001). The diameter of the left ventricular outflow tract (LVOT) remained unchanged, but the velocity time integral of the LVOT increased significantly from 21.7 (4.39) cm to 23.6 (5.14) cm. There was no significant correlation between changes in blood flow of the CCA and changes in cardiac output (coefficient −0.365, p = 0.079). In conclusion, NE increased the diameter and blood flow of the CCA significantly, without changing the PSV in patients with septic shock.
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17
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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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18
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Zhou X, Pan J, Wang Y, Wang H, Xu Z, Zhuo W. Left ventricular-arterial coupling as a predictor of stroke volume response to norepinephrine in septic shock - a prospective cohort study. BMC Anesthesiol 2021; 21:56. [PMID: 33596822 PMCID: PMC7886849 DOI: 10.1186/s12871-021-01276-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 01/28/2021] [Indexed: 12/17/2022] Open
Abstract
Background Left ventricular-arterial coupling (VAC), defined as the ratio of arterial elastance (Ea) to left ventricular end-systolic elastance (Ees), is a key determinant of cardiovascular performance. This study aims to evaluate whether left VAC can predict stroke volume (SV) response to norepinephrine (NE) in septic shock patients. Methods This was a prospective cohort study conducted in an intensive care unit of a tertiary teaching hospital in China. We recruited septic shock patients who had persistent hypotension despite fluid resuscitation and required NE to maintain mean arterial pressure (MAP) > 65 mmHg. Those patients in whom the target MAP was not reached after NE infusion were ineligible. Echocardiographic variables were measured before (baseline) and after NE infusion. SV responder was defined by a ≥ 15% increase in SV after NE infusion. Results Of 34 septic shock patients included, 19 (56%) were SV responders. Before NE infusion, SV responders had a lower Ees (1.13 ± 0.24 mmHg/mL versus 1.50 ± 0.46 mmHg/mL, P = 0.005) and a higher Ea/Ees ratio (1.47 ± 0.40 versus 1.02 ± 0.30, P = 0.001) than non-responders, and Ea in SV responders was comparable to that in non-responders (1.62 ± 0.36 mmHg/mL versus 1.43 ± 0.28 mmHg/mL, P = 0.092). NE significantly increased Ea and Ees in both groups. The Ea/Ees ratio was normalized by NE administration in SV responders but unchanged in non-responders. The baseline Ea/Ees ratio was positively correlated with NE-induced SV increases (r = 0.688, P < 0.001). Logistic regression analysis indicated that the baseline Ea/Ees ratio was a predictor of SV increases induced by NE (odd ratio 0.008, 95% confidence interval (CI): 0.000 to 0.293), with an area under the receiver operating characteristic curve of 0.816 (95% CI: 0.646 to 0.927). Conclusions The left VAC has the ability to predict SV response to NE infusion in septic shock patients. Trial registration Chinese Clinical Trial Registry, ChiCTR1900024031, Registered 23 June 2019 - Retrospectively registered, http://www.chictr.org.cn/edit.aspx?pid=40359&htm=4.
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Affiliation(s)
- Xiaoyang Zhou
- Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, 315000, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, Zhejiang, 315000, China
| | - Jianneng Pan
- Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, 315000, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, Zhejiang, 315000, China
| | - Yang Wang
- Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, 315000, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, Zhejiang, 315000, China
| | - Hua Wang
- Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, 315000, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, Zhejiang, 315000, China
| | - Zhaojun Xu
- Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, 315000, China. .,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, Zhejiang, 315000, China.
| | - Weibo Zhuo
- Department of Intensive Care Medicine, Ningbo Fenghua District Hospital of Traditional Chinese Medicine Medical Community, Ningbo, Zhejiang, 315500, China.
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Roy TK, Secomb TW. Effects of impaired microvascular flow regulation on metabolism-perfusion matching and organ function. Microcirculation 2020; 28:e12673. [PMID: 33236393 DOI: 10.1111/micc.12673] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022]
Abstract
Impaired tissue oxygen delivery is a major cause of organ damage and failure in critically ill patients, which can occur even when systemic parameters, including cardiac output and arterial hemoglobin saturation, are close to normal. This review addresses oxygen transport mechanisms at the microcirculatory scale, and how hypoxia may occur in spite of adequate convective oxygen supply. The structure of the microcirculation is intrinsically heterogeneous, with wide variations in vessel diameters and flow pathway lengths, and consequently also in blood flow rates and oxygen levels. The dynamic processes of structural adaptation and flow regulation continually adjust microvessel diameters to compensate for heterogeneity, redistributing flow according to metabolic needs to ensure adequate tissue oxygenation. A key role in flow regulation is played by conducted responses, which are generated and propagated by endothelial cells and signal upstream arterioles to dilate in response to local hypoxia. Several pathophysiological conditions can impair local flow regulation, causing hypoxia and tissue damage leading to organ failure. Therapeutic measures targeted to systemic parameters may not address or may even worsen tissue oxygenation at the microvascular level. Restoration of tissue oxygenation in critically ill patients may depend on restoration of endothelial cell function, including conducted responses.
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Affiliation(s)
- Tuhin K Roy
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Timothy W Secomb
- Department of Physiology, University of Arizona, Tucson, AZ, 85724, USA
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20
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Li Y, Li H, Zhang D. Timing of norepinephrine initiation in patients with septic shock: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:488. [PMID: 32762765 PMCID: PMC7409707 DOI: 10.1186/s13054-020-03204-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 07/26/2020] [Indexed: 12/13/2022]
Abstract
Background The effect of the timing of norepinephrine initiation on clinical outcomes in patients with septic shock is uncertain. A systematic review and meta-analysis was performed to evaluate the impact of early and late start of norepinephrine support on clinical outcomes in patients with septic shock. Methods We searched the PubMed, Cochrane, and Embase databases for randomized controlled trials (RCTs) and cohort studies from inception to the 1st of March 2020. We included studies involving adult patients (> 18 years) with septic shock. All authors reported our primary outcome of short-term mortality and clearly comparing early versus late norepinephrine initiation with clinically relevant secondary outcomes (ICU length of stay, time to achieved target mean arterial pressure (≥ 65 mmHg), and volume of intravenous fluids within 6 h). Results were expressed as odds ratio (OR) and mean difference (MD) with accompanying 95% confidence interval (CI). Results Five studies including 929 patients were included. The primary outcome of this meta-analysis showed that the short-term mortality of the early group was lower than that of the late group (odds ratio [OR] = 0.45; 95% CI, 0.34 to 0.61; P < 0.00001; χ2 = 3.74; I2 = 0%). Secondary outcomes demonstrated that the time to achieved target MAP of the early group was shorter than that of the late group (mean difference = − 1.39; 95% CI, − 1.81 to − 0.96; P < 0.00001; χ2 = 1.03; I2 = 0%). The volume of intravenous fluids within 6 h of the early group was less than that of the late group (mean difference = − 0.50; 95% CI, − 0.68 to − 0.32; P < 0.00001; χ2 = 33.76; I2 = 94%). There was no statistically significant difference in the ICU length of stay between the two groups (mean difference = − 0.11; 95% CI, − 1.27 to 1.05; P = 0.86; χ2 = 0.85; I2 = 0%). Conclusions Early initiation of norepinephrine in patients with septic shock was associated with decreased short-term mortality, shorter time to achieved target MAP, and less volume of intravenous fluids within 6 h. There was no significant difference in ICU length of stay between early and late groups. Further large-scale RCTs are still required to confirm these results.
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Affiliation(s)
- Yuting Li
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, 130021, Jilin, China
| | - Hongxiang Li
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, 130021, Jilin, China
| | - Dong Zhang
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, 130021, Jilin, China.
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21
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Li Y, Li H, Zhang D. Timing of norepinephrine initiation in patients with septic shock: a systematic review and meta-analysis. CRITICAL CARE (LONDON, ENGLAND) 2020. [PMID: 32762765 DOI: 10.1186/s13054-020-03204-x.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The effect of the timing of norepinephrine initiation on clinical outcomes in patients with septic shock is uncertain. A systematic review and meta-analysis was performed to evaluate the impact of early and late start of norepinephrine support on clinical outcomes in patients with septic shock. METHODS We searched the PubMed, Cochrane, and Embase databases for randomized controlled trials (RCTs) and cohort studies from inception to the 1st of March 2020. We included studies involving adult patients (> 18 years) with septic shock. All authors reported our primary outcome of short-term mortality and clearly comparing early versus late norepinephrine initiation with clinically relevant secondary outcomes (ICU length of stay, time to achieved target mean arterial pressure (≥ 65 mmHg), and volume of intravenous fluids within 6 h). Results were expressed as odds ratio (OR) and mean difference (MD) with accompanying 95% confidence interval (CI). RESULTS Five studies including 929 patients were included. The primary outcome of this meta-analysis showed that the short-term mortality of the early group was lower than that of the late group (odds ratio [OR] = 0.45; 95% CI, 0.34 to 0.61; P < 0.00001; χ2 = 3.74; I2 = 0%). Secondary outcomes demonstrated that the time to achieved target MAP of the early group was shorter than that of the late group (mean difference = - 1.39; 95% CI, - 1.81 to - 0.96; P < 0.00001; χ2 = 1.03; I2 = 0%). The volume of intravenous fluids within 6 h of the early group was less than that of the late group (mean difference = - 0.50; 95% CI, - 0.68 to - 0.32; P < 0.00001; χ2 = 33.76; I2 = 94%). There was no statistically significant difference in the ICU length of stay between the two groups (mean difference = - 0.11; 95% CI, - 1.27 to 1.05; P = 0.86; χ2 = 0.85; I2 = 0%). CONCLUSIONS Early initiation of norepinephrine in patients with septic shock was associated with decreased short-term mortality, shorter time to achieved target MAP, and less volume of intravenous fluids within 6 h. There was no significant difference in ICU length of stay between early and late groups. Further large-scale RCTs are still required to confirm these results.
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Affiliation(s)
- Yuting Li
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, 130021, Jilin, China
| | - Hongxiang Li
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, 130021, Jilin, China
| | - Dong Zhang
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, 130021, Jilin, China.
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