1
|
Stampfl M, DeBlieux P. A Clinical Review of Vasopressors in Emergency Medicine. J Emerg Med 2024; 67:e31-e41. [PMID: 38789351 DOI: 10.1016/j.jemermed.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 01/22/2024] [Accepted: 03/06/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Vasopressor medications raise blood pressure through vasoconstriction and are essential in reversing the hypotension seen in many critically ill patients. Previously, vasopressor administration was largely limited to continuous infusions through central venous access. OBJECTIVES OF THE REVIEW This review addresses the clinical use of vasopressors in various shock states, including practical considerations and innovations in vasopressor administration. The focus is on the clinical administration of vasopressors across a range of shock states, including hypovolemic, distributive, cardiogenic, and obstructive shock. DISCUSSION Criteria for starting vasopressors are not clearly defined, though early use may be beneficial. A number of physiologic factors affect the body's response to vasopressors, such as acidosis and adrenal insufficiency. Peripheral and push-dose administration of vasopressors are becoming more common. Distributive shock is characterized by inappropriate vasodilation and vasopressors play a crucial role in maintaining adequate blood pressure. The use of vasopressors is more controversial in hypovolemic shock, as the preferred treatment is correction of the volume deficit. Evidence for vasopressors is limited in cardiogenic shock. For obstructive shock, vasopressors can temporize a patient's blood pressure until definitive therapy can reverse the underlying cause. CONCLUSION Across the categories of shock states, norepinephrine has wide applicability and is a reasonable first-line agent for shock of uncertain etiology. Keeping a broad differential when hypotension is refractory to vasopressors may help to identify adjunctive treatments in physiologic states that impair vasopressor effectiveness. Peripheral administration of vasopressors is safe and facilitates early administration, which may help to improve outcomes in some shock states.
Collapse
Affiliation(s)
- Matthew Stampfl
- UW Health Med Flight, Madison, Wisconsin; BerbeeWalsh Department of Emergency Medicine, Madison, Wisconsin.
| | - Peter DeBlieux
- Louisiana State University Medical Center, New Orleans, Louisiana; Tulane University School of Medicine Department of Surgery, New Orleans, Louisiana
| |
Collapse
|
2
|
Vats V, Nagori A, Singh P, Dutt R, Bandhey H, Wason M, Lodha R, Sethi T. Early Prediction of Hemodynamic Shock in Pediatric Intensive Care Units With Deep Learning on Thermal Videos. Front Physiol 2022; 13:862411. [PMID: 35923238 PMCID: PMC9340772 DOI: 10.3389/fphys.2022.862411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
Shock is one of the major killers in intensive care units, and early interventions can potentially reverse it. In this study, we advance a noncontact thermal imaging modality for continuous monitoring of hemodynamic shock working on 1,03,936 frames from 406 videos recorded longitudinally upon 22 pediatric patients. Deep learning was used to preprocess and extract the Center-to-Peripheral Difference (CPD) in temperature values from the videos. This time-series data along with the heart rate was finally analyzed using Long-Short Term Memory models to predict the shock status up to the next 6 h. Our models achieved the best area under the receiver operating characteristic curve of 0.81 ± 0.06 and area under the precision-recall curve of 0.78 ± 0.05 at 5 h, providing sufficient time to stabilize the patient. Our approach, thus, provides a reliable shock prediction using an automated decision pipeline that can provide better care and save lives.
Collapse
Affiliation(s)
- Vanshika Vats
- Indraprastha Institute of Information Technology, Delhi, India
| | - Aditya Nagori
- Indraprastha Institute of Information Technology, Delhi, India
- CSIR-Institute of Genomics and Integrative Biology, New Delhi, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, India
| | - Pradeep Singh
- Indraprastha Institute of Information Technology, Delhi, India
| | - Raman Dutt
- Computer Science and Engineering, Shiv Nadar University, Greater Noida, India
| | - Harsh Bandhey
- Indraprastha Institute of Information Technology, Delhi, India
| | - Mahika Wason
- Indraprastha Institute of Information Technology, Delhi, India
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Tavpritesh Sethi
- Indraprastha Institute of Information Technology, Delhi, India
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
- *Correspondence: Tavpritesh Sethi,
| |
Collapse
|
3
|
Kilian S, Surrey A, McCarron W, Mueller K, Wessman BT. Vasopressor Administration via Peripheral Intravenous Access for Emergency Department Stabilization in Septic Shock Patients. Indian J Crit Care Med 2022; 26:811-815. [PMID: 36864853 PMCID: PMC9973174 DOI: 10.5005/jp-journals-10071-24243] [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] [Indexed: 11/23/2022] Open
Abstract
Background Septic shock is commonly treated in the emergency department (ED) with vasopressors. Prior data have shown that vasopressor administration through a peripheral intravenous line (PIV) is feasible. Objectives To characterize vasopressor administration for patients presenting to an academic ED in septic shock. Materials and methods Retrospective observational cohort study evaluating initial vasopressor administration for septic shock. ED patients from June 2018 to May 2019 were screened. Exclusion criteria included other shock states, hospital transfers, or heart failure history. Patient demographics, vasopressor data, and length of stay (LOS) were collected. Cases were grouped by initiation site: PIV, ED placed central line (ED-CVL), or tunneled port/indwelling central line (Prior-CVL). Results Of the 136 patients identified, 69 were included. Vasopressors were initiated via PIV in 49%, ED-CVL in 25%, and prior-CVL in 26%. The time to initiation was 214.8 minutes in PIV and 294.7 minutes in ED-CVL (p = 0.240). Norepinephrine predominated all groups. No extravasation or ischemic complications were identified with PIV vasopressor administration. Twenty-eight-day mortality was 20.6% for PIV, 17.6% for ED-CVL, and 61.1% for prior-CVL. Of 28-day survivors, ICU LOS was 4.44 for PIV and 4.86 for ED-CVL (p = 0.687), while vasopressor days were 2.26 for PIV and 3.14 for ED-CVL (p = 0.050). Conclusion Vasopressors are being administered via PIVs for ED septic shock patients. Norepinephrine comprised the majority of initial PIV vasopressor administration. There were no documented episodes of extravasation or ischemia. Further studies should look at the duration of PIV administration with potential avoidance of central venous cannulation altogether in appropriate patients. How to cite this article Kilian S, Surrey A, McCarron W, Mueller K, Wessman BT. Vasopressor Administration via Peripheral Intravenous Access for Emergency Department Stabilization in Septic Shock Patients. Indian J Crit Care Med 2022;26(7):811-815.
Collapse
Affiliation(s)
- Scott Kilian
- Department of Emergency Medicine, Washington University in St Louis, School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri, United States of America
| | - Aaron Surrey
- Division of Critical Care Medicine, Department of Anesthesiology, Washington University in St Louis, School of Medicine, St Louis, Missouri, United States of America
| | - Weston McCarron
- Department of Emergency Medicine, Washington University in St Louis, School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri, United States of America
| | - Kristen Mueller
- Department of Emergency Medicine, Washington University in St Louis, School of Medicine, St Louis, Missouri, United States of America
| | - Brian Todd Wessman
- Department of Anesthesiology and Emergency Medicine, Washington University in St Louis, School of Medicine, St Louis, Missouri, United States of America,Brian Todd Wessman, Department of Anesthesiology and Emergency Medicine, Washington University in St Louis, School of Medicine, St Louis, Missouri, United States of America, Phone: +13143628538, e-mail:
| |
Collapse
|
4
|
Impact of Adjuvant Use of Midodrine to Intravenous Vasopressors: A Systematic Review and Meta-Analysis. Crit Care Res Pract 2021; 2021:5588483. [PMID: 34055408 PMCID: PMC8147551 DOI: 10.1155/2021/5588483] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/20/2021] [Accepted: 05/03/2021] [Indexed: 12/18/2022] Open
Abstract
Purpose To evaluate the efficacy and safety of midodrine use in intensive care units (ICU) to facilitate weaning off intravenous vasopressors (IVV). Methods We searched PubMed/MEDLINE, Cochrane library, and Google Scholar (inception through October 18th, 2020) for studies evaluating adjuvant use of midodrine to IVV in the ICU. The outcomes of interest were ICU length of stay (LOS), hospital LOS, mortality, IVV reinstitution, ICU readmission, and bradycardia. Estimates were pooled using the random-effects model. We reported effect sizes as standardized mean difference (SMD) for continuous outcomes and risk ratios (RRs) for other outcomes with a 95% confidence interval (CI). Results A total of 6 studies were found that met inclusion criteria and had sufficient data for our quantitative analysis (1 randomized controlled trial and 5 retrospective studies). A total of 2,857 patients were included: 600 in the midodrine group and 2,257 patients in the control group. Midodrine use was not associated with a significant difference in ICU LOS (SMD 0.16 days; 95% CI −0.23 to 0.55), hospital LOS (SMD 0.03 days; 95% CI −0.33 to 0.0.39), mortality (RR 0.87; 95% CI 0.52 to 1.46), IVV reinstitution (RR 0.47; 95% CI 0.17 to 1.3), or ICU readmission (RR 1.03; 95% CI 0.71 to 1.49) when compared to using only IVV. However, there were higher trends of bradycardia with midodrine use that did not reach significance (RR 7.64; 95% CI 0.23 to 256.42). Conclusion This meta-analysis suggests that midodrine was not associated with a significant decrease in ICU LOS, hospital LOS, mortality, or ICU readmissions.
Collapse
|
5
|
Reese TJ, Del Fiol G, Tonna JE, Kawamoto K, Segall N, Weir C, Macpherson BC, Kukhareva P, Wright MC. Impact of integrated graphical display on expert and novice diagnostic performance in critical care. J Am Med Inform Assoc 2021; 27:1287-1292. [PMID: 32548627 DOI: 10.1093/jamia/ocaa086] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 04/17/2020] [Accepted: 04/28/2020] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE To determine the impact of a graphical information display on diagnosing circulatory shock. MATERIALS AND METHODS This was an experimental study comparing integrated and conventional information displays. Participants were intensivists or critical care fellows (experts) and first-year medical residents (novices). RESULTS The integrated display was associated with higher performance (87% vs 82%; P < .001), less time (2.9 vs 3.5 min; P = .008), and more accurate etiology (67% vs 54%; P = .048) compared to the conventional display. When stratified by experience, novice physicians using the integrated display had higher performance (86% vs 69%; P < .001), less time (2.9 vs 3.7 min; P = .03), and more accurate etiology (65% vs 42%; P = .02); expert physicians using the integrated display had nonsignificantly improved performance (87% vs 82%; P = .09), time (2.9 vs 3.3; P = .28), and etiology (69% vs 67%; P = .81). DISCUSSION The integrated display appeared to support efficient information processing, which resulted in more rapid and accurate circulatory shock diagnosis. Evidence more strongly supported a difference for novices, suggesting that graphical displays may help reduce expert-novice performance gaps.
Collapse
Affiliation(s)
- Thomas J Reese
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Joseph E Tonna
- Division of Emergency Medicine and Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Kensaku Kawamoto
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Noa Segall
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Charlene Weir
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Brekk C Macpherson
- School of Nursing, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Polina Kukhareva
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Melanie C Wright
- College of Pharmacy, Idaho State University, Pocatello, Idaho, USA
| |
Collapse
|
6
|
Utilization and extravasation of peripheral norepinephrine in the emergency department. Am J Emerg Med 2021; 39:55-59. [DOI: 10.1016/j.ajem.2020.01.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 01/06/2020] [Indexed: 11/23/2022] Open
|
7
|
Abstract
BACKGROUND Worldwide, cardiogenic shock (CS) is the leading cause of death in patients admitted with an acute myocardial infarction (AMI). CS is characterised by reduced cardiac output secondary to systolic dysfunction which can lead to multi-organ failure. The mainstay of medical treatment in CS are inotropes and vasopressors to improve cardiac output. However, current clinical guidelines do not direct clinicians as to which agents to use and in what combinations. This article aims to review the current evidence on the management of CS with a major focus on the use of inotropes and vasopressors. METHOD A literature review was conducted analysing published literature from the following databases: PubMed, MedLine, Cochrane Library and Embase, as well as a manual search of articles that were deemed relevant. Relevant articles were identified by using keywords such as "cardiogenic shock". RESULTS Literature was assessed to review the use of inotropes and vasopressors in CS. Dopamine and adrenaline were associated with increased mortality and arrhythmias. Dobutamine was associated with an improvement in cardiac output, at the determinant of causing arrhythmias. Conversely, noradrenaline was associated with a lower likelihood of arrhythmias and most importantly decreased mortality in CS. Compared to other inotropes, levosimendan appears to have a better safety profile and is associated with decreased mortality in CS, particularly when combined with a vasopressor. Our literature review suggests that treatment combination of the inotrope levosimendan with the vasopressor noradrenaline may be the most effective management option in CS.
Collapse
|
8
|
Rinehart J, Lee S, Saugel B, Joosten A. Automated Blood Pressure Control. Semin Respir Crit Care Med 2020; 42:47-58. [PMID: 32746471 DOI: 10.1055/s-0040-1713083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Arterial pressure management is a crucial task in the operating room and intensive care unit. In high-risk surgical and in critically ill patients, sustained hypotension is managed with continuous infusion of vasopressor agents, which most commonly have direct α agonist activity like phenylephrine or norepinephrine. The current standard of care to guide vasopressor infusion is manual titration to an arterial pressure target range. This approach may be improved by using automated systems that titrate vasopressor infusions to maintain a target pressure. In this article, we review the evidence behind blood pressure management in the operating room and intensive care unit and discuss current and potential future applications of automated blood pressure control.
Collapse
Affiliation(s)
- Joseph Rinehart
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Orange, California
| | - Sean Lee
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Orange, California
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Outcomes Research Consortium, Cleveland, Ohio
| | - Alexandre Joosten
- Department of Anesthesiology, Erasme Hospital, Brussels, Belgium.,Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| |
Collapse
|
9
|
Busse LW, Ostermann M. Vasopressor Therapy and Blood Pressure Management in the Setting of Acute Kidney Injury. Semin Nephrol 2020; 39:462-472. [PMID: 31514910 DOI: 10.1016/j.semnephrol.2019.06.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Acute kidney injury (AKI) is common in the setting of shock. Hemodynamic instability is a risk factor for the development of AKI, and pathophysiological mechanisms include loss of renal perfusion pressure and impaired microcirculation. Although restoration of mean arterial pressure (MAP) may mitigate the risk of AKI to some extent, evidence on this is conflicting. Also debatable is the optimal blood pressure needed to minimize the risk of kidney injury. A MAP of 65 mm Hg traditionally has been considered adequate to maintain renal perfusion pressure, and studies have failed to consistently show improved outcomes at higher levels of MAP. Therapeutic options to support renal perfusion consist of catecholamines, vasopressin, and angiotensin II. Although catecholamines are the most studied, they are associated with adverse events at higher doses, including AKI. Vasopressin and angiotensin II are noncatecholamine options to support blood pressure and may improve microcirculatory hemodynamics through unique mechanisms, including differential vasoconstriction of efferent and afferent arterioles within the nephron. Future areas of study include methods by which clinicians can measure renal blood flow in a macrocirculatory and microcirculatory way, a personalized approach to blood pressure management in septic shock using patient-specific measures of perfusion adequacy, and novel agents that may improve the microcirculation within the kidneys without causing adverse microcirculatory effects in other organs.
Collapse
Affiliation(s)
- Laurence W Busse
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA.
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' National Health Service Foundation Hospital, London, United Kingdom
| |
Collapse
|
10
|
Outcomes in Patients with Vasodilatory Shock and Renal Replacement Therapy Treated with Intravenous Angiotensin II. Crit Care Med 2019; 46:949-957. [PMID: 29509568 PMCID: PMC5959265 DOI: 10.1097/ccm.0000000000003092] [Citation(s) in RCA: 173] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Supplemental Digital Content is available in the text. Objective: Acute kidney injury requiring renal replacement therapy in severe vasodilatory shock is associated with an unfavorable prognosis. Angiotensin II treatment may help these patients by potentially restoring renal function without decreasing intrarenal oxygenation. We analyzed the impact of angiotensin II on the outcomes of acute kidney injury requiring renal replacement therapy. Design: Post hoc analysis of the Angiotensin II for the Treatment of High-Output Shock 3 trial. Setting: ICUs. Patients: Patients with acute kidney injury treated with renal replacement therapy at initiation of angiotensin II or placebo (n = 45 and n = 60, respectively). Interventions: IV angiotensin II or placebo. Measurements and Main Results: Primary end point: survival through day 28; secondary outcomes included renal recovery through day 7 and increase in mean arterial pressure from baseline of ≥ 10 mm Hg or increase to ≥ 75 mm Hg at hour 3. Survival rates through day 28 were 53% (95% CI, 38%–67%) and 30% (95% CI, 19%–41%) in patients treated with angiotensin II and placebo (p = 0.012), respectively. By day 7, 38% (95% CI, 25%–54%) of angiotensin II patients discontinued RRT versus 15% (95% CI, 8%–27%) placebo (p = 0.007). Mean arterial pressure response was achieved in 53% (95% CI, 38%–68%) and 22% (95% CI, 12%–34%) of patients treated with angiotensin II and placebo (p = 0.001), respectively. Conclusions: In patients with acute kidney injury requiring renal replacement therapy at study drug initiation, 28-day survival and mean arterial pressure response were higher, and rate of renal replacement therapy liberation was greater in the angiotensin II group versus the placebo group. These findings suggest that patients with vasodilatory shock and acute kidney injury requiring renal replacement therapy may preferentially benefit from angiotensin II.
Collapse
|
11
|
Mamilla D, Araque KA, Brofferio A, Gonzales MK, Sullivan JN, Nilubol N, Pacak K. Postoperative Management in Patients with Pheochromocytoma and Paraganglioma. Cancers (Basel) 2019; 11:E936. [PMID: 31277296 PMCID: PMC6678461 DOI: 10.3390/cancers11070936] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 06/29/2019] [Accepted: 07/01/2019] [Indexed: 12/26/2022] Open
Abstract
Pheochromocytomas and paragangliomas (PPGLs) are rare catecholamine-secreting neuroendocrine tumors of the adrenal medulla and sympathetic/parasympathetic ganglion cells, respectively. Excessive release of catecholamines leads to episodic symptoms and signs of PPGL, which include hypertension, headache, palpitations, and diaphoresis. Intraoperatively, large amounts of catecholamines are released into the bloodstream through handling and manipulation of the tumor(s). In contrast, there could also be an abrupt decline in catecholamine levels after tumor resection. Because of such binary manifestations of PPGL, patients may develop perplexing and substantially devastating cardiovascular complications during the perioperative period. These complications include hypertension, hypotension, arrhythmias, myocardial infarction, heart failure, and cerebrovascular accident. Other complications seen in the postoperative period include fever, hypoglycemia, cortisol deficiency, urinary retention, etc. In the interest of safe patient care, such emergencies require precise diagnosis and treatment. Surgeons, anesthesiologists, and intensivists must be aware of the clinical manifestations and complications associated with a sudden increase or decrease in catecholamine levels and should work closely together to be able to provide appropriate management to minimize morbidity and mortality associated with PPGLs.
Collapse
Affiliation(s)
- Divya Mamilla
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - Katherine A Araque
- Adult Endocrinology Department, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Alessandra Brofferio
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Melissa K Gonzales
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - James N Sullivan
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Naris Nilubol
- Endocrine Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
| |
Collapse
|
12
|
Simonetto DA, Piccolo Serafim L, Gallo de Moraes A, Gajic O, Kamath PS. Management of Sepsis in Patients With Cirrhosis: Current Evidence and Practical Approach. Hepatology 2019; 70:418-428. [PMID: 30516866 DOI: 10.1002/hep.30412] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/30/2018] [Indexed: 12/13/2022]
Abstract
Sepsis in patients with cirrhosis is associated with high mortality. An impaired immune response accounts for the increased infection risk observed in these patients. Hemodynamic and systemic changes suggestive of sepsis may be observed in patients with cirrhosis in the absence of infection; therefore, diagnosis and treatment of sepsis may be delayed. The optimal management of the critically ill patient with sepsis and cirrhosis has not been well established and is generally extrapolated from consensus guidelines and expert recommendations made for management of patients without cirrhosis with sepsis. Despite the lack of strong evidence, we propose a contemporary pragmatic approach to sepsis management in patients with cirrhosis, including the choice of fluids, vasopressors, and antibiotics.
Collapse
Affiliation(s)
- Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Laura Piccolo Serafim
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Alice Gallo de Moraes
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN
| |
Collapse
|
13
|
Baker JE, Martin GE, Katsaros G, Lewis HV, Wakefield CJ, Josephs SA, Nomellini V, Makley AT, Goodman MD. Variability of fluid administration during exploratory laparotomy for abdominal trauma. Trauma Surg Acute Care Open 2018; 3:e000240. [PMID: 30623027 PMCID: PMC6307576 DOI: 10.1136/tsaco-2018-000240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 10/16/2018] [Accepted: 10/30/2018] [Indexed: 11/30/2022] Open
Abstract
Background Approximately 8% of traumatically injured patients require transfusion with packed red blood cells (pRBC) and only 1% to 2% require massive transfusion. Intraoperative massive transfusion was defined as requiring greater than 5 units (u) of pRBC in 4 hours. Despite the majority of patients not requiring transfusion, the appropriate amount and type of crystalloid administered during the era of damage control resuscitation have not been analyzed. We sought to determine the types of crystalloid used during trauma laparotomies and the potential effects on resuscitation. Methods Patients who underwent laparotomy after abdominal trauma from January 2014 to December 2016 at the University of Cincinnati Medical Center were identified. Patients were grouped based on requiring 0u, 1u to 4u, and ≥5u pRBC during intraoperative resuscitation. Demographic, physiologic, pharmacologic, operative, and postoperative data were collected. Statistical analysis was performed with Kruskal-Wallis test and Pearson’s correlation coefficient. Results Lactated Ringer’s (LR) solution was the most used crystalloid type received in the 0u and 1u to 4u pRBC cohorts, whereas normal saline (NS) was the most common in the ≥5u pRBC cohort. Most patients received two types of crystalloid intraoperatively. NS and LR were most frequently the first crystalloids administered, with Normosol infusion occurring later. The amount of crystalloid received correlated with operative length, but did not correlate with the estimated blood loss. Neither the type of crystalloid administered nor the anesthesia provider type was associated with changes in postoperative resuscitation parameters or electrolyte concentrations. Discussion There is a wide variation in the amount and types of crystalloids administered during exploratory laparotomy for trauma. Interestingly, the amount or type of crystalloid given did not affect resuscitation parameters regardless of blood product requirement. Level of evidence Level IV.
Collapse
Affiliation(s)
- Jennifer E Baker
- Divisions of Trauma and Research, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Grace E Martin
- Divisions of Trauma and Research, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Gianna Katsaros
- Divisions of Trauma and Research, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Hannah V Lewis
- Divisions of Trauma and Research, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Connor J Wakefield
- Divisions of Trauma and Research, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sean A Josephs
- Department of Anesthesia, University of Cincinnati, Cincinnati, Ohio, USA
| | - Vanessa Nomellini
- Divisions of Trauma and Research, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Amy T Makley
- Divisions of Trauma and Research, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Michael D Goodman
- Divisions of Trauma and Research, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| |
Collapse
|
14
|
Abstract
Angiotensin II (Ang II), part of the renin-angiotensin-aldosterone system (RAS), is a potent vasoconstrictor and has been recently approved for use by the US Food and Drug Administration in high-output shock. Though not a new drug, the recently published Angiotensin II for the Treatment of High Output Shock (ATHOS-3) trial, as well as a number of retrospective analyses have sparked renewed interest in the use of Ang II, which may have a role in treating refractory shock. We describe refractory shock, the unique mechanism of action of Ang II, RAS dysregulation in shock, and the evidence supporting the use of Ang II to restore blood pressure. Evidence suggests that Ang II may preferentially be of benefit in acute kidney injury and acute respiratory distress syndrome, where the RAS is known to be disrupted. Additionally, there may be a role for Ang II in cardiogenic shock, angiotensin converting enzyme inhibitor overdose, cardiac arrest, liver failure, and in settings of extracorporeal circulation.
Collapse
Affiliation(s)
- Rachel L Bussard
- Critical Care Pharmacy Specialist, Department of Pharmacy, Emory St Joseph's Hospital, Atlanta, GA, USA
| | - Laurence W Busse
- Department of Critical Care, Emory St Joseph's Hospital, Atlanta, GA, USA,
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA, USA,
| |
Collapse
|
15
|
Noel-Morgan J, Muir WW. Anesthesia-Associated Relative Hypovolemia: Mechanisms, Monitoring, and Treatment Considerations. Front Vet Sci 2018; 5:53. [PMID: 29616230 PMCID: PMC5864866 DOI: 10.3389/fvets.2018.00053] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/02/2018] [Indexed: 12/14/2022] Open
Abstract
Although the utility and benefits of anesthesia and analgesia are irrefutable, their practice is not void of risks. Almost all drugs that produce anesthesia endanger cardiovascular stability by producing dose-dependent impairment of cardiac function, vascular reactivity, and compensatory autoregulatory responses. Whereas anesthesia-related depression of cardiac performance and arterial vasodilation are well recognized adverse effects contributing to anesthetic risk, far less emphasis has been placed on effects impacting venous physiology and venous return. The venous circulation, containing about 65–70% of the total blood volume, is a pivotal contributor to stroke volume and cardiac output. Vasodilation, particularly venodilation, is the primary cause of relative hypovolemia produced by anesthetic drugs and is often associated with increased venous compliance, decreased venous return, and reduced response to vasoactive substances. Depending on factors such as patient status and monitoring, a state of relative hypovolemia may remain clinically undetected, with impending consequences owing to impaired oxygen delivery and tissue perfusion. Concurrent processes related to comorbidities, hypothermia, inflammation, trauma, sepsis, or other causes of hemodynamic or metabolic compromise, may further exacerbate the condition. Despite scientific and technological advances, clinical monitoring and treatment of relative hypovolemia still pose relevant challenges to the anesthesiologist. This short perspective seeks to define relative hypovolemia, describe the venous system’s role in supporting normal cardiovascular function, characterize effects of anesthetic drugs on venous physiology, and address current considerations and challenges for monitoring and treatment of relative hypovolemia, with focus on insights for future therapies.
Collapse
Affiliation(s)
- Jessica Noel-Morgan
- Center for Cardiovascular & Pulmonary Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - William W Muir
- QTest Labs, Columbus, OH, United States.,College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, United States
| |
Collapse
|
16
|
|
17
|
Matsiukevich D, Piraino G, Lahni P, Hake PW, Wolfe V, O'Connor M, James J, Zingarelli B. Metformin ameliorates gender-and age-dependent hemodynamic instability and myocardial injury in murine hemorrhagic shock. Biochim Biophys Acta Mol Basis Dis 2017; 1863:2680-2691. [PMID: 28579457 DOI: 10.1016/j.bbadis.2017.05.027] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 05/02/2017] [Accepted: 05/29/2017] [Indexed: 01/04/2023]
Abstract
Severity of multiple organ failure is significantly impacted by age and gender in patients with hemorrhagic shock. However, the molecular mechanisms underlying the enhanced organ injury are not fully understood. AMP-activated protein kinase (AMPK) is a pivotal orchestrator of metabolic responses during stress. We investigated whether hemorrhage-induced myocardial injury is age and gender dependent and whether treatment with metformin, an AMPK activator, affords cardioprotective effects. C57/BL6 young (3-5months) and mature (9-12months) male and female mice were subjected to hemorrhagic shock by blood withdrawing followed by resuscitation with blood and Lactated Ringer's solution. Vehicle-treated young and mature mice of both genders had a similar elevation of plasma inflammatory cytokines at 3h after resuscitation. However, vehicle-treated male mature mice experienced hemodynamic instability and higher myocardial damage than young male mice, as evaluated by echocardiography, histology and cardiovascular injury biomarkers. There was also a gender-dependent difference in cardiovascular injury in the mature group as vehicle-treated male mice exhibited more severe organ injury than female mice. At molecular analysis, vehicle-treated mature mice of both genders exhibited a marked downregulation of AMPKα activation and nuclear translocation of peroxisome proliferator-activated receptor γ co-activator α when compared with young mice. Treatment with metformin improved cardiovascular function and survival in mature animals of both genders. However, specific cardioprotective effects of metformin were gender-dependent. Metformin did not affect hemodynamic or inflammatory responses in young animals. Thus, our data suggest that targeting metabolic recovery with metformin may be a potential treatment approach in severe hemorrhage in adult population.
Collapse
Affiliation(s)
- Dzmitry Matsiukevich
- Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Giovanna Piraino
- Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Patrick Lahni
- Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Paul W Hake
- Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Vivian Wolfe
- Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Michael O'Connor
- Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jeanne James
- Department of Pediatrics, Cardiovascular Imaging Core of the Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Basilia Zingarelli
- Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| |
Collapse
|
18
|
Tartavoulle TM. Management of Sepsis in Patients with Pulmonary Arterial Hypertension in the Intensive Care Unit. Crit Care Nurs Clin North Am 2017; 29:15-23. [PMID: 28160954 DOI: 10.1016/j.cnc.2016.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Pulmonary arterial hypertension is a lethal condition, and the management of sepsis in patients with pulmonary arterial hypertension is challenging. As the disease progresses, the right ventricle is susceptible to failure due to a high pulmonary vascular resistance. The limited ability of the right ventricle to increase cardiac output in septic shock makes it difficult to deliver oxygen to the organ and tissues. Intravascular volume replacement and vasoactive drugs should only be considered after a thorough assessment. Priorities of care include improving cardiac output and oxygen delivery by optimizing preload, reducing afterload, and improving contractility.
Collapse
Affiliation(s)
- Todd M Tartavoulle
- School of Nursing, Louisiana State University Health Sciences Center, 1900 Gravier Street, New Orleans, LA 70112, USA.
| |
Collapse
|
19
|
Kang R, Zeng L, Xie Y, Yan Z, Zhou B, Cao L, Klionsky DJ, Tracey KJ, Li J, Wang H, Billiar TR, Jiang J, Tang D. A novel PINK1- and PARK2-dependent protective neuroimmune pathway in lethal sepsis. Autophagy 2016; 12:2374-2385. [PMID: 27754761 DOI: 10.1080/15548627.2016.1239678] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Although the PINK1-PARK2 pathway contributes to the pathogenesis of Parkinson disease, its roles in sepsis (a major challenge for critical care) were previously unknown. Here, we show that pink1-/- and park2-/- mice are more sensitive to polymicrobial sepsis-induced multiple organ failure and death. The decrease in the circulating level of the neurotransmitter dopamine in pink1-/- and park2-/- mice accelerates the release of a late sepsis mediator, HMGB1, via HIF1A-dependent anaerobic glycolysis and subsequent NLRP3-dependent inflammasome activation. Genetic depletion of Nlrp3 or Hif1a in pink1-/- and park2-/- mice confers protection against lethal polymicrobial sepsis. Moreover, pharmacological administration of dopamine agonist (e.g., pramipexole), HMGB1-inhibitor (e.g., neutralizing antibody or glycyrrhizin), or NLRP3-inhibitor (e.g., MCC950) reduces septic death in pink1-/- and park2-/- mice. The mRNA expression of HIF1A and NLRP3 is upregulated, whereas the mRNA expression of PINK1 and PARK2 is downregulated in peripheral blood mononuclear cells of patients with sepsis. Thus, an impaired PINK1-PARK2-mediated neuroimmunology pathway contributes to septic death and may represent a novel therapeutic target in critical care medicine.
Collapse
Affiliation(s)
- Rui Kang
- a Department of Surgery , University of Pittsburgh , Pittsburgh , PA , USA
| | - Ling Zeng
- a Department of Surgery , University of Pittsburgh , Pittsburgh , PA , USA.,b State Key Laboratory of Trauma, Burns and Combined Injury, Research Institute of Surgery, Research institute for Traffic Medicine of People's Liberation Army, Daping Hospital, Third Military Medical University , Chongqing , China
| | - Yangchun Xie
- a Department of Surgery , University of Pittsburgh , Pittsburgh , PA , USA
| | - Zhengwen Yan
- a Department of Surgery , University of Pittsburgh , Pittsburgh , PA , USA.,c Department of Neurology , Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University , Guangzhou, Guangdong , China
| | - Borong Zhou
- d Department of Neurology.,e Centre of DAMP Biology, Third Affiliated Hospital of Guangzhou Medical University , Guangzhou, Guangdong , China
| | - Lizhi Cao
- f Department of Pediatrics , Xiangya Hospital, Central South University , Changsha, Hunan , China
| | - Daniel J Klionsky
- g Life Sciences Institute and Department of Molecular, Cellular and Developmental Biology , University of Michigan , Ann Arbor , MI , USA
| | - Kevin J Tracey
- h Laboratory of Emergency Medicine, The Feinstein Institute for Medical Research , Manhasset , NY , USA
| | - Jianhua Li
- h Laboratory of Emergency Medicine, The Feinstein Institute for Medical Research , Manhasset , NY , USA
| | - Haichao Wang
- h Laboratory of Emergency Medicine, The Feinstein Institute for Medical Research , Manhasset , NY , USA
| | - Timothy R Billiar
- a Department of Surgery , University of Pittsburgh , Pittsburgh , PA , USA
| | - Jianxin Jiang
- b State Key Laboratory of Trauma, Burns and Combined Injury, Research Institute of Surgery, Research institute for Traffic Medicine of People's Liberation Army, Daping Hospital, Third Military Medical University , Chongqing , China
| | - Daolin Tang
- a Department of Surgery , University of Pittsburgh , Pittsburgh , PA , USA.,e Centre of DAMP Biology, Third Affiliated Hospital of Guangzhou Medical University , Guangzhou, Guangdong , China
| |
Collapse
|
20
|
Hendy A, Bubenek-Turconi ŞI. The Diagnosis and Hemodynamic Monitoring of Circulatory Shock: Current and Future Trends. ACTA ACUST UNITED AC 2016; 2:115-123. [PMID: 29967849 DOI: 10.1515/jccm-2016-0018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 07/15/2016] [Indexed: 01/08/2023]
Abstract
Circulatory shock is a complex clinical syndrome encompassing a group of conditions that can arise from different etiologies and presented by several different hemodynamic patterns. If not corrected, cell dysfunction, irreversible multiple organ insufficiency, and death may occur. The four basic types of shock, hypovolemic, cardiogenic, obstructive and distributive, have features similar to that of hemodynamic shock. It is therefore essential, when monitoring hemodynamic shock, to making accurate clinical assessments which will guide and dictate appropriate management therapy. The European Society of Intensive Care has recently made recommendations for monitoring hemodynamic shock. The present paper discusses the issues raised in the new statements, including individualization of blood pressure targets, prediction of fluid responsiveness, and the use of echocardiography as the first means during the initial evaluation of circulatory shock. Also, the place of more invasive hemodynamic monitoring techniques and future trends in hemodynamic and metabolic monitoring in circulatory shock, will be debated.
Collapse
Affiliation(s)
- Adham Hendy
- Ph.D Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,1st Department of Cardiovascular Anesthesia and Intensive Care, "C.C.Iliescu" Emergency Institute for Cardiovascular Diseases, Bucharest, Romania
| | - Şerban-Ion Bubenek-Turconi
- Ph.D Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,1st Department of Cardiovascular Anesthesia and Intensive Care, "C.C.Iliescu" Emergency Institute for Cardiovascular Diseases, Bucharest, Romania
| |
Collapse
|
21
|
Morozowich ST, Ramakrishna H. Pharmacologic agents for acute hemodynamic instability: recent advances in the management of perioperative shock- a systematic review. Ann Card Anaesth 2016; 18:543-54. [PMID: 26440241 PMCID: PMC4881674 DOI: 10.4103/0971-9784.166464] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Despite the growing body of evidence evaluating the efficacy of vasoactive agents in the management of hemodynamic instability and circulatory shock, it appears no agent is superior. This is becoming increasingly accepted as current guidelines are moving away from detailed algorithms for the management of shock, and instead succinctly state that vasoactive agents should be individualized and guided by invasive hemodynamic monitoring. This extends to the perioperative period, where vasoactive agent selection and use may still be left to the discretion of the treating physician with a goal-directed approach, consisting of close hemodynamic monitoring and administration of the lowest effective dose to achieve the hemodynamic goals. Successful therapy depends on the ability to rapidly diagnose the etiology of circulatory shock and thoroughly understand its pathophysiology as well as the pharmacology of vasoactive agents. This review focuses on the physiology and resuscitation goals in perioperative shock, as well as the pharmacology and recent advances in vasoactive agent use in its management.
Collapse
Affiliation(s)
| | - Harish Ramakrishna
- Department of Anesthesiology, Mayo Clinic, College of Medicine; Department of Anesthesiology, Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Phoenix, Arizona, USA
| |
Collapse
|
22
|
Bighamian R, Rubbo C, Thorsen JE, Reisner AT. Is there opportunity for automated decision-support and closed-loop control in ICU patients receiving vasopressor infusion? ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2016; 2014:1949-52. [PMID: 25570362 DOI: 10.1109/embc.2014.6943994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Vasopressors are administered to critically ill patients suffering from a body-wide reduction in blood circulation. In theory, if the vasopressor infusion is either too high or too low, it could be harmful to the patient. In a retrospective analysis, we investigated the degree to which today's intensive care unit (ICU) patients receive appropriate vasopressor therapy, in terms of how often the mean arterial pressure (MAP) was kept within a normative range. Using the MIMIC II database, we studied patients with minute-by-minute MAP data, sourced from the bedside monitor, who were receiving vasopressor therapy. For each record, we identified MAP samples that were out-of-range, i.e., MAP <; 60 mmHg or MAP > 100 mmHg, and grouped these into out-of-range episodes. Each out-of-range episode was categorized as either transient (<; 15 min) or sustained (≥ 15 min). Out of the 224 ICU stays, we identified 152 ICU stays (68% of ICU stays) with at least one sustained MAP out-of-range episode. In that subset, MAP was frequently out-of-range (out-of-range 18.4% of the time) due to a combination of sustained episodes of hypotension and hypertension. Compared with all ICU stays, those stays with sustained out-of-range events did not demonstrate an increased MAP variability per hour. It is possible that the out-of-range events resulted from insufficient dose-adjustment. Technologies that might continuously optimize vasopressor dosing throughout the patient's stay and thereby minimize these abnormal cardiovascular states may be worthy of further study.
Collapse
|
23
|
Chirichella TJ, Dunham CM, Zimmerman MA, Phelan EM, Mandell MS, Conzen KD, Kelley SE, Nydam TL, Bak TE, Kam I, Wachs ME. Donor preoperative oxygen delivery and post-extubation hypoxia impact donation after circulatory death hypoxic cholangiopathy. World J Gastroenterol 2016; 22:3392-3403. [PMID: 27022221 PMCID: PMC4806197 DOI: 10.3748/wjg.v22.i12.3392] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 10/06/2015] [Accepted: 12/01/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate donation after circulatory death (DCD) orthotopic liver transplant outcomes [hypoxic cholangiopathy (HC) and patient/graft survival] and donor risk-conditions.
METHODS: From 2003-2013, 45 DCD donor transplants were performed. Predonation physiologic data from UNOS DonorNet included preoperative systolic and diastolic blood pressure, heart rate, pH, SpO2, PaO2, FiO2, and hemoglobin. Mean arterial blood pressure was computed from the systolic and diastolic blood pressures. Donor preoperative arterial O2 content was computed as [hemoglobin (gm/dL) × 1.37 (mL O2/gm) × SpO2%) + (0.003 × PaO2)]. The amount of preoperative donor red blood cell transfusions given and vasopressor use during the intensive care unit stay were documented. Donors who were transfused ≥ 1 unit of red-cells or received ≥ 2 vasopressors in the preoperative period were categorized as the red-cell/multi-pressor group. Following withdrawal of life support, donor ischemia time was computed as the number-of-minutes from onset of diastolic blood pressure < 60 mmHg until aortic cross clamping. Donor hypoxemia time was the number-of-minutes from onset of pulse oximetry < 80% until clamping. Donor hypoxia score was (ischemia time + hypoxemia time) ÷ donor preoperative hemoglobin.
RESULTS: The 1, 3, and 5 year graft and patient survival rates were 83%, 77%, 60%; and 92%, 84%, and 72%, respectively. HC occurred in 49% with 16% requiring retransplant. HC occurred in donors with increased age (33.0 ± 10.6 years vs 25.6 ± 8.4 years, P = 0.014), less preoperative multiple vasopressors or red-cell transfusion (9.5% vs 54.6%, P = 0.002), lower preoperative hemoglobin (10.7 ± 2.2 gm/dL vs 12.3 ± 2.1 gm/dL, P = 0.017), lower preoperative arterial oxygen content (14.8 ± 2.8 mL O2/100 mL blood vs 16.8 ± 3.3 mL O2/100 mL blood, P = 0.049), greater hypoxia score >2.0 (69.6% vs 25.0%, P = 0.006), and increased preoperative mean arterial pressure (92.7 ± 16.2 mmHg vs 83.8 ± 18.5 mmHg, P = 0.10). HC was independently associated with age, multi-pressor/red-cell transfusion status, arterial oxygen content, hypoxia score, and mean arterial pressure (r2 = 0.6197). The transplantation rate was greater for the later period with more liberal donor selection [era 2 (7.1/year)], compared to our early experience [era 1 (2.5/year)]. HC occurred in 63.0% during era 2 and in 29.4% during era 1 (P = 0.03). Era 2 donors had longer times for extubation-to-asystole (14.4 ± 4.7 m vs 9.3 ± 4.5 m, P = 0.001), ischemia (13.9 ± 5.9 m vs 9.7 ± 5.6 m, P = 0.03), and hypoxemia (16.0 ± 5.1 m vs 11.1 ± 6.7 m, P = 0.013) and a higher hypoxia score > 2.0 rate (73.1% vs 28.6%, P = 0.006).
CONCLUSION: Easily measured donor indices, including a hypoxia score, provide an objective measure of DCD liver transplantation risk for recipient HC. Donor selection criteria influence HC rates.
Collapse
|
24
|
Pliquett RU, Radler D, Tamm A, Greinert D, Greinert R, Girndt M. Oliguric acute kidney injury as a main symptom of bradycardia and arteriosclerosis resolved by pacemaker implantation: a case report. J Med Case Rep 2014; 8:289. [PMID: 25175670 PMCID: PMC4159969 DOI: 10.1186/1752-1947-8-289] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 07/12/2014] [Indexed: 11/15/2022] Open
Abstract
Introduction Cardiovascular comorbidities regularly determine renal function. We report a case of acute kidney injury (Acute Kidney Injury Network stage 3) due to an intermittent third-degree atrioventricular block, which had not been diagnosed before. Case presentation A 76-year-old Caucasian man with liver cirrhosis due to non-alcoholic fatty liver disease, and type-2 diabetes was cognitively impaired and had reduced vigilance presumably caused by hepatic encephalopathy and/or Alzheimer dementia. Within 2 years, two hospitalizations occurred for syncope attributed to orthostatic failure and hypovolemia. During the last hospitalization, oliguric acute kidney injury occurred. Sonography ruled out a post-renal cause. His renal resistive index was 1.0; his heart rate was below 50 beats per minute. After cessation of beta-blocker therapy, Holter electrocardiogram showed a new intermittent third-degree atrioventricular block with pauses for less than 3 seconds. Pacemaker insertion resolved his acute kidney injury, despite resumption of beta-blocker therapy. During four months of follow-up, syncope has not occurred, and vigilance was stable. However, his renal resistive index of 1.0 remained. Conclusions Here, typical neurologic symptoms of bradycardia were misclassified. Diagnostic work-up of oliguric acute kidney injury revealed intermittent third-degree heart block. The pathomechanism of acute kidney injury relates to relevant bradycardia and increased vascular stiffness attenuating arterial diastolic renal blood flow.
Collapse
Affiliation(s)
- Rainer U Pliquett
- Department of Internal Medicine II, University Hospital Halle, Martin Luther University of Halle-Wittenberg, Halle, Saale, Germany.
| | | | | | | | | | | |
Collapse
|
25
|
Liu Y, Davari-Farid S, Arora P, Porhomayon J, Nader ND. Early versus late initiation of renal replacement therapy in critically ill patients with acute kidney injury after cardiac surgery: a systematic review and meta-analysis. J Cardiothorac Vasc Anesth 2014; 28:557-63. [PMID: 24731742 DOI: 10.1053/j.jvca.2013.12.030] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate the impact of early versus late renal replacement therapy (RRT) on mortality in patients with acute kidney injury (AKI) after cardiac surgery. DESIGN Meta-analysis of 9 retrospective cohort studies and 2 randomized clinical trials extracted from the Medline engine from 1950 to 2013. SETTING University medical school. PARTICIPANTS 841 Patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 841 patients were studied. Pooled estimates of the odds ratio with 95% confidence interval using a random-effect model were conducted as well as the heterogeneity, publication bias, and sensitivity analysis. Primary outcome was 28-day mortality, and secondary outcome was the intensive care unit (ICU) length of stay. The 28-days mortality rate was lower in the early RRT group (OR = 0.29, 95% CI, 0.16-0.52, p<0.0001, NNT = 5). Heterogeneity was high (I2 = 56%), and publication bias was low. Secondary outcome suggested 3.9 (1.5-6.3) days shorter ICU stay in the early RRT group, p<0.0001, with extremely high heterogeneity (I(2) = 99%), and low publication bias. Specifically, studies before 2000 and studies with mortality less than 50% in the late RRT group reported significantly higher odds ratio and mean difference than overall value favoring early RRT. CONCLUSION Early initiation of RRT for patients with AKI after cardiac surgery revealed lower 28-days mortality and shorter ICU length of stay. However, this was based on 11 studies of various qualities with very high heterogeneity of results. Defining treatment guidelines needs further research with a larger and better database.
Collapse
Affiliation(s)
- Yao Liu
- SUNY at Buffalo, Buffalo, NY
| | | | | | | | | |
Collapse
|
26
|
Gabbay U, Bobrovsky BZ. A novel hypothesis comprehensively explains shock, heart failure and aerobic exhaustion through an assumed central physiological control of the momentary cardiovascular performance reserve. Med Hypotheses 2014; 82:694-9. [PMID: 24679381 DOI: 10.1016/j.mehy.2014.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 03/05/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Heart failure (HF) and shock are incomprehensively understood, inconclusively defined and lack a single conclusive test. The proceedings that preceded and triggered clinical manifestations are occult. The relationships in between different shock and HF types and between each HF type and its matched shock are poorly understood. THE ASSUMED HYPOTHESIS We suggest that HF and shock are attributed to a momentary cardiovascular performance reserve - "the reserve". The reserve is controlled through an assumed central physiological mechanism that continuously detects and responds accordingly--"the reserve control". The assumed reserve is maximal at rest, and decreases with aerobic activity. When it decreases to a given threshold the reserve control alerts by induces manifestations of dyspnea and fatigue enforcing activity decrease, follow which the manifestations dissolve. HF is a condition of low reserve at baseline; hence, fatigue and dyspnea are frequently experienced following mild activity. Shock is assumed to occur when the cardiovascular reserve deteriorates below a sustainable limit where the reserve control induces a salvage-sacrifice response, preserving vital organ perfusion while impairing microcirculation effective perfusion in non-vital organ in which it causes cellular hypoxia followed by the familiar devastating cascade of events seen in shock. DISCUSSION AND CONCLUSIONS The hereby hypothesis may comprehensively explain the heart failure - shock puzzle as no alternative theory had ever succeeded. It provides the missing link between the different types of HF as of shock and in between. The hypothesis poses a great prove challenge but opens new research and clinical possibilities.
Collapse
Affiliation(s)
- Uri Gabbay
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; School of Electrical Engineering, Tel Aviv University, Tel Aviv, Israel.
| | - Ben Zion Bobrovsky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; School of Electrical Engineering, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
27
|
Third-line antiepileptic therapy and outcome in status epilepticus: the impact of vasopressor use and prolonged mechanical ventilation. Crit Care Med 2012; 40:2677-84. [PMID: 22732291 DOI: 10.1097/ccm.0b013e3182591ff1] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES To characterize associations between antiepileptic drugs with sedating or anesthetic effects (third-line antiepileptic drugs) vs. other antiepileptic agents, and short-term outcomes, in status epilepticus. Furthermore, to evaluate the role of adverse hemodynamic and respiratory effects of these agents in status epilepticus treatment. DESIGN Retrospective comparative analysis. SETTING Tertiary academic medical center with two emergency departments and two neurologic intensive care units. PATIENTS Adults admitted with a diagnosis of status epilepticus defined as seizures lasting continuously >5 mins, or for discrete periods in succession. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 126 patients with 144 separate status epilepticus admissions, 57 were female (45%) with mean age 54.7 ± 15.7 yrs. Status epilepticus was convulsive in 132 cases (92%). Status epilepticus etiologies included subtherapeutic antiepileptic drugs (43%), alcohol or other nonantiepileptic drug (13%), and acute central nervous system disease (12%). Third-line antiepileptic drugs were administered in 47 cases (33%). Seventy-eight status epilepticus episodes (54%) had good outcomes (Glasgow Outcome Score = 1, 2) at the time of hospital discharge. On univariate analysis, poor outcome (Glasgow Outcome Score > 2) was associated with older age (mean 59.8 ± 15.5 vs. 50.5 ± 13.8 yrs, p < .001), acute central nervous system disease (21% vs. 4%, p = .001), mechanical ventilation (76% vs. 53%, p = .004), longer duration of ventilation (median 10 days [range 1-56] vs. 2 days [range 1-10], p < .001), treatment with vasopressors (35% vs. 5%, p < .001), and treatment with third-line antiepileptic drugs (51% vs. 17%, p < .001). Death was associated with acute central nervous system disease, prolonged ventilation, treatment with vasopressors, and treatment with third-line antiepileptic drugs. Predictors of poor outcome among all status epilepticus episodes were older age (odds ratio 1.06; 95% confidence interval 1.03-1.09; p < .001), treatment with third-line antiepileptic therapy (odds ratio 5.64; 95% confidence interval 2.31-13.75; p < .001), and first episode of status epilepticus (odds ratio 3.73; 95% confidence interval 1.38-10.10; p = .010). Among status epilepticus episodes treated by third-line antiepileptic drugs, predictors of poor outcome were older age (odds ratio, 1.09; 95% confidence interval 1.01-1.18; p = .038) and longer ventilation (odds ratio, 1.47; 95% confidence interval 1.08-2.00; p = .015). Predictors of mortality among all status epilepticus episodes were treatment with third-line antiepileptic drugs (odds ratio, 12.08; 95% confidence interval 2.30-63.39; p = .003) and older age (odds ratio, 1.06; 95% confidence interval 1.00-1.12; p = .045). CONCLUSIONS Third-line antiepileptic drug therapies with sedating or anesthetic effects predicted poor outcome and death in status epilepticus. Hypotension requiring vasopressor therapy and duration of mechanical ventilation induced by these agents may be contributing factors, especially when pentobarbital is used. These findings may inform decision making on drug therapy in status epilepticus and help develop safer and more effective treatment strategies to improve outcome.
Collapse
|
28
|
Velez JCQ, Nietert PJ. Therapeutic response to vasoconstrictors in hepatorenal syndrome parallels increase in mean arterial pressure: a pooled analysis of clinical trials. Am J Kidney Dis 2011; 58:928-38. [PMID: 21962618 DOI: 10.1053/j.ajkd.2011.07.017] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 07/18/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Vasoconstrictor therapy has been advocated as treatment for hepatorenal syndrome (HRS). Our aim was to explore across all tested vasoconstrictors whether achievement of a substantial increase in arterial blood pressure is associated with recovery of kidney function in HRS. STUDY DESIGN Pooled analysis of published studies identified by electronic database search. SETTING & POPULATION Data pooled across 501 participants in 21 studies. SELECTION CRITERIA FOR STUDIES Human studies evaluating the efficacy of a vasoconstrictor administered for 72 hours or longer in adults with HRS type 1 or 2. INTERVENTION Vasoconstrictor therapy. OUTCOMES & MEASUREMENTS Cohorts' mean arterial pressure (MAP), serum creatinine level, urinary output, and plasma renin activity (PRA) at baseline and subsequent times during treatment. Linear regression models were constructed to estimate mean daily changes in MAP, serum creatinine level, urinary output, and PRA for each study subgroup. Correlations were used to assess for association between variables. RESULTS An increase in MAP is associated strongly with a decrease in serum creatinine level, but is not associated with an increase in urinary output. Associations were stronger when analyses were restricted to randomized clinical trials and were not limited to cohorts with either lower baseline MAP or lower baseline serum creatinine level. Most studies tested terlipressin as vasoconstrictor, whereas fewer studies tested ornipressin, midodrine, octreotide, or norepinephrine. Excluding cohorts of participants treated with terlipressin or ornipressin did not eliminate the association. Furthermore, a decrease in PRA correlated with improvement in kidney function. LIMITATIONS Studies were not originally designed to test our question. We lacked access to individual patient data. CONCLUSIONS An increase in MAP during vasoconstrictor therapy in patients with HRS is associated with improvement in kidney function across the spectrum of drugs tested to date. These results support consideration for a goal-directed approach to the treatment of HRS.
Collapse
Affiliation(s)
- Juan Carlos Q Velez
- Division of Nephrology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | | |
Collapse
|
29
|
Anesthesia care for liver transplantation. Transplant Rev (Orlando) 2011; 25:36-43. [PMID: 21126662 DOI: 10.1016/j.trre.2010.10.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Accepted: 10/04/2010] [Indexed: 12/13/2022]
Abstract
Intraoperative transfusion practices for liver transplantation have evolved dramatically since the first transplants of the 1960s. It is important for today's clinicians to be current in their understanding of how transplant patients should be managed with regard to their coagulation profile, volume status, and general hemodynamic state. The anesthesia team is presented with the unique task of manipulating this tenuous balance in a rapid and precise manner when managing patients undergoing liver transplantation. Although significant progress has been made in reducing blood product administration, it is still common to encounter large volume blood loss in these cases. Increasingly, clinicians are challenged to justify transfusion practices with a stronger evidentiary base. The current state of the literature for transfusion guidelines and blood product management in this particular patient subset will be discussed, as well as a variety of means (both pharmacologic and otherwise) used to reduce the need for transfusion. The aim was to review the latest evidence on these topics, as well as to highlight areas that need further clarification regarding their role in the optimal care of these patients.
Collapse
|
30
|
Liu KD. Critical care nephrology: Core Curriculum 2009. Am J Kidney Dis 2009; 53:898-910. [PMID: 19303680 DOI: 10.1053/j.ajkd.2008.12.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Accepted: 12/12/2008] [Indexed: 02/08/2023]
Affiliation(s)
- Kathleen D Liu
- Division of Nephrology, Department of Medicine, Critical Care Medicine, University of California San Francisco, San Francisco, CA 94133, USA.
| |
Collapse
|