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Salvail W, Salvail D, Chagnon F, Lesur O. Apelin-13 administration allows for norepinephrine sparing in a rat model of cecal ligation and puncture-induced septic shock. Intensive Care Med Exp 2024; 12:68. [PMID: 39103658 DOI: 10.1186/s40635-024-00650-7] [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: 12/02/2023] [Accepted: 07/21/2024] [Indexed: 08/07/2024] Open
Abstract
BACKGROUND Infusion of exogenous catecholamines (i.e., norepinephrine [NE] and dobutamine) is a recommended treatment for septic shock with myocardial dysfunction. However, sustained catecholamine infusion is linked to cardiac toxicity and impaired responsiveness. Several pre-clinical and clinical studies have investigated the use of alternative vasopressors in the treatment of septic shock, with limited benefits and generally no effect on mortality. Apelin-13 (APL-13) is an endogenous positive inotrope and vasoactive peptide and has been demonstrated cardioprotective with vasomodulator and sparing life effects in animal models of septic shock. A primary objective of this study was to evaluate the NE-sparing effect of APL-13 infusion in an experimental sepsis-induced hypotension. METHODS For this goal, sepsis was induced by cecal ligation and puncture (CLP) in male rats and the arterial blood pressure (BP) monitored continuously via a carotid catheter. Monitoring, fluid resuscitation and experimental treatments were performed on conscious animals. Based on pilot assays, normal saline fluid resuscitation (2.5 mL/Kg/h) was initiated 3 h post-CLP and maintained up to the endpoint. Thus, titrated doses of NE, with or without fixed-doses of APL-13 or the apelin receptor antagonist F13A co-infusion were started when 20% decrease of systolic BP (SBP) from baseline was achieved, to restore SBP values ≥ 115 ± 1.5 mmHg (baseline average ± SEM). RESULTS A reduction in mean NE dose was observed with APL-13 but not F13A co-infusion at pre-determined treatment time of 4.5 ± 0.5 h (17.37 ± 1.74 µg/Kg/h [APL-13] vs. 25.64 ± 2.61 µg/Kg/h [Control NE] vs. 28.60 ± 4.79 µg/Kg/min [F13A], P = 0.0491). A 60% decrease in NE infusion rate over time was observed with APL-13 co-infusion, (p = 0.008 vs NE alone), while F13A co-infusion increased the NE infusion rate over time by 218% (p = 0.003 vs NE + APL-13). Associated improvements in cardiac function are likely mediated by (i) enhanced left ventricular end-diastolic volume (0.18 ± 0.02 mL [Control NE] vs. 0.30 ± 0.03 mL [APL-13], P = 0.0051), stroke volume (0.11 ± 0.01 mL [Control NE] vs. 0.21 ± 0.01 mL [APL-13], P < 0.001) and cardiac output (67.57 ± 8.63 mL/min [Control NE] vs. 112.20 ± 8.53 mL/min [APL-13], P = 0.0036), and (ii) a reduced effective arterial elastance (920.6 ± 81.4 mmHg/mL/min [Control NE] vs. 497.633.44 mmHg/mL/min. [APL-13], P = 0.0002). APL-13 administration was also associated with a decrease in lactate levels compared to animals only receiving NE (7.08 ± 0.40 [Control NE] vs. 4.78 ± 0.60 [APL-13], P < 0.01). CONCLUSION APL-13 exhibits NE-sparing benefits in the treatment of sepsis-induced shock, potentially reducing deleterious effects of prolonged exogenous catecholamine administration.
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Affiliation(s)
- William Salvail
- Centre de Recherche Clinique du CHU Sherbrooke (CRCHUS), CHUS, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
- IPS Therapeutique Inc., Sherbrooke, QC, Canada
| | | | - Frédéric Chagnon
- Centre de Recherche Clinique du CHU Sherbrooke (CRCHUS), CHUS, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Olivier Lesur
- Centre de Recherche Clinique du CHU Sherbrooke (CRCHUS), CHUS, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.
- Département de Soins Intensifs et Service de PneumologieCHUS, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, 3001 12th Avenue Nord, SherbrookeSherbrooke, QC, J1H 5N4, Canada.
- Département de Médecine, CHUS, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.
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Guinot PG, Desebbe O, Besch G, Guerci P, Gaudard P, Lena D, Mertes PM, Abou-Arab O, Bouhemad B. Prospective randomized double-blind study to evaluate the superiority of Vasopressin versus Norepinephrine in the management of the patient at renal risk undergoing cardiac surgery with cardiopulmonary bypass (NOVACC trial). Am Heart J 2024; 272:86-95. [PMID: 38492626 DOI: 10.1016/j.ahj.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/11/2024] [Accepted: 03/13/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Cardiac surgery-associated acute kidney injury (CS-AKI) affects up to 30% of patients, increasing morbidity and healthcare costs. This condition results from complex factors like ischemia-reperfusion injury and renal hemodynamic changes, often exacerbated by surgical procedures. Norepinephrine, commonly used in cardiac surgeries, may heighten the risk of CS-AKI. In contrast, vasopressin, a noncatecholaminergic agent, shows potential in preserving renal function by favorably affecting renal hemodynamic. Preliminary findings, suggest vasopressin could reduce the incidence of CS-AKI compared to norepinephrine. Additionally, vasopressin is linked to a lower incidence of postoperative atrial fibrillation, another factor contributing to longer hospital stays and higher costs. This study hypothesizes that vasopressin could effectively reduce CS-AKI occurrence and severity by optimizing renal perfusion during cardiac surgeries. STUDY DESIGN The NOVACC trial (NCT05568160) is a multicenter, randomized, double blinded superiority-controlled trial testing the superiority of vasopressin over norepinephrine in patients scheduled for cardiac surgery with cardiopulmonary bypass (CPB). The primary composite end point is the occurrence of acute kidney injury and death. The secondary end points are neurological, cardiologic, digestive, and vasopressor related complications at day 7, day 30, day 90, hospital and intensive care unit lengths of stay, medico-economic costs at day 90. CONCLUSION The NOVACC trial will assess the effectiveness of vasopressin in cardiac surgery with CPB in reducing acute kidney injury, mortality, and medical costs. CLINICAL TRIAL REGISTRATION NCT05568160.
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Affiliation(s)
- Pierre-Grégoire Guinot
- Department of Anesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, F-21000 Dijon, France.
| | | | - Guillaume Besch
- Department of Anesthesiology and Critical Care Medicine, Besançon Regional University Medical Centre, Besançon, France; EA3920, University of Franche-Comté, Besançon, France
| | - Philippe Guerci
- Department of Anesthesia and Critical Care, University Hospital of Nancy, Nancy, France
| | - Philippe Gaudard
- Department of Anesthesia and Critical Care, University Hospital of Montpellier, Montepellier, France
| | - Diane Lena
- Institut Arnault Tzanck, Saint Laurent du Var, France
| | - Paul Michel Mertes
- Department of Anesthesia and Critical Care, University Hospital of Strasbourg, Strasbourg, France
| | - Osama Abou-Arab
- Department of Anesthesia and Critical Care, University Hospital of Amiens, Amiens, France
| | - Belaid Bouhemad
- Department of Anesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, F-21000 Dijon, France
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Gramish J, Hattan A, Aljuhani O, Parameaswari PJ, Alshehri S, Korayem GB, Alkofide H, Alalawi M, Vishwakarma R, Alsowaida YS, Alqahtani R, Binorayir L, Abutaleb M, Alotaibi A, Aljohani M, Aljohani S, Samreen S, Jawhari S, Alanazi R, Al Sulaiman KA. The Impact of Midodrine Tapering Versus Nontapering Regimens on the Clinical Outcomes of Critically Ill Patients: A Retrospective Cohort Study. Ann Pharmacother 2024; 58:223-233. [PMID: 37248667 DOI: 10.1177/10600280231173290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND Midodrine has been used in the intensive care unit (ICU) setting to reduce the time to vasopressor discontinuation. The limited data supporting midodrine use have led to variability in the pattern of initiation and discontinuation of midodrine. OBJECTIVES To compare the effectiveness and safety of 2 midodrine discontinuation regimens during weaning vasopressors in critically ill patients. METHODS A retrospective cohort study was conducted at King Abdulaziz Medical City. Included patients were adults admitted to ICU who received midodrine after being unable to be weaned from intravenous vasopressors for more than 24 hours. Patients were categorized into two subgroups depending on the pattern of midodrine discontinuation (tapered dosing regimen vs. nontapered regimen). The primary endpoint was the incidence of inotropes and vasopressors re-initiation after midodrine discontinuation. RESULTS The incidence of inotropes or vasopressors' re-initiation after discontinuation of midodrine was lower in the tapering group (15.4%) compared with the non-tapering group (40.7%) in the crude analysis as well as regression analysis (odd ratio [OR] = 0.15; 95% CI = 0.03, 0.73, P = 0.02). The time required for the antihypertensive medication(s) initiation after midodrine discontinuation was longer in patients who had dose tapering (beta coefficient (95% CI): 3.11 (0.95, 5.28), P = 0.005). Moreover, inotrope or vasopressor requirement was lower 24 hours post midodrine initiation. In contrast, the two groups had no statistically significant differences in 30-day mortality, in-hospital mortality, or ICU length of stay. CONCLUSION AND RELEVANCE These real-life data showed that tapering midodrine dosage before discontinuation in critically ill patients during weaning from vasopressor aids in reducing the frequency of inotrope or vasopressor re-initiation. Application of such a strategy might be a reasonable approach among ICU patients unless contraindicated.
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Affiliation(s)
- Jawaher Gramish
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Ahmed Hattan
- Pharmaceutical Care Services, King Abdullah bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Ohoud Aljuhani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - P J Parameaswari
- Research Support Department, Research and Innovation Center, King Saud Medical City, Ministry of Health, Riyadh, Saudi Arabia
| | - Shaden Alshehri
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ghazwa B Korayem
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Hadeel Alkofide
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Mai Alalawi
- Department of Pharmaceutical Sciences, Fakeeh College for Medical Sciences, Jeddah, Saudi Arabia
| | | | - Yazed Saleh Alsowaida
- Department of Clinical Pharmacy, College of Pharmacy, Hail University, Hail, Saudi Arabia
| | - Rahaf Alqahtani
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Luluh Binorayir
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed Abutaleb
- Pharmaceutical Care Services, King Fahad Central Hospital, Jazan Health, Jazan, Saudi Arabia
| | - Alanoud Alotaibi
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Majidah Aljohani
- Pharmaceutical Care Division, King Saud Medical City, Riyadh, Saudi Arabia
| | - Sarah Aljohani
- Pharmaceutical Care Services, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Sana Samreen
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Suad Jawhari
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Raghad Alanazi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Khalid A Al Sulaiman
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- Saudi Critical Care Pharmacy Research Platform, Riyadh, Saudi Arabia
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Andrei S, Bar S, Nguyen M, Bouhemad B, Guinot PG. Effect of norepinephrine on the vascular waterfall and tissue perfusion in vasoplegic hypotensive patients: a prospective, observational, applied physiology study in cardiac surgery. Intensive Care Med Exp 2023; 11:52. [PMID: 37599310 PMCID: PMC10440321 DOI: 10.1186/s40635-023-00539-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/22/2023] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND Norepinephrine is a commonly used drug for treating vasoplegic acute circulatory failure in ICU. The prediction of norepinephrine macro- and micro-circulatory response is complicated by its uneven receptors' distribution between the arterial and the venous structures, and by the presence of a physiological vascular waterfall (VW) that disconnects the arterial and the venous circulation in two pressure systems. The objectives of this study were to describe the VW in patients with arterial hypotension due to vasodilatory circulatory shock, and its behavior according to its response to norepinephrine infusion. METHODS A prospective, observational, bi-centric study has included adult patients, for whom the physician decided to initiate norepinephrine during the six first hours following admission to the ICU after cardiac surgery, and unresponsive to a fluid challenge. The mean systemic pressure (MSP) and the critical closing pressure (CCP) were measured at inclusion and after norepinephrine infusion. RESULTS Thirty patients were included. Norepinephrine increased arterial pressure and total peripheral resistances in all cohort. The cohort was dichotomized as VW responders (patients with a change of VW over the least significant change (≥ 93% increase in VW)), and as VW non-responders. In 19 (63%) of the 30 patients, VW increased from 3.47 [- 14.43;7.71] mmHg to 43.6 [25.8;48.1] mmHg, p < 0.001) with norepinephrine infusion, being classified as VW responders. The VW responders improved cardiac index (from 1.8 (0.6) L min-1 m-2 to 2.2 (0.5) L min-1 m-2, p = 0.002), capillary refill time (from to 4.2 (1.1) s to 3.1 (1) s, p = 0.006), and pCO2 gap (from 9 [7;10] mmHg to 6 [4;8] mmHg, p = 0.04). No baseline parameters were able to predict the VW response to norepinephrine. In comparison, VW non-responders did not significantly change the VW (from 5 [-5;16] mmHg to -2 [-12;15] mmHg, p = 0.17), cardiac index (from 1.6 (0.3) L min-1 m-2 to 1.8 (0.4) L min-1 m-2, p = 0.09) and capillary refill time (from 4.1 (1) s to 3.7 (1.4), p = 0.44). CONCLUSIONS In post-cardiac surgery patients with vasoplegic arterial hypotension, the vascular waterfall is low. Norepinephrine did not systematically restore the vascular waterfall. Increase of the vascular waterfall was associated with an improvement of laboratory and clinical parameters of tissue perfusion.
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Affiliation(s)
- Stefan Andrei
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, 2 Bd Maréchal de Lattre de Tassigny, 21000, Dijon, France.
- Anaesthesiology and Critical Care Department, Carol Davila University of Medicine, Eroii Sanitari Bvd, no. 8, sector 5, Bucharest, Romania.
| | - Stéphane Bar
- Anaesthesiology and Critical Care Department, Amiens University Hospital, Amiens, France
| | - Maxime Nguyen
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, 2 Bd Maréchal de Lattre de Tassigny, 21000, Dijon, France
- University of Burgundy Franche Comté, LNC UMR1231, 21000, Dijon, France
| | - Bélaid Bouhemad
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, 2 Bd Maréchal de Lattre de Tassigny, 21000, Dijon, France
- University of Burgundy Franche Comté, LNC UMR1231, 21000, Dijon, France
| | - Pierre-Grégoire Guinot
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, 2 Bd Maréchal de Lattre de Tassigny, 21000, Dijon, France
- University of Burgundy Franche Comté, LNC UMR1231, 21000, Dijon, France
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Sekino M, Murakami Y, Sato S, Shintani R, Kaneko S, Iwasaki N, Araki H, Ichinomiya T, Higashijima U, Hara T. Modifications of peripheral perfusion in patients with vasopressor-dependent septic shock treated with polymyxin B-direct hemoperfusion. Sci Rep 2023; 13:7295. [PMID: 37147345 PMCID: PMC10163011 DOI: 10.1038/s41598-023-34084-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 04/24/2023] [Indexed: 05/07/2023] Open
Abstract
Abnormal peripheral perfusion (PP) worsens the prognosis of patients with septic shock. Polymyxin B-direct hemoperfusion (PMX-DHP) increases blood pressure and reduces vasopressor doses. However, the modification of PP following administration of PMX-DHP in patients with vasopressor-dependent septic shock have not yet been elucidated. A retrospective exploratory observational study was conducted in patients with septic shock treated with PMX-DHP. Pulse-amplitude index (PAI), vasoactive inotropic score (VIS), and cumulative fluid balance data were extracted at PMX-DHP initiation (T0) and after 24 (T24) and 48 (T48) h. Changes in these data were analyzed in all patients and two subgroups (abnormal PP [PAI < 1] and normal PP [PAI ≥ 1]) based on the PAI at PMX-DHP initiation. Overall, 122 patients (abnormal PP group, n = 67; normal PP group, n = 55) were evaluated. Overall and in the abnormal PP group, PAI increased significantly at T24 and T48 compared with that at T0, with a significant decrease in VIS. Cumulative 24-h fluid balance after PMX-DHP initiation was significantly higher in the abnormal PP group. PMX-DHP may be an effective intervention to improve PP in patients with abnormal PP; however, caution should be exercised as fluid requirements may differ from that of patients with normal PP.
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Affiliation(s)
- Motohiro Sekino
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Yu Murakami
- Department of Anesthesiology, Nagasaki Harbor Medical Center, 6-39 Shinchi, Nagasaki, 850-8555, Japan
| | - Shuntaro Sato
- Clinical Research Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Ryosuke Shintani
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Shohei Kaneko
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Naoya Iwasaki
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Hiroshi Araki
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Taiga Ichinomiya
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Ushio Higashijima
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Tetsuya Hara
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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Andrei S, Bahr PA, Berthoud V, Popescu BA, Nguyen M, Bouhemad B, Guinot PG. Diuretics depletion improves cardiac output and ventriculo-arterial coupling in congestive ICU patients during hemodynamic de-escalation. J Clin Monit Comput 2023:10.1007/s10877-023-01011-7. [PMID: 37097337 DOI: 10.1007/s10877-023-01011-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 04/04/2023] [Indexed: 04/26/2023]
Abstract
PURPOSE Congestion was shown to hamper organ perfusion, but the exact timing of diuretic initiation during hemodynamic de-escalation in shock is unclear. The aim of this study was to describe the hemodynamic effects of diuretic initiation in the stabilized shock. METHODS We performed a monocentric, retrospective analysis, in a cardiovascular medico-surgical ICU. We included consecutive resuscitated adult patients, for whom the clinician decided to introduce loop diuretic treatment for clinical signs of fluid overload. The patients were hemodynamically evaluated at the moment of diuretic introduction and 24 h later. RESULTS Seventy ICU patients were included in this study, with a median duration of ICU stay before diuretic initiation of 2 [1-3] days. 51(73%) patients were classified as congestive (central venous pressure > 12 mmHg). After treatment, the cardiac index increased towards normal values in the congestive group (2.7 ± 0.8 L min- 1 m- 2 from 2.5 ± 0.8 L min- 1 m- 2, p = 0.042), but not in the non-congestive group (2.7 ± 0.7 L min- 1 m- 2 from baseline 2.7 ± 0.8 L min- 1 m- 2, p = 0.968). A decrease in arterial lactate concentrations was observed in the congestive group (2.1 ± 2 mmol L- 1 vs. 1.3 ± 0.6 mmol L- 1, p < 0.001). The diuretic therapy was associated with an improvement of ventriculo-arterial coupling comparing with baseline values in the congestive group (1.69 ± 1 vs. 1.92 ± 1.5, p = 0.03). The norepinephrine use decreased in congestive patients (p = 0.021), but not in the non-congestive group (p = 0.467). CONCLUSION The initiation of diuretics in ICU congestive patients with stabilized shock was associated with improvement of cardiac index, ventriculo-arterial coupling, and tissue perfusion parameter. These effects were not observed in non-congestive patients.
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Affiliation(s)
- Stefan Andrei
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, 21000, France.
- University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania.
| | - Pierre-Alain Bahr
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, 21000, France
- University of Burgundy and Franche-Comté, LNC UMR1231, Dijon, F-21000, France
| | - Vivien Berthoud
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, 21000, France
| | - Bogdan A Popescu
- University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Euroecolab, Emergency Institute for Cardiovascular Diseases "Prof Dr C Iliescu", Bucharest, Romania
| | - Maxime Nguyen
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, 21000, France
- University of Burgundy and Franche-Comté, LNC UMR1231, Dijon, F-21000, France
| | - Belaid Bouhemad
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, 21000, France
- University of Burgundy and Franche-Comté, LNC UMR1231, Dijon, F-21000, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, 21000, France
- University of Burgundy and Franche-Comté, LNC UMR1231, Dijon, F-21000, France
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Liang B, Su J, Shao H, Chen H, Xie B. The outcome of IV vitamin C therapy in patients with sepsis or septic shock: a meta-analysis of randomized controlled trials. Crit Care 2023; 27:109. [PMID: 36915173 PMCID: PMC10012592 DOI: 10.1186/s13054-023-04392-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 03/03/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND To update a meta-analysis of randomized controlled trials (RCTs) and further explore the outcome of IV vitamin C (IVVC) administration in sepsis or septic shock patients. METHODS This study is a meta-analysis of RCTs. The RCTs of vitamin C therapy in sepsis or septic shock were searched in PubMed, EMBASE and Clinical Trials.gov from inception to January 16, 2023. We registered the protocol with PROSPERO (CRD42022354875). The primary outcome was delta Sequential Organ Failure Assessment (SOFA) score at 72-96 h. Two reviewers independently assessed RCTs according to eligibility criteria: (1) study type: RCT; (2) patient population: patients ≥ 18 years with sepsis or septic shock; (3) intervention: IVVC at any doses as monotherapy or combined with thiamine or and hydrocortisone compared with standard of care, no intervention or placebo (defined as control group); (4) the RCT described short-term mortality or SOFA score. Then, two authors independently extracted related information from RCTs. RESULTS Eighteen RCTs (n = 3364 patients) were identified in this meta-analysis. There were significant effects in the delta SOFA score from baseline to 72-96 h (MD, - 0.62; 95% CI, - 1.00 to - 0.25; p = 0.001) and the duration of vasopressor use (MD, - 15.07; 95% CI, - 21.59 to - 8.55; p < 0.00001) with IVVC therapy. Treatment with IVVC was not shown to improve short-term mortality (OR, 0.89; 95% CI, 0.77 to 1.04; p = 0.14); nevertheless, dose at 25-100 mg/kg/d subgroup associated with a significant reduction in short-term mortality (OR, 0.80; 95% CI, 0.65 to 0.97; p = 0.03). An increase adverse event was observed in IVVC therapy (OR, 1.98; 95% CI, 1.06 to 3.68; p = 0.03). CONCLUSION In this meta-analysis, IVVC in sepsis or septic shock patients significantly improved delta SOFA score and reduced the duration of vasopressor use, whereas it was not associated with reduction in short-term mortality and had higher adverse events.
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Affiliation(s)
- Baofang Liang
- Department of Healthcare-associated Infection Management, Affiliated Dongguan Hospital, Southern Medical University, Dongguan, Guangdong, China
| | - Jianwei Su
- Department of Clinical Pharmacy, Dongguan Tungwah Hospital, Dongguan, Guangdong, China
| | - Hanquan Shao
- Department of Critical Care Medicine, Affiliated Dongguan Hospital, Southern Medical University, Dongguan, Guangdong, China
| | - Huiying Chen
- Department of Critical Care Medicine, Affiliated Dongguan Hospital, Southern Medical University, Dongguan, Guangdong, China
| | - Baocheng Xie
- Department of Pharmacy, Affiliated Dongguan Hospital, Southern Medical University, Dongguan, Guangdong, China.
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Guinot PG, Durand B, Besnier E, Mertes PM, Bernard C, Nguyen M, Berthoud V, Abou-Arab O, Bouhemad B, Martin A, Duclos V, Spitz A, Constandache T, Grosjean S, Radhouani M, Anciaux JB, Missaoui A, Morgant MC, Bouchot O, Jazayeri S, Demailly Z, Huette P, Guilbart M, Besserve P, Beyls C, Dupont H, Kindo M, Wpiff T. Epidemiology, risk factors and outcomes of norepinephrine use in cardiac surgery with cardiopulmonary bypass: a multicentric prospective study. Anaesth Crit Care Pain Med 2023; 42:101200. [PMID: 36758855 DOI: 10.1016/j.accpm.2023.101200] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 01/27/2023] [Accepted: 01/27/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND The present study was designed to describe the prevalence of norepinephrine use, the factors associated with its use, and the incidence of postoperative complications according to norepinephrine use, in patients undergoing cardiac surgery with cardiopulmonary bypass. METHOD We performed a prospective, multicenter, observational study in 4 University-affiliated medico-surgical cardiovascular units. We analyzed all patients treated with cardiac surgery after excluding pre-ECMO surgery, LVAD implantation, heart transplantation and intra-operative hemorrhage. RESULTS Of 9316 patients screened during the study period, 2862 were included and 2510 were analyzed. Among them, 1549 (61%) were treated with norepinephrine with a median maximal dose of 0.11 [0.06-0.2] μg.kg-1.min-1 and a median duration of 10 h [2-24]. Norepinephrine was most often started in the operating room before cardiopulmonary bypass. The multiple regression logistic analysis identified several modifiable (haematocrit, maintenance of beta-blocker, cardiopulmonary bypass time, glucose-insulin-potassium, Custodiol cardioplegia, Delnido cardioplegia, and fibrinogen transfusion) and non-modifiable factors (age, ASA score, chronic high blood pressure, coronary disease, dyslipidemia, right ventricular dysfunction, left ventricular dysfunction, active endocarditis, and valvular aortic surgery) associated with norepinephrine use. Mortality, morbidity (neurological and renal complications, death) and length of stay in the ICU were higher in patients treated with norepinephrine. CONCLUSION Norepinephrine is often used in cardiac surgical patients but for <24 h with a low dose. Many preoperative and surgical factors are associated with norepinephrine use. Patients supported by norepinephrine have a higher incidence of major postoperative events.
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Affiliation(s)
- Pierre-Grégoire Guinot
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, F-21000 Dijon, France.
| | - Bastien Durand
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Emmanuel Besnier
- Department of Anaesthesiology and Critical Care Medicine, Rouen University Medical Centre, 76000 Rouen, France
| | - Paul-Michel Mertes
- Department of Anaesthesiology and Critical Care Medicine, Strasbourg University Medical Centre, Strasbourg, France
| | - Chloe Bernard
- Department of Cardiac Surgery, Dijon University Medical Centre, 21000 Dijon, France
| | - Maxime Nguyen
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, F-21000 Dijon, France
| | - Vivien Berthoud
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Osama Abou-Arab
- Department of Anaesthesiology and Critical Care Medicine, Amiens University Medical Centre, 80000 Amiens, France
| | - Belaid Bouhemad
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, F-21000 Dijon, France
| | - Audrey Martin
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Valerian Duclos
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Alexandra Spitz
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Tiberiu Constandache
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Sandrine Grosjean
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Mohamed Radhouani
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Jean-Baptiste Anciaux
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Anis Missaoui
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Marie-Catherine Morgant
- Department of Anaesthesiology and Critical Care Medicine, Rouen University Medical Centre, 76000 Rouen, France
| | - Olivier Bouchot
- Department of Anaesthesiology and Critical Care Medicine, Rouen University Medical Centre, 76000 Rouen, France
| | - Saed Jazayeri
- Department of Anaesthesiology and Critical Care Medicine, Rouen University Medical Centre, 76000 Rouen, France
| | - Zoe Demailly
- Department of Anaesthesiology and Critical Care Medicine, Rouen University Medical Centre, 76000 Rouen, France
| | - Pierre Huette
- Department of Anaesthesiology and Critical Care Medicine, Strasbourg University Medical Centre, Strasbourg, France
| | - Mathieu Guilbart
- Department of Anaesthesiology and Critical Care Medicine, Strasbourg University Medical Centre, Strasbourg, France
| | - Patricia Besserve
- Department of Anaesthesiology and Critical Care Medicine, Strasbourg University Medical Centre, Strasbourg, France
| | - Christophe Beyls
- Department of Anaesthesiology and Critical Care Medicine, Strasbourg University Medical Centre, Strasbourg, France
| | - Hervé Dupont
- Department of Cardiovascular Surgery, University Hospitals of Strasbourg, Strasbourg, France
| | - Michel Kindo
- Department of Cardiovascular Surgery, University Hospitals of Strasbourg, Strasbourg, France
| | - Thibaut Wpiff
- Department of Cardiac Surgery, Dijon University Medical Centre, 21000 Dijon, France
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Semedi BP, Rehatta NM, Soetjipto S, Nugraha J, Mahyuddin MH, Arnindita JN, Wairooy NAP. How Effective is Angiotensin II in Decreasing Mortality of Vasodilatory Shock? A Systematic Review. Open Access Emerg Med 2023; 15:1-11. [PMID: 36636460 PMCID: PMC9830054 DOI: 10.2147/oaem.s391167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 12/20/2022] [Indexed: 01/05/2023] Open
Abstract
Background Patients with severe vasodilation accompanied by refractory hypotension despite high doses of vasopressors were associated with a high mortality rate. The Ang-2 for the Treatment of High-Output Shock (ATHOS) 3 trial demonstrated that angiotensin 2 (Ang-2) could effectively increase MAP and blood pressure in vasodilatory shock patients. This systematic review aims to summarize the impact of Ang-2 for the treatment of vasodilatory shock on clinical outcomes, including length of stay, MAP level (before and after), and mortality also Ang-2 dose needed. Methods A systematic search in PubMed, Sage, ScienceDirect, Scopus and Gray literature was conducted to obtain studies about the use of Ang-2 in vasodilatory shock patients. Results In all of the studies that we obtained, there were different results regarding mortality in patients with vasodilatory shock with Ang-2. Mortality was significantly lower when Ang-2 was administered to patients with elevated renin. The initial dose of Ang-2 can be started at 10-20 ng/kg/min, but there is no agreement on the maximum dose. Ang-2 may be considered a third-line vasopressor if the targeted MAP has not been achieved after administration of norepinephrine >200 ng/kg/min for more than 6 hours. Although not statistically significant, the use of Ang-2 can reduce the length of stay in the ICU and in the hospital when compared to patients without Ang-2 therapy, in addition to reducing the dose of vasopressor. Conclusion Overall, the use of Ang-2 has potential to be a regimen for patients with vasodilatory shock. Further study is needed to obtain more data.
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Affiliation(s)
- Bambang Pujo Semedi
- Doctoral Program of Medical Science, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, 60132, Indonesia,Department of Anesthesiology and Reanimation, Medical Faculty of Medicine, Universitas Airlangga—Dr Soetomo General Hospital, Surabaya, East Java, 60132, Indonesia
| | - Nancy Margarita Rehatta
- Department of Anesthesiology and Reanimation, Medical Faculty of Medicine, Universitas Airlangga—Dr Soetomo General Hospital, Surabaya, East Java, 60132, Indonesia,Correspondence: Nancy Margarita Rehatta, Email
| | - Soetjipto Soetjipto
- Department of Medical Biochemistry, Medical Faculty of Universitas Airlangga, Surabaya, East Java, 60132, Indonesia
| | - Jusak Nugraha
- Department of Clinical Pathology, Medical Faculty of Universitas Airlangga, Surabaya, East Java, 60132, Indonesia
| | | | | | - Nabilah A P Wairooy
- Medical Faculty Universitas Airlangga, Surabaya, East Java, 60132, Indonesia
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10
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Huette P, Guinot PG, Beyls C, Goldberg E, Guilbart M, Dupont H, Mahjoub Y, Meynier J, Abou-Arab O. Norepinephrine exposure and acute kidney injury after cardiac surgery under cardiopulmonary bypass: A post-hoc cardiox trial analysis. J Clin Anesth 2022; 83:110972. [PMID: 36115286 DOI: 10.1016/j.jclinane.2022.110972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/29/2022] [Accepted: 09/06/2022] [Indexed: 10/14/2022]
Affiliation(s)
- Pierre Huette
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, F- 80054 Amiens, France.
| | - Pierre-Grégoire Guinot
- Department of Anesthesiology and Critical Care Medicine, Dijon University Hospital, 2 Bd Maréchal de Lattre of Tassigny, France
| | - Christophe Beyls
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, F- 80054 Amiens, France
| | - Eliza Goldberg
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, F- 80054 Amiens, France
| | - Mathieu Guilbart
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, F- 80054 Amiens, France
| | - Hervé Dupont
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, F- 80054 Amiens, France
| | - Yazine Mahjoub
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, F- 80054 Amiens, France
| | - Jonathan Meynier
- Department of Statistics, Amiens University Hospital, F-80054 Amiens, France
| | - Osama Abou-Arab
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, F- 80054 Amiens, France
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11
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The use of metaraminol as a vasopressor in critically unwell patients: a narrative review and a survey of UK practice. J Crit Care Med (Targu Mures) 2022; 8:193-203. [PMID: 36062042 PMCID: PMC9396948 DOI: 10.2478/jccm-2022-0017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 06/14/2022] [Indexed: 11/20/2022] Open
Abstract
Abstract
Background
Major international guidelines state that norepinephrine should be used as the first-line vasopressor to achieve adequate blood pressure in patients with hypotension or shock. However, recent observational studies report that in the United Kingdom and Australia, metaraminol is often used as second line medication for cardiovascular support.
Aim of the study
The aim of this study was to carry out a systematic review of metaraminol use for management of shock in critically unwell patients and carry out a survey evaluating whether UK critical care units use metaraminol and under which circumstances.
Methods
A systematic review literature search was conducted. A short telephone survey consisting of 6 questions regarding metaraminol use was conducted across 30 UK critical care units which included a mix of tertiary and district general intensive care units.
Results
Twenty-six of thirty contacted centres responded to our survey. Metaraminol was used in 88% of them in various settings and circumstances (emergency department, theatres, medical emergencies on medical wards), with 67% reporting use of metaraminol infusions in the critical care setting. The systematic literature review revealed several case reports and only two studies conducted in the last 20 years investigating the effect of metaraminol as a stand-alone vasopressor. Both studies focused on different aspects of metaraminol use and the data was incomparable, hence we decided not to perform a meta-analysis.
Conclusions
Metaraminol is widely used as a vasopressor inside and outside of the critical care setting in the UK despite limited evidence supporting its safety and efficacy for treating shock. Further service evaluation, observational studies and prospective randomised controlled trials are warranted to validate the role and safety profile of metaraminol in the treatment of the critically unwell patient.
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12
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Caruso V, Besch G, Nguyen M, Pili-Floury S, Bouhemad B, Guinot PG. Treatment of Hyperlactatemia in Acute Circulatory Failure Based on CO2-O2-Derived Indices: Study Protocol for a Prospective, Multicentric, Single, Blind, Randomized, Superiority Study (The LACTEL Study). Front Cardiovasc Med 2022; 9:898406. [PMID: 35811716 PMCID: PMC9260150 DOI: 10.3389/fcvm.2022.898406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/09/2022] [Indexed: 12/03/2022] Open
Abstract
Background Hyperlactatemia is a biological marker of tissue hypoperfusion with well-known diagnostic, prognostic, and therapeutic implications in shock states. In daily clinical practice, it is difficult to find out the exact mechanism underlying hyperlactatemia. Central venous to arterial CO2 difference (pCO2 gap) is a better parameter of tissue hypoperfusion than the usual ones (clinical examination and mixed venous saturation). Furthermore, the ratio between the pCO2 gap and p(v–a)CO2/C(a–v)O2 may be a promising indicator of anaerobic metabolism, allowing for the identification of different causes of tissue hypoxia and hyperlactatemia. The main aim of the study is to demonstrate that initial hemodynamic resuscitation based on an algorithm integrating the pCO2 gap and p(v–a)CO2/C(a–v)O2 ratio vs. usual clinical practice in acute circulatory failure improves lactate clearance. Methods LACTEL is a randomized, prospective, multicentric, controlled study. It compares the treatment of hyperlactatemia using an algorithm based on the pCO2 gap and P(v–a)CO2/C(a–v)O2 ratio vs. usual clinical practice in acute circulatory failure. A total of 90 patients were enrolled in each treatment group. The primary endpoint is the number of patients with a lactate clearance of more than 10% 2 h after inclusion. Lactate levels were monitored during the first 48 h of treatment as hemodynamic parameters, biological markers of organ failure, and 28-day mortality. Discussion pCO2 derivate indices may be of better interest than routine clinical indices to differentiate causes of hyperlactatemia and diagnose anaerobiosis. LACTEL results will provide clinical insights into the role of these indices in the early hemodynamic management of acute circulatory failure in the ICU. Clinical Trial Registration www.clinicaltrials.gov; identifier: NCT05032521.
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Affiliation(s)
- Vincenza Caruso
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France
- University of Burgundy Franche-Comté, LNC UMR1231, Dijon, France
- *Correspondence: Vincenza Caruso
| | - Guillaume Besch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besançon, Besançon, France
- EA3920, University of Franche-Comté, Besançon, France
| | - Maxime Nguyen
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France
- University of Burgundy Franche-Comté, LNC UMR1231, Dijon, France
| | - Sebastien Pili-Floury
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besançon, Besançon, France
- EA3920, University of Franche-Comté, Besançon, France
| | - Belaid Bouhemad
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France
- University of Burgundy Franche-Comté, LNC UMR1231, Dijon, France
| | - Pierre-Grégoire Guinot
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France
- University of Burgundy Franche-Comté, LNC UMR1231, Dijon, France
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13
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Andrei S, Popescu BA, Caruso V, Nguyen M, Bouhemad B, Guinot PG. Role of Electromechanical Dyssynchrony Assessment During Acute Circulatory Failure and Its Relation to Ventriculo-Arterial Coupling. Front Cardiovasc Med 2022; 9:907891. [PMID: 35800171 PMCID: PMC9253504 DOI: 10.3389/fcvm.2022.907891] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/24/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction Two parallel paradigms of cardiovascular efficiency and haemodynamic optimisation coexist in haemodynamic research. Targeting ventriculo-arterial (VA) coupling [i.e., the ratio between arterial and ventricular elastance (EV)] and electromechanical coupling are two promising approaches in acute circulatory failure. However, validation of the parameters of electromechanical coupling in critically ill patients is ongoing. Furthermore, a unifying link between VA and electromechanical coupling may exist, as EV is correlated with different times of the cardiac cycle. Materials and Methods This study was a retrospective analysis of a prospectively collected observational database from one tertiary center ICU. We analyzed the relationship between electromechanical dyssynchrony and acute circulatory failure hemodynamics before and after treatment (i.e., fluid expansion, dobutamine, or norepinephrine infusion). The relationship between electromechanical coupling and VA coupling was also investigated. Adult patients with haemodynamic instability were included. Haemodynamic parameters, including arterial pressure, cardiac index, VA coupling, stroke work index/pressure–volume area (SWI/PVA), t-IVT, and Tei's index, were collected before and after treatment. A t-IVT of >12 s/min was classified as intraventricular dyssynchrony. Results We included 54 patients; 39 (72.2%) were classified as having intraventricular dyssynchrony at baseline. These patients with baseline dyssynchrony showed a statistically significant amelioration of t-IVT (from 18 ± 4 s to 14 ± 6 s, p = 0.001), left ventricular EV [from 1.1 (0.72–1.52) to 1.33 (0.84–1.67) mmHg mL−1, p = 0.001], VA coupling [from 2 (1.67–2.59) to 1.80 (1.40–2.21), p = 0.001], and SWI/PVA [from 0.58 (0.49–0.65) to 0.64 (0.51–0.68), p = 0.007]. Patients without baseline dyssynchrony showed no statistically significant results. The improvement in VA coupling was mediated by an amelioration of EV. All patients improved their arterial pressure and cardiac index with treatment. The haemodynamic treatment group exhibited no effect on changing t-IVT. Conclusion Acute circulatory failure is associated with electromechanical dyssynchrony. Cardiac electromechanical coupling was improved by haemodynamic treatment only if altered at baseline. The improvement of cardiac electromechanical coupling was associated with the improvement of markers of cardiocirculatory efficacy and efficiency (i.e., SWI/PVA and VA coupling). This study was the first to demonstrate a possible link between cardiac electromechanical coupling and VA coupling in patients with acute circulatory failure.
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Affiliation(s)
- Stefan Andrei
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France
- University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
- *Correspondence: Stefan Andrei
| | - Bogdan A. Popescu
- University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
- Department of Cardiology, Euroecolab, Emergency Institute for Cardiovascular Diseases “Prof. Dr. C. C. Iliescu”, Bucharest, Romania
| | - Vincenza Caruso
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Maxime Nguyen
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France
- University of Burgundy Franche Comté, LNC UMR1231, Dijon, France
| | - Belaid Bouhemad
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France
- University of Burgundy Franche Comté, LNC UMR1231, Dijon, France
| | - Pierre-Grégoire Guinot
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France
- University of Burgundy Franche Comté, LNC UMR1231, Dijon, France
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14
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Andrei S, Nguyen M, Abou-Arab O, Bouhemad B, Guinot PG. Arterial Hypotension Following Norepinephrine Decrease in Septic Shock Patients Is Not Related to Preload Dependence: A Prospective, Observational Cohort Study. Front Med (Lausanne) 2022; 9:818386. [PMID: 35273979 PMCID: PMC8901484 DOI: 10.3389/fmed.2022.818386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/24/2022] [Indexed: 11/30/2022] Open
Abstract
Background The optimal management of hypotensive patients during norepinephrine weaning is unclear. The primary study aim was to assess the ability of preload dependence to predict hypotension following norepinephrine weaning. The secondary aims were to describe the effect of norepinephrine weaning on preload dependence, and the cardiovascular effects of fluid expansion in hypotensive patients following norepinephrine weaning. Materials and Methods This was a prospective observational monocentric study. We included PiCCO®-monitored patients with norepinephrine-treated septic shock, for whom the physician decided to decrease the norepinephrine dosage during the de-escalation phase. Three consecutive steps were evaluated with hemodynamic measurements: baseline, after norepinephrine decrease, and after 500 mL fluid expansion. Results Forty-five patients were included. Preload dependence assessed by stroke volume changes following passive leg raising was not predictive of pressure response to norepinephrine weaning [AUC of 0.42 (95%CI: 0.25–0.59, p = 0.395)]. After fluid expansion, there was no difference in the prior preload dependence between pressure-responders and non-pressure-responders (14 vs. 13%, p = 1). The pressure response to norepinephrine decrease was not associated with pressure response after fluid expansion (40 vs. 23%, p = 0.211). Conclusion Hypotension following norepinephrine decrease was not predicted by preload dependence, and there was no association between arterial hypotension after norepinephrine decrease and fluid response.
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Affiliation(s)
- Stefan Andrei
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France.,Anaesthesiology and Intensive Care Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Maxime Nguyen
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France.,University of Burgundy Franche Comté, Dijon, France
| | - Osama Abou-Arab
- Anaesthesiology and Critical Care Department, Amiens Picardie University Hospital, Dijon, France
| | - Belaid Bouhemad
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France.,University of Burgundy Franche Comté, Dijon, France
| | - Pierre-Grégoire Guinot
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France.,University of Burgundy Franche Comté, Dijon, France
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15
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Andrei S, Nguyen M, Longrois D, Popescu BA, Bouhemad B, Guinot PG. Ventriculo-Arterial Coupling Is Associated With Oxygen Consumption and Tissue Perfusion in Acute Circulatory Failure. Front Cardiovasc Med 2022; 9:842554. [PMID: 35282354 PMCID: PMC8904883 DOI: 10.3389/fcvm.2022.842554] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 01/31/2022] [Indexed: 01/24/2023] Open
Abstract
IntroductionThe determination of ventriculo-arterial coupling is gaining an increasing role in cardiovascular and sport medicine. However, its relevance in critically ill patients is still under investigation. In this study we measured the association between ventriculo-arterial coupling and oxygen consumption (VO2) response after hemodynamic interventions in cardiac surgery patients with acute circulatory instability.Material and MethodsSixty-one cardio-thoracic ICU patients (67 ± 12 years, 80% men) who received hemodynamic therapeutic interventions (fluid challenge or norepinephrine infusion) were included. Arterial pressure, cardiac output, heart rate, arterial (EA), and ventricular elastances (EV), total indexed peripheral resistances were assessed before and after hemodynamic interventions. VO2 responsiveness was defined as VO2 increase >15% following the hemodynamic intervention. Ventriculo-arterial coupling was assessed measuring the EA/EV ratio by echocardiography. The left ventricle stroke work to pressure volume area ratio (SW/PVA) was also calculated.ResultsIn the overall cohort, 24 patients (39%) were VO2 responders, and 48 patients had high ventriculo-arterial (EA/EV) coupling ratio with a median value of 1.9 (1.6–2.4). Most of those patients were classified as VO2 responders (28 of 31 patients, p = 0.031). Changes in VO2 were correlated with those of indexed total peripheral resistances, EA, EA/EV and cardiac output. EA/EV ratio predicted VO2 increase with an AUC of 0.76 [95% CI: 0.62–0.87]; p = 0.001. In principal component analyses, EA/EV and SW/PVA ratios were independently associated (p < 0.05) with VO2 response following interventions.ConclusionsVO2 responders were characterized by baseline high ventriculo-arterial coupling ratio due to high EA and low EV. Baseline EA/EV and SW/PVA ratios were associated with VO2 changes independently of the hemodynamic intervention used. These results underline the pathophysiological significance of measuring ventriculo-arterial coupling in patients with hemodynamic instability, as a potential therapeutic target.
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Affiliation(s)
- Stefan Andrei
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France
- Department of Anaesthesia and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
- *Correspondence: Stefan Andrei
| | - Maxime Nguyen
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France
- LNC UMR1231, University of Burgundy Franche Comte, Dijon, France
| | - Dan Longrois
- Anaesthesiology and Critical Care Department, Bichat Claude Bernard Hospital and INSERM1148, Paris, France
| | - Bogdan A. Popescu
- Department of Anaesthesia and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
- Department of Cardiology, Emergency Institute for Cardiovascular Diseases “Prof. Dr. C. C. Iliescu”, Bucharest, Romania
| | - Belaid Bouhemad
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France
- LNC UMR1231, University of Burgundy Franche Comte, Dijon, France
| | - Pierre-Grégoire Guinot
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France
- LNC UMR1231, University of Burgundy Franche Comte, Dijon, France
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Motiejunaite J, Deniau B, Blet A, Gayat E, Mebazaa A. Inotropes and vasopressors are associated with increased short-term mortality but not long-term survival in critically ill patients. Anaesth Crit Care Pain Med 2021; 41:101012. [PMID: 34952218 DOI: 10.1016/j.accpm.2021.101012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 11/03/2021] [Accepted: 11/08/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Limited information is currently available on the impact of vasoactive medications in intensive care (ICU) and long-term outcomes. The main objective of our study was to describe the association between the use of inotropes and/or vasopressors and ICU mortality. Secondary objectives were to evaluate the association between the use of vasoactive drugs and in-hospital as well as 1-year all-cause mortality in ICU survivors. METHODS FROG-ICU was a prospective, observational, multi-centre cohort designed to investigate long-term mortality of critically ill adult patients. Cox proportional hazards models were used to evaluate the association between the use of inotropes and/or vasopressors and ICU mortality, as well as in-hospital and 1-year all-cause mortality in a propensity-score matched cohort. RESULTS The study included 2087 patients, 939 of whom received inotropes and/or vasopressors during the initial ICU stay. Patients treated with vasoactive medications were older and had a more severe clinical presentation. In a propensity score-matched cohort of 1201 patients, ICU mortality was higher in patients who received vasoactive medications (HR of 1.40 [1.10 - 1.78], p = 0.007). One thousand six hundred thirty-five patients survived the index ICU hospitalisation. There was no significant difference according to the use of inotropes and/or vasopressors in the propensity-score matched cohort on in-hospital mortality (HR of 0.94 [0.60 - 1.49], p = 0.808) as well as one-year all-cause mortality (HR 0.94 [0.71 - 1.24], p = 0.643). CONCLUSION Inotropic and/or vasopressor therapy is a strong predictor of in-ICU death. However, the use of inotropes and/or vasopressors during ICU admission was not associated with a worse prognosis after ICU discharge.
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Affiliation(s)
- Justina Motiejunaite
- Service de Physiologie - Explorations Fonctionnelles, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, 46, rue Henri Huchard, 75018 Paris, France; Université de Paris, Paris, France.
| | - Benjamin Deniau
- Université de Paris, Paris, France; Department of Anaesthesiology and Critical Care, Department of Anaesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France; Inserm UMR-S 942 MASCOT, Lariboisière Hospital - Paris, France
| | - Alice Blet
- Université de Paris, Paris, France; Department of Anaesthesiology and Critical Care, Department of Anaesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France; Inserm UMR-S 942 MASCOT, Lariboisière Hospital - Paris, France
| | - Etienne Gayat
- Université de Paris, Paris, France; Department of Anaesthesiology and Critical Care, Department of Anaesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France; Inserm UMR-S 942 MASCOT, Lariboisière Hospital - Paris, France
| | - Alexandre Mebazaa
- Université de Paris, Paris, France; Department of Anaesthesiology and Critical Care, Department of Anaesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France; Inserm UMR-S 942 MASCOT, Lariboisière Hospital - Paris, France
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Guinot PG, Nguyen M, Duclos V, Berthoud V, Bouhemad B. Oral Water Has Cardiovascular Effects Up to 60 min in Shock Patients. Front Cardiovasc Med 2021; 8:803979. [PMID: 34988132 PMCID: PMC8722716 DOI: 10.3389/fcvm.2021.803979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/29/2021] [Indexed: 11/05/2022] Open
Abstract
Aim: Little is known about the cardiovascular effects of oral water intake in shock patients. This study was designed to assess the effect of oral water on stroke volume and blood pressure during a 1-h time period. Method and Results: This open-label, randomized clinical trial included patients admitted to intensive care with acute circulatory failure. Three ICU units at the anesthesia and critical care department of the Dijon Bourgogne University Hospital. Patients were randomized 1:1 to an intervention or standard care group. The intervention group received 500 ml of oral water while the standard care group received intravenous administration of 500 ml of physiological saline solution. Baseline SV did not differ between the two groups (36 ml [28;51] vs. 38 ml [30;51], p = 0.952). The number of patients who were fluid responders did not differ between the two groups [n = 19 (76%) vs. n = 18 (72%), p = 1]. The median change in stroke volume during the three time points did not differ between the two groups (p < 0.05). In the intervention group, blood pressure increased up to 60 min. In the control group, blood pressure quickly increased at the end of fluid expansion, then returned close to baseline value at 60 min. Conclusion: Shock patients who were administered oral water experienced improvements in blood pressure and blood flow up to 60 min when compared with patients who received intravenous saline solution. Further studies are warranted to confirm these effects. Clinical Trial Registration: www.clinicaltrials.gov, identifier: NCT03951519.
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Affiliation(s)
- Pierre-Grégoire Guinot
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France,University of Burgundy Franche Comté, LNC UMR1231, Dijon, France,*Correspondence: Pierre-Grégoire Guinot
| | - Maxime Nguyen
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France,University of Burgundy Franche Comté, LNC UMR1231, Dijon, France
| | - Valerian Duclos
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France
| | - Vivien Berthoud
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France
| | - Belaid Bouhemad
- Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France,University of Burgundy Franche Comté, LNC UMR1231, Dijon, France
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