1
|
Valente T, Bocchini G, Massimo C, Rea G, Lieto R, Guarino S, Muto E, Abu-Omar A, Scaglione M, Sica G. Multidetector CT Imaging Biomarkers as Predictors of Prognosis in Shock: Updates and Future Directions. Diagnostics (Basel) 2023; 13:2304. [PMID: 37443697 PMCID: PMC10341185 DOI: 10.3390/diagnostics13132304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
A severe mismatch between the supply and demand of oxygen is the common sequela of all types of shock, which present a mortality of up to 80%. Various organs play a protective role in shock and contribute to whole-body homeostasis. The ever-increasing number of multidetector CT examinations in severely ill and sometimes unstable patients leads to more frequently encountered findings leading to imminent death, together called "hypovolemic shock complex". Features on CT include dense opacification of the right heart and major systemic veins, venous layering of contrast material and blood, densely opacified parenchyma in the right hepatic lobe, decreased enhancement of the abdominal organ, a dense pulmonary artery, contrast pooling in dependent lungs, and contrast stasis in pulmonary veins. These findings are biomarkers and prognostic indicators of paramount importance which stratify risk and improve patient outcomes. In this review, we illustrate the various CT patterns in shock and review the spectrum and prognostic significance of thoraco-abdominal vascular and visceral alarming signs of impending death with the intention of increasing awareness among radiologists and radiographers to prepare for immediate resuscitation when required.
Collapse
Affiliation(s)
- Tullio Valente
- Department of Radiology, Monaldi Hospital, Azienda dei Colli, 80131 Naples, Italy (G.S.)
| | - Giorgio Bocchini
- Department of Radiology, Monaldi Hospital, Azienda dei Colli, 80131 Naples, Italy (G.S.)
| | - Candida Massimo
- Department of Radiology, Monaldi Hospital, Azienda dei Colli, 80131 Naples, Italy (G.S.)
| | - Gaetano Rea
- Department of Radiology, Monaldi Hospital, Azienda dei Colli, 80131 Naples, Italy (G.S.)
| | - Roberta Lieto
- Department of Radiology, Monaldi Hospital, Azienda dei Colli, 80131 Naples, Italy (G.S.)
| | - Salvatore Guarino
- Department of Radiology, Monaldi Hospital, Azienda dei Colli, 80131 Naples, Italy (G.S.)
| | - Emanuele Muto
- Department of Radiology, Monaldi Hospital, Azienda dei Colli, 80131 Naples, Italy (G.S.)
| | - Ahmad Abu-Omar
- Department of Radiology, Vancouver General Hospital, 899 W 12th Avenue, Vancouver, BC V5Z 1M9, Canada
| | - Mariano Scaglione
- Department of Radiology, James Cook University Hospital, Middlesbrough TS4 3BW, UK
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
| | - Giacomo Sica
- Department of Radiology, Monaldi Hospital, Azienda dei Colli, 80131 Naples, Italy (G.S.)
| |
Collapse
|
2
|
Yu P, Skinner M, Esangbedo I, Lasa JJ, Li X, Natarajan S, Raman L. Predicting Cardiac Arrest in Children with Heart Disease: A Novel Machine Learning Algorithm. J Clin Med 2023; 12:jcm12072728. [PMID: 37048811 PMCID: PMC10095110 DOI: 10.3390/jcm12072728] [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: 02/06/2023] [Revised: 03/25/2023] [Accepted: 03/30/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Children with congenital and acquired heart disease are at a higher risk of cardiac arrest compared to those without heart disease. Although the monitoring of cardiopulmonary resuscitation quality and extracorporeal resuscitation technologies have advanced, survival after cardiac arrest in this population has not improved. Cardiac arrest prevention, using predictive algorithms with machine learning, has the potential to reduce cardiac arrest rates. However, few studies have evaluated the use of these algorithms in predicting cardiac arrest in children with heart disease. METHODS We collected demographic, laboratory, and vital sign information from the electronic health records (EHR) of all the patients that were admitted to a single-center pediatric cardiac intensive care unit (CICU), between 2010 and 2019, who had a cardiac arrest during their CICU admission, as well as a comparator group of randomly selected non-cardiac-arrest controls. We compared traditional logistic regression modeling against a novel adaptation of a machine learning algorithm (functional gradient boosting), using time series data to predict the risk of cardiac arrest. RESULTS A total of 160 unique cardiac arrest events were matched to non-cardiac-arrest time periods. Using 11 different variables (vital signs and laboratory values) from the EHR, our algorithm's peak performance for the prediction of cardiac arrest was at one hour prior to the cardiac arrest (AUROC of 0.85 [0.79,0.90]), a performance that was similar to our previously published multivariable logistic regression model. CONCLUSIONS Our novel machine learning predictive algorithm, which was developed using retrospective data that were collected from the EHR and predicted cardiac arrest in the children that were admitted to a single-center pediatric cardiac intensive care unit, demonstrated a performance that was similar to that of a traditional logistic regression model. While these results are encouraging, future research, including prospective validations with multicenter data, is warranted prior to the implementation of this algorithm as a real-time clinical decision support tool.
Collapse
Affiliation(s)
- Priscilla Yu
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA
| | - Michael Skinner
- Department of Computer Science, University of Texas at Dallas, Richardson, TX 75080, USA
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA
| | - Ivie Esangbedo
- Section of Cardiac Critical Care, Division of Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA 98195, USA
| | - Javier J Lasa
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA
| | - Xilong Li
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA
| | - Sriraam Natarajan
- Department of Computer Science, University of Texas at Dallas, Richardson, TX 75080, USA
| | - Lakshmi Raman
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA
| |
Collapse
|
3
|
Geevarghese M, Patel K, Gulati A, Ranjan AK. Role of adrenergic receptors in shock. Front Physiol 2023; 14:1094591. [PMID: 36726848 PMCID: PMC9885157 DOI: 10.3389/fphys.2023.1094591] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/04/2023] [Indexed: 01/18/2023] Open
Abstract
Shock is a severe, life-threatening medical condition with a high mortality rate worldwide. All four major categories of shock (along with their various subtypes)-hypovolemic, distributive, cardiogenic, and obstructive, involve a dramatic mismatch between oxygen supply and demand, and share standard features of decreased cardiac output, reduced blood pressure, and overall hypoperfusion. Immediate and appropriate intervention is required regardless of shock type, as a delay can result in cellular dysfunction, irreversible multiple organ failure, and death. Studies have shown that dysfunction and downregulation of adrenergic receptors (ARs) are often implicated in these shock conditions; for example, their density is shown to be decreased in hypovolemic and cardiogenic shock, while their reduced signaling in the brain and vasculature decrease blood perfusion and oxygen supply. There are two main categories of ARs, α, and β, each with its subtypes and distributions. Our group has demonstrated that a dose of .02 mg/kg body wt of centhaquine (CQ) specifically activates α2B ARs on venous circulation along with the central α2A ARs after hypovolemic/hemorrhagic shock. Activating these receptors by CQ increases cardiac output (CO) and reduces systemic vascular resistance (SVR), with a net increase in blood pressure and tissue perfusion. The clinical trials of CQ conducted by Pharmazz Inc. in India have demonstrated significantly improved survival in shock patients. CQ improved blood pressure and shock index, indicating better blood circulation, and reduced lactate levels in the blood compared to in-use standard resuscitative agents. After successful clinical trials, CQ is being marketed as a drug (Lyfaquin®) for hypovolemic/hemorrhagic shock in India, and United States FDA has approved the phase III IND application. It is anticipated that the phase III trial in the United States will begin in 2023. Thus, we have demonstrated that α2 ARs could be suitable targets for treating or managing hypovolemic/hemorrhagic shock. Further understanding of ARs in shock would help find new potential pharmacological targets.
Collapse
Affiliation(s)
- Mathew Geevarghese
- Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, IL, United States
| | - Krishna Patel
- Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, IL, United States
| | - Anil Gulati
- Pharmazz Inc., Research and Development, Willowbrook, IL, United States,Department of Bioengineering, The University of Illinois at Chicago, Chicago, IL, United States,Midwestern University College of Pharmacy Downers Grove, Downers Grove, IL, United States,*Correspondence: Anil Gulati, ; Amaresh K. Ranjan,
| | - Amaresh K. Ranjan
- Midwestern University College of Pharmacy Downers Grove, Downers Grove, IL, United States,*Correspondence: Anil Gulati, ; Amaresh K. Ranjan,
| |
Collapse
|
4
|
Bonanno FG. Management of Hemorrhagic Shock: Physiology Approach, Timing and Strategies. J Clin Med 2022; 12:jcm12010260. [PMID: 36615060 PMCID: PMC9821021 DOI: 10.3390/jcm12010260] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/22/2022] [Accepted: 11/27/2022] [Indexed: 12/30/2022] Open
Abstract
Hemorrhagic shock (HS) management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage from progressing from any named and visible vessel is the main stem fundamental praxis of efficacy and effectiveness and an essential, obligatory, life-saving step. Blood loss replacement serves the purpose of preventing ischemia/reperfusion toxemia and optimizing tissue oxygenation and microcirculation dynamics. The "physiological classification of HS" dictates the timely management and suits the 'titrated hypotensive resuscitation' tactics and the 'damage control surgery' strategy. In any hypotensive but not yet critical shock, the body's response to a fluid load test determines the cut-off point between compensation and progression between the time for adopting conservative treatment and preparing for surgery or rushing to the theater for rapid bleeding source control. Up to 20% of the total blood volume is given to refill the unstressed venous return volume. In any critical level of shock where, ab initio, the patient manifests signs indicating critical physiology and impending cardiac arrest or cardiovascular accident, the balance between the life-saving reflexes stretched to the maximum and the insufficient distal perfusion (blood, oxygen, and substrates) remains in a liable and delicate equilibrium, susceptible to any minimal change or interfering variable. In a cardiac arrest by exsanguination, the core of the physiological issue remains the rapid restoration of a sufficient venous return, allowing the heart to pump it back into systemic circulation either by open massage via sternotomy or anterolateral thoracotomy or spontaneously after aorta clamping in the chest or in the abdomen at the epigastrium under extracorporeal resuscitation and induced hypothermia. This is the only way to prevent ischemic damage to the brain and the heart. This is accomplishable rapidly and efficiently only by a direct approach, which is a crush laparotomy if the bleeding is coming from an abdominal +/- lower limb site or rapid sternotomy/anterolateral thoracotomy if the bleeding is coming from a chest +/- upper limbs site. Without first stopping the bleeding and refilling the heart, any further exercise is doomed to failure. Direct source control via laparotomy/thoracotomy, with the concomitant or soon following venous refilling, are the two essential, initial life-saving steps.
Collapse
Affiliation(s)
- Fabrizio G Bonanno
- Department of Surgery, Polokwane Provincial Hospital, Cnr Hospital & Dorp Street, Polokwane 0700, South Africa
| |
Collapse
|
5
|
Budi HS, Elsayed Ramadan D, Anitasari S, Widya Pangestika E. Estimation of Platelet Count and Bleeding Time of Mice Treated with Musa paradisiaca var. sapientum (L.) Kuntze Extract. J Exp Pharmacol 2022; 14:301-308. [PMID: 36321066 PMCID: PMC9618238 DOI: 10.2147/jep.s358105] [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: 01/12/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022] Open
Abstract
Objective The aim of this study was to estimate the platelet count and bleeding time on peripheral blood smear of mice tail wound using Musa paradisiaca var. sapientum (L.) Kuntze (ambonese banana stem extract). Design Randomized post-test-only control group design. Materials and Methods Twenty-four male mice (Mus Musculus) were randomly divided into 4 groups. A negative control group was treated with carboxymethyl cellulose (CMC), a positive control group (K+) treated aspirin 100 mg/kg body weight, group P1 treated with aspirin 100 mg/kg body weight and tranexamic acid 50 mg/kg body weight, and group P2 treated with 30% of ambonese banana stem extract (ABSE). The mean and standard deviation data of platelet counts and bleeding time were analyzed by one-way ANOVA statistical software. Results and Discussion Tranexamic acid had no significant effect on platelets count compared to CMC group (p = 0.871), but administration of aspirin resulted in low platelets count significantly (p = 0.003). The platelet counts of ABSE and CMC groups were not significant different (p = 0.937). Aspirin has significantly shown prolonged bleeding time than CMC, tranexamic acid, and ABSE groups. However, there was no difference between the tranexamic acid and ABSE groups (p=0.934). The bleeding time of tranexamic acid and ABSE groups was similar, although the platelet count in the ABSE group was lower than in the CMC group. Conclusion This study proved that ambonese banana stem extract has a potency to shorten the bleeding time in mice tail wound without interfering to platelet count.
Collapse
Affiliation(s)
- Hendrik Setia Budi
- Department of Oral Biology, Dental Pharmacology, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia,Correspondence: Hendrik Setia Budi, Department of Oral Biology, Dental Pharmacology, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia, Tel/Fax +62315020255, Email
| | - Doaa Elsayed Ramadan
- Doctoral Program, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia,Directorate of Damietta Health Affairs, Ministry of Health and Population, Cairo, Egypt
| | - Silvia Anitasari
- Department of Dental Material and Devices, Dentistry Program, Faculty of Medicine, Universitas Mulawarman, Samarinda, Indonesia,School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Elza Widya Pangestika
- Undergraduate Program, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia
| |
Collapse
|
6
|
Dos Santos F, Li JB, Moreira NJ, Mazor R, Aletti F, Kistler EB. Enteral gabexate mesilate improves volume requirements and autonomic cardiovascular function after experimental trauma/hemorrhagic shock in the absence of blood reperfusion. Am J Transl Res 2022; 14:7391-7402. [PMID: 36398214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 05/20/2022] [Indexed: 06/16/2023]
Abstract
The standard of care for fluid resuscitation of trauma/hemorrhagic shock (T/HS) is the infusion of blood. However, in many instances, blood product transfusion may not be feasible. Consequently, crystalloid solutions may be utilized as temporizing cost-effective resuscitation fluids. In this study, we explored an alternative therapeutic strategy of enteral protease inhibition adjunctive to intravenous Lactated Ringer's (LR) reperfusion after T/HS. Male Wistar rats underwent midline laparotomy (trauma) and an enteral catheter was inserted orally and positioned post-pyloric for the infusion of vehicle (Golytely®) with or without the serine protease inhibitor gabexate mesilate (GM) (n=8/group). Hemorrhagic shock was induced by blood removal to reduce the mean arterial blood pressure (MAP) to 35-40 mmHg for 90 minutes, before resuscitation with LR. Animals treated with enteral GM required significantly less crystalloid volume to achieve hemodynamic stability and displayed improvements in both blood pressure and autonomic function (via increased baroreflex sensitivity to vasopressors, heightened vascular sympathetic modulation, elevated levels of circulating catecholamines, and increased α1-adrenergic receptor density) compared to untreated (control) shocked animals. Resistance arteries isolated from healthy donor animals and perfused with plasma from untreated T/HS animals revealed impaired vascular response to the α1 adrenergic agonist phenylephrine and decreased reactivity to sodium nitroprusside that was preserved in the GM-treated group. These findings suggest that blockade of serine proteases within the intestinal lumen in non-blood resuscitated experimental T/HS preserves and enhances peripheral sympathetic modulation, improving hemodynamics. Enteral infusion of gabexate mesilate may be a new and promising approach to the management of trauma/hemorrhagic shock.
Collapse
Affiliation(s)
- Fernando Dos Santos
- Department of Anesthesiology & Critical Care, University of California San Diego, La Jolla, CA, USA
| | - Joyce B Li
- Department of Bioengineering, University of California San Diego, La Jolla, CA, USA
| | - Nathalia Jd Moreira
- Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo São Paulo, Brazil
| | - Rafi Mazor
- Department of Anesthesiology & Critical Care, University of California San Diego, La Jolla, CA, USA
| | - Federico Aletti
- Department of Bioengineering, University of California San Diego, La Jolla, CA, USA
- Instituto de Ciência e Tecnologia, Universidade Federal de São Paulo São José dos Campos, Brazil
| | - Erik B Kistler
- Department of Anesthesiology & Critical Care, University of California San Diego, La Jolla, CA, USA
- Veterans Affairs San Diego Healthcare System San Diego, CA, USA
| |
Collapse
|
7
|
Kulkarni AP, Govil D, Samavedam S, Srinivasan S, Ramasubban S, Venkataraman R, Pichamuthu K, Jog SA, Divatia JV, Myatra SN. ISCCM Guidelines for Hemodynamic Monitoring in the Critically Ill. Indian J Crit Care Med 2022; 26:S66-S76. [PMID: 36896359 PMCID: PMC9989872 DOI: 10.5005/jp-journals-10071-24301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/26/2022] [Indexed: 11/09/2022] Open
Abstract
Hemodynamic assessment along with continuous monitoring and appropriate therapy forms an integral part of management of critically ill patients with acute circulatory failure. In India, the infrastructure in ICUs varies from very basic facilities in smaller towns and semi-urban areas, to world-class, cutting-edge technology in corporate hospitals, in metropolitan cities. Surveys and studies from India suggest a wide variation in clinical practices due to possible lack of awareness, expertise, high costs, and lack of availability of advanced hemodynamic monitoring devices. We, therefore, on behalf of the Indian Society of Critical Care Medicine (ISCCM), formulated these evidence-based guidelines for optimal use of various hemodynamic monitoring modalities keeping in mind the resource-limited settings and the specific needs of our patients. When enough evidence was not forthcoming, we have made recommendations after achieving consensus amongst members. Careful integration of clinical assessment and critical information obtained from laboratory data and monitoring devices should help in improving outcomes of our patients. How to cite this article Kulkarni AP, Govil D, Samavedam S, Srinivasan S, Ramasubban S, Venkataraman R, et al. ISCCM Guidelines for Hemodynamic Monitoring in the Critically Ill. Indian J Crit Care Med 2022;26(S2):S66-S76.
Collapse
Affiliation(s)
- Atul Prabhakar Kulkarni
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Deepak Govil
- Institute of Critical Care and Anesthesia, Medanta - The Medicity, Gurugram, Haryana, India
| | - Srinivas Samavedam
- Department of Critical Care, Virinchi Hospital, Hyderabad, Telangana, India
| | | | | | - Ramesh Venkataraman
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Kishore Pichamuthu
- Department of Medical Intensive Care Unit, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Sameer Arvind Jog
- Department of Critical Care Medicine, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra India
| | - Jigeeshu V Divatia
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra India
| | - Sheila Nainan Myatra
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| |
Collapse
|
8
|
Lee JY, Lee HS, Park SB, Lee KH. Tamsulosin-induced life-threatening hypotension in a patient with spinal cord injury: A case report. World J Clin Cases 2022; 10:9142-9147. [PMID: 36157672 PMCID: PMC9477057 DOI: 10.12998/wjcc.v10.i25.9142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/08/2022] [Accepted: 07/22/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Tamsulosin, a selective α1-adrenergic receptor antagonist, is commonly used for treating neurogenic bladder in patients with spinal cord injury (SCI). No severe adverse events have been described with such tamsulosin use. To our knowledge, we report the first case of severe life-threatening hypotension as an adverse effect of tamsulosin in a person with SCI. Therefore, we report this case to inform that this severe adverse effect of tamsulosin can occur when treating patients with SCI.
CASE SUMMARY A 59-year-old woman was diagnosed with cervical spinal cord myelopathy and was classified as American Spinal Injury Association Impairment Scale D, neurological level of injury C3. Because she suffered from voiding difficulty due to neurogenic bladder, we prescribed tamsulosin. Her vital signs remained stable, but occasional hypotensive symptoms followed defecation. We reduced the dose of tamsulosin, but after administering tamsulosin for 9 d, she experienced life-threatening hypotension with no evidence of hypovolemic shock, neurogenic shock, cardiogenic shock, or septic shock. A hypotensive condition induced by tamsulosin was the suspected cause, and her symptoms could be associated with adverse effects of tamsulosin. As symptoms resolved after stopping tamsulosin, and no other reason was found, we concluded that tamsulosin was the cause of her symptoms.
CONCLUSION Caution for severe hypotension is needed when administering tamsulosin for neurogenic bladder in a patient with SCI.
Collapse
Affiliation(s)
- Jae Young Lee
- Rehabilitation Medicine, Hanyang University Hospital, Seoul 04763, South Korea
| | - Ho Seok Lee
- Rehabilitation Medicine, Hanyang University Hospital, Seoul 04763, South Korea
| | - Si-Bog Park
- Rehabilitation Medicine, Hanyang University Hospital, Seoul 04763, South Korea
| | - Kyu Hoon Lee
- Rehabilitation Medicine, Hanyang University Hospital, Seoul 04763, South Korea
| |
Collapse
|
9
|
Natraj R, Ranjit S. BESTFIT-T3: A Tiered Monitoring Approach to Persistent/Recurrent Paediatric Septic Shock - A Pilot Conceptual Report. Indian J Crit Care Med 2022; 26:863-870. [PMID: 36864878 PMCID: PMC9973186 DOI: 10.5005/jp-journals-10071-24246] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective Persistent shock (PS) or recurrent shock (RS) after initial fluids and vasoactives can be secondary to myriad complex mechanisms, and these patients can have a high mortality. We developed a noninvasive tiered hemodynamic monitoring approach which included, in addition to basic echocardiography, cardiac output monitoring and advanced Doppler studies to determine the etiology and provide targeted therapy of PS/RS. Design Prospective observational study. Setting Tertiary Care Pediatric Intensive Care Unit, India. Methods A pilot conceptual report describing the clinical presentation of 10 children with PS/RS using advanced ultrasound and noninvasive cardiac output monitoring. Children with PS/RS after initial fluids and vasoactive agents despite basic echocardiography underwent BESTFIT + T3 (Basic Echocardiography in Shock Therapy for Fluid and Inotrope Titration) with lung ultrasound and advanced 3-tiered monitoring (T1-3). Results Among 10/53 children with septic shock and PS/RS over a 24-month study period, BESTFIT + T3 revealed combinations of right ventricular dysfunction, diastolic dysfunction (DD), altered vascular tone, and venous congestion (VC). By integrating information obtained by BESTFIT + T1-3 and the clinical context, we were able to modify the therapeutic regimen and successfully reverse shock in 8/10 patients. Conclusion We present our pilot results with BESTFIT + T3, a novel approach that can noninvasively interrogate major cardiac, arterial, and venous systems that may be particularly useful in regions where expensive rescue therapies are out of reach. We suggest that, with practice, intensivists already experienced in bedside POCUS can use the information obtained by BESTFIT + T3 to direct time-sensitive precision cardiovascular therapy in persistent/recurrent pediatric septic shock. How to cite this article Natraj R, Ranjit S. BESTFIT-T3: A Tiered Monitoring Approach to Persistent/Recurrent Paediatric Septic Shock - A Pilot Conceptual Report. Indian J Crit Care Med 2022;26(7):863-870.
Collapse
Affiliation(s)
- Rajeswari Natraj
- Paediatric ICU, Apollo Children’s Hospital, Chennai, Tamil Nadu, India,Rajeswari Nataraj, Paediatric ICU, Apollo Children’s Hospital, Chennai, Tamil Nadu, India, Phone: +91 9884058200, e-mail:
| | - Suchitra Ranjit
- Paediatric ICU, Apollo Children’s Hospital, Chennai, Tamil Nadu, India
| |
Collapse
|
10
|
Dos Santos F, Li JB, Mazor R, Aletti F, Kistler EB. Efficacy of Tranexamic Acid in Blood Versus Crystalloid-Resuscitated Trauma/Hemorrhagic Shock. J Surg Res 2022; 279:89-96. [PMID: 35752157 DOI: 10.1016/j.jss.2022.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 04/22/2022] [Accepted: 05/22/2022] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Whole blood (WB) or blood products are not always immediately available for repletion of lost intravascular volume in trauma/hemorrhagic shock (T/HS), and thus, resuscitation with crystalloid solutions is often necessary. Recently, we have shown enteral tranexamic acid (TXA) to be effective as a mild protease inhibitor in blood-resuscitated T/HS by counteracting proteolytic activity in and leaking from the gut with resultant preservation of systemic vascular integrity. We hypothesized that enteral TXA would improve hemodynamic stability after T/HS in the absence of blood reperfusion. METHODS We directly compared resuscitation with enteral TXA versus intravenous (IV) TXA in conjunction with lactated Ringer's solution (LR) or WB reperfusion in an experimental T/HS model. Rats were subjected to laparotomy and exsanguinated to a mean arterial blood pressure of 35-40 mm Hg for 90 min, followed by LR or WB reperfusion and monitored for 120 min. TXA was administered via IV (10 mg/kg) or enteral infusion (150 mM) 20 min after establishment of hemorrhage for 150 min. RESULTS Animals resuscitated with LR were unable to restore or maintain a survivable mean arterial blood pressure (>65 mm Hg), regardless of TXA treatment route. In contrast, rats reperfused with WB and given TXA either enterally or IV displayed hemodynamic improvements superior to WB controls. CONCLUSIONS Results suggest that the beneficial hemodynamic responses to enteral or IV TXA after experimental T/HS depend upon reperfusion of WB or components present in WB as TXA, regardless of delivery mode, does not have appreciable hemodynamic effects when paired with LR reperfusion.
Collapse
Affiliation(s)
- Fernando Dos Santos
- Department of Anesthesiology & Critical Care, University of California, San Diego, La Jolla, California.
| | - Joyce B Li
- Department of Bioengineering, University of California, San Diego, La Jolla, California
| | - Rafi Mazor
- Department of Anesthesiology & Critical Care, University of California, San Diego, La Jolla, California
| | - Federico Aletti
- Department of Bioengineering, University of California, San Diego, La Jolla, California
| | - Erik B Kistler
- Department of Anesthesiology & Critical Care, University of California, San Diego, La Jolla, California; Department of Bioengineering, University of California, San Diego, La Jolla, California; Veterans Affairs San Diego Healthcare System, San Diego, California
| |
Collapse
|
11
|
Schmitzberger FF, Hall AE, Hughes ME, Belle A, Benson B, Ward KR, Bassin BS. Detection of Hemodynamic Status Using an Analytic Based on an Electrocardiogram Lead Waveform. Crit Care Explor 2022; 4:e0693. [PMID: 35620767 PMCID: PMC9116956 DOI: 10.1097/cce.0000000000000693] [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: 11/25/2022] Open
Abstract
OBJECTIVES Delayed identification of hemodynamic deterioration remains a persistent issue for in-hospital patient care. Clinicians continue to rely on vital signs associated with tachycardia and hypotension to identify hemodynamically unstable patients. A novel, noninvasive technology, the Analytic for Hemodynamic Instability (AHI), uses only the continuous electrocardiogram (ECG) signal from a typical hospital multiparameter telemetry monitor to monitor hemodynamics. The intent of this study was to determine if AHI is able to predict hemodynamic instability without the need for continuous direct measurement of blood pressure. DESIGN Retrospective cohort study. SETTING Single quaternary care academic health system in Michigan. PATIENTS Hospitalized adult patients between November 2019 and February 2020 undergoing continuous ECG and intra-arterial blood pressure monitoring in an intensive care setting. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One million two hundred fifty-two thousand seven hundred forty-two 5-minute windows of the analytic output were analyzed from 597 consecutive adult patients. AHI outputs were compared with vital sign indications of hemodynamic instability (heart rate > 100 beats/min, systolic blood pressure < 90 mm Hg, and shock index of > 1) in the same window. The observed sensitivity and specificity of AHI were 96.9% and 79.0%, respectively, with an area under the curve (AUC) of 0.90 for heart rate and systolic blood pressure. For the shock index analysis, AHI's sensitivity was 72.0% and specificity was 80.3% with an AUC of 0.81. CONCLUSIONS The AHI-derived hemodynamic status appropriately detected the various gold standard indications of hemodynamic instability (hypotension, tachycardia and hypotension, and shock index > 1). AHI may provide continuous dynamic hemodynamic monitoring capabilities in patients who traditionally have intermittent static vital sign measurements.
Collapse
Affiliation(s)
| | - Ashley E Hall
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, MI
| | - Morgan E Hughes
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, MI
| | | | | | - Kevin R Ward
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, MI
- Department of Emergency Medicine, Division of Critical Care, Michigan Medicine, Ann Arbor, MI
- Max Harry Weil Institute for Critical Care Research and Innovation, Michigan Medicine, Ann Arbor, MI
| | - Benjamin S Bassin
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, MI
- Department of Emergency Medicine, Division of Critical Care, Michigan Medicine, Ann Arbor, MI
- Max Harry Weil Institute for Critical Care Research and Innovation, Michigan Medicine, Ann Arbor, MI
| |
Collapse
|
12
|
Yu P, Esangbedo I, Li X, Wolovits J, Thiagarajan R, Raman L. Early Changes in Near-Infrared Spectroscopy Are Associated With Cardiac Arrest in Children With Congenital Heart Disease. Front Pediatr 2022; 10:894125. [PMID: 35832576 PMCID: PMC9271890 DOI: 10.3389/fped.2022.894125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The association of near-infrared spectroscopy (NIRS) with various outcomes after pediatric cardiac surgery has been studied extensively. However, the role of NIRS in the prediction of cardiac arrest (CA) in children with heart disease has yet to be evaluated. We sought to determine if a model utilizing regional cerebral oximetry (rSO2c) and somatic oximetry (rSO2s) could predict CA in children admitted to a single-center pediatric cardiac intensive care unit (CICU). METHODS We retrospectively reviewed 160 index CA events for patients admitted to our pediatric CICU between November 2010 and January 2019. We selected 711 control patients who did not have a cardiac arrest. Hourly data was collected from the electronic health record (EHR). We previously created a machine-learning algorithm to predict the risk of CA using EHR data. Univariable analysis was done on these variables, which we then used to create a multivariable logistic regression model. The outputs from the model were presented by odds ratio (OR) and 95% confidence interval (CI). RESULTS We created a multivariable model to evaluate the association of CA using five variables: arterial saturation (SpO2)- rSO2c difference, SpO2-rSO2s difference, heart rate, diastolic blood pressure, and vasoactive inotrope score. While the SpO2-rSO2c difference was not a significant contributor to the multivariable model, the SpO2-rSO2s difference was. The average SpO2-rSO2s difference cutoff with the best prognostic accuracy for CA was 29% [CI 26-31%]. In the multivariable model, a 10% increase in the SpO2-rSO2s difference was independently associated with increased odds of CA [OR 1.40 (1.18, 1.67), P < 0.001] at 1 h before CA. Our model predicted CA with an AUROC of 0.83 at 1 h before CA. CONCLUSION In this single-center case-control study of children admitted to a pediatric CICU, we created a multivariable model utilizing hourly data from the EHR to predict CA. At 1 h before the event, for every 10% increase in the SpO2-rSO2s difference, the odds of cardiac arrest increased by 40%. These findings are important as the field explores ways to capitalize on the wealth of data at our disposal to improve patient care.
Collapse
Affiliation(s)
- Priscilla Yu
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Ivie Esangbedo
- Division of Cardiac Critical Care, Department of Pediatrics, University of Washington Seattle, Seattle, WA, United States
| | - Xilong Li
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Joshua Wolovits
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Ravi Thiagarajan
- Division of Cardiovascular Critical Care, Department of Pediatrics, Harvard University, Boston, MA, United States
| | - Lakshmi Raman
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| |
Collapse
|
13
|
Jávor P, Csonka E, Butt E, Rárosi F, Babik B, Török L, Varga E, Hartmann P. Comparison of the Previous and Current Trauma-Related Shock Classifications: A Retrospective Cohort Study from a Level I Trauma Center. Eur Surg Res 2021; 62:229-237. [PMID: 34482309 DOI: 10.1159/000516102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/12/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE The aim was to examine the predictive value of the hypovolemic shock classification currently accepted by the Advanced Trauma Life Support (ATLS) program over the previous one, which used only vital signs (VS) for patient allocation. The primary outcome was 30-day mortality; as secondary outcome, heart rate (HR), systolic blood pressure (SBP), Glasgow Coma Scale (GCS) and base deficit (BD) data were compared and investigated in terms of mortality prediction. METHODS Retrospective analysis at a level I trauma center between 2014 and 2019. Adult patients treated by trauma teams were allocated into severity classes (I-IV) based on the criteria of the current and previous ATLS classifications, respectively. The prognostic values for the classifications were determined with Fisher's exact test and χ2 test for independence, and compared with the 2-proportion Z test. The individual variables were analyzed with receiver-operating characteristic (ROC) analyses. RESULTS A total of 156 patients met the inclusion criteria. Mortality was effectively predicted by both classifications, and there was no statistically significant difference between the predictive performances. According to ROC analyses, GCS, BD and SBP had significant prognostic values while HR change was ineffective in this regard. CONCLUSIONS The currently used ATLS shock classification does not appear to be superior to the VS-based previous classification. GCS, BD and SBP are useful parameters to predict the prognosis. Changes in HR do not reflect the clinical course accurately; thus, further studies will be needed to determine the value of this parameter in trauma-associated hypovolemic-hemorrhagic shock conditions.
Collapse
Affiliation(s)
- Péter Jávor
- Department of Traumatology, University of Szeged, Szeged, Hungary,
| | - Endre Csonka
- Department of Traumatology, University of Szeged, Szeged, Hungary
| | - Edina Butt
- Department of Traumatology, University of Szeged, Szeged, Hungary
| | - Ferenc Rárosi
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Barna Babik
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - László Török
- Department of Traumatology, University of Szeged, Szeged, Hungary
| | - Endre Varga
- Department of Traumatology, University of Szeged, Szeged, Hungary
| | - Petra Hartmann
- Institute of Surgical Research, University of Szeged, Szeged, Hungary
| |
Collapse
|
14
|
Drozd A, Wolska M, Szarpak L. Intraosseous vascular access in emergency and trauma settings: a comparison of the most universally used intraosseous devices. Expert Rev Med Devices 2021; 18:855-864. [PMID: 34325586 DOI: 10.1080/17434440.2021.1962287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: Obtaining successful vascular access is an essential component of the emergency and trauma setting. The modern practice of medicine advocates IO access for patients in a critical condition, especially when IV access is problematic or unobtainable. Various medical devices allowing for IO access have been coined and used in the management of critical patients.Areas covered: This study aims to review the literature regarding different intraosseous devices used to obtain vascular access (Bone Injection Gun (BIG), EZ-IO, NIO, Jamshidi, and First Access for Shock and Trauma (FAST-1) and discuss their clinical and experimental role in the emergency and trauma settings.Expert opinion: The development of medical technology contributes to an increasing number of intraosseous devices facilitating vascular access in challenging scenarios, including cardiopulmonary resuscitation, anaphylactic, or hypovolemic shock. Each of these devices provides an effective route for fluid resuscitation, drug delivery, laboratory evaluation, and shortening the timeframe for established vascular access, provided that the person obtaining the access is acquainted with the use of the device.
Collapse
Affiliation(s)
- Anna Drozd
- Outcomes Research Unit, Polish Society of Disaster Medicine, Warsaw, Poland
| | - Marta Wolska
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Center for Preclinical Research and Technology CEPT, Warsaw, Poland
| | - Lukasz Szarpak
- Outcomes Research Unit, Polish Society of Disaster Medicine, Warsaw, Poland.,Institute of Outcomes Research, Maria Sklodowska-Curie Medical Academy in Warsaw, Warsaw, Poland.,Outcomes Research Unit, Maria Sklodowska-Curie Bialystok Oncology Center, Bialystok, Poland
| |
Collapse
|
15
|
Abstract
BACKGROUND Circulatory shock is a life-threatening disorder that is associated with high mortality, with a state of systemic and tissue hypoperfusion that can lead to organ failure, including the brain, where altered mental state is often observed. We hypothesized that cerebral autoregulation (CA) is impaired in patients with circulatory shock. METHODS Adult patients with circulatory shock and healthy controls were included. Cerebral blood flow velocity (CBFV, transcranial Doppler ultrasound) and arterial blood pressure (BP, Finometer or intra-arterial line) were continuously recorded during 5 min in both groups. Autoregulation Index (ARI) was estimated from the CBFV response to a step change in BP, derived by transfer function analysis; ARI ≤ 4 was considered impaired CA. The relationship between organ dysfunction, assessed with the Sequential Organ Failure Assessment (SOFA) score and the ARI, was assessed with linear regression. RESULTS Twenty-five shock patients and 28 age-matched healthy volunteers were studied. The mean ± SD SOFA score was 10.8 ± 4.3. Shock patients compared with control subjects had lower ARI values (4.0 ± 2.1 vs. 5.9 ± 1.5, P = 0.001). Impaired CA was more common in shock patients (44.4% vs. 7.1%, P = 0.003). There was a significant inverse relationship between the ARI and the SOFA score (R = -0.63, P = 0.0008). CONCLUSIONS These results suggest that circulatory shock is often associated with impaired CA and that the severity of CA alterations is correlated with the degree of multiple organ failure, reinforcing the need to monitor cerebral hemodynamics in patients with circulatory shock.
Collapse
|
16
|
Ranjan AK, Zhang Z, Briyal S, Gulati A. Centhaquine Restores Renal Blood Flow and Protects Tissue Damage After Hemorrhagic Shock and Renal Ischemia. Front Pharmacol 2021; 12:616253. [PMID: 34012389 PMCID: PMC8126696 DOI: 10.3389/fphar.2021.616253] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/24/2021] [Indexed: 12/30/2022] Open
Abstract
Background: Centhaquine (CQ) (Lyfaquin®) is in late stage clinical development as a safe and effective first-in-class resuscitative agent for hemorrhagic shock patients (NCT02408731, NCT04056065, and NCT04045327). Acute kidney injury (AKI) is known to be associated with hemorrhagic shock. Hence, effect of CQ on protection of kidneys from damage due to hemorrhagic shock was investigated. Methods: To assess effect of CQ on AKI in shock, we created a rat model with hemorrhagic shock and AKI. Renal arteries were clamped and de-clamped to induce AKI like ischemia/reperfusion model and hemorrhage was carried out by withdrawing blood for 30 min. Rats were resuscitated with CQ (0.02 mg/kg) for 10 min. MAP, heart rate (HR), and renal blood flow (RBF) were monitored for 120 min. Results: CQ produced a significant improvement in RBF compared to vehicle (p< 0.003) even though MAP and HR was similar in CQ and vehicle groups. Blood lactate level was lower (p = 0.0064) in CQ than vehicle at 120 min post-resuscitation. Histopathological analysis of tissues indicated greater renal damage in vehicle than CQ. Western blots showed higher HIF-1α (p = 0.0152) and lower NGAL (p = 0.01626) levels in CQ vs vehicle. Immunofluorescence in the kidney cortex and medulla showed significantly higher (p< 0.045) expression of HIF-1α and lower expression of Bax (p< 0.044) in CQ. Expression of PHD 3 (p< 0.0001) was higher, while the expression of Cytochrome C (p = 0.01429) was lower in the cortex of CQ than vehicle. Conclusion: Results show CQ (Lyfaquin®) increased renal blood flow, augmented hypoxia response, decreased tissue damage and apoptosis following hemorrhagic shock induced AKI, and may be explored to prevent/treat AKI. Translational Statement: Centhaquine (CQ) is safe for human use and currently in late stage clinical development as a first-in-class resuscitative agent to treat hemorrhagic shock. In the current study, we have explored a novel role of CQ in protection from hemorrhagic shock induced AKI, indicating its potential to treat/prevent AKI.
Collapse
Affiliation(s)
- Amaresh K. Ranjan
- Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, United States
| | - Zhong Zhang
- Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, United States
| | - Seema Briyal
- Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, United States
| | - Anil Gulati
- Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, United States
- Pharmazz Inc. Research and Development, Willlowbrook, IL, United States
| |
Collapse
|
17
|
Prikhodko VA, Selizarova NO, Okovityi SV. [Molecular mechanisms for hypoxia development and adaptation to it. Part I]. Arkh Patol 2021; 83:52-61. [PMID: 33822555 DOI: 10.17116/patol20218302152] [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] [Indexed: 11/17/2022]
Abstract
Hypoxia is a typical pathological process characterized by the occurrence of oxygen deficiency in tissues and cells and accompanied by the development of immediate and delayed compensatory and adaptive reactions. Reprogramming of the mitochondrial electron transport chain (ETC) function is one the most essential regulatory mechanisms that allow for immediate adaptation to hypoxia. Succinic acid, or succinate, is involved in this process not only as one of the intermediates of the tricarboxylic acid (TAC) cycle, but also as a signaling molecule. In this connection, the purpose of this review was to systematize the available data on the molecular mechanisms for the development of hypoxia and its adaptation at the ETC/TAC coupling site, as well as on the role of succinic acid in these processes.
Collapse
Affiliation(s)
- V A Prikhodko
- Saint Petersburg State Chemical and Pharmaceutical University of the Ministry of Health of the Russian Federation, Saint Petersburg, Russia
| | - N O Selizarova
- Saint Petersburg State Chemical and Pharmaceutical University of the Ministry of Health of the Russian Federation, Saint Petersburg, Russia
| | - S V Okovityi
- Saint Petersburg State Chemical and Pharmaceutical University of the Ministry of Health of the Russian Federation, Saint Petersburg, Russia
| |
Collapse
|
18
|
Melnikov S, Furmanov A, Gololobov A, Atrash M, Broyer C, Gelkop M, Gezunterman S, David T, Eisenberg L, Kadry E, Nave R, Shalom E, Shoval N, Traytel G, Zaid N, Goldberg S, Vardi A. Recommendations From the Professional Advisory Committee on Nursing Practice in the Care of ECMO-Supported Patients. Crit Care Nurse 2021; 41:e1-e8. [PMID: 33588431 DOI: 10.4037/ccn2021415] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND By July 2020, the Extracorporeal Life Support Organization had documented more than 133 000 extracorporeal membrane oxygenation (ECMO) implementations, with more than 61 000 implementations in adult patients. No clear policies regarding the authority and responsibility of nursing staff in the treatment of ECMO-supported patients are currently available. OBJECTIVE To formulate evidence-based recommendations for nursing care of ECMO-supported patients. METHODS The National Head Nurse's office and the Professional Guidelines Department in the Nursing Division of Israel's Ministry of Health formed the Professional Advisory Committee on Nursing Practice in the Care of ECMO-Supported Patients to address concerns regarding the current state of professional nursing practice in the care of these patients. The Professional Advisory Committee brought together 15 senior Israeli ECMO nursing experts who explored the potential of registered nurses in caring for ECMO-supported patients, considered the competencies of nurses treating ECMO-supported patients, discussed training programs and health care policy, and examined nursing outcomes for quality assurance. RESULTS The Professional Advisory Committee formulated recommendations regarding the following priority issues: (1) determining boundaries of professional authority and nurses' responsibilities, including designated activities for different professional ranks of registered nurses; (2) providing appropriate content for the training programs offered, such as generic/basic, above-basic, and clinical specialization nursing programs; and (3) defining relevant quality measures for nursing treatment of ECMO-supported patients. CONCLUSIONS Introducing international standards would ensure the safety and effectiveness of nursing care for ECMO-supported patients through quality and risk management and establishment of new evidence-based nursing practices.
Collapse
Affiliation(s)
- Semyon Melnikov
- Semyon Melnikov is a senior lecturer in the Department of Nursing, Steyer School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Alex Furmanov
- Alex Furmanov is a head nurse of neuro and cardiothoracic surgery intensive care units (ICUs) at Hadassah Medical Center, Ein Kerem, Jerusalem, Israel
| | - Alik Gololobov
- Alik Gololobov is a coordinator of nursing professional development and standards at Assuta Medical Center, Tel Aviv
| | - Muhammad Atrash
- Muhammad Atrash is a head nurse of the ICU at Baruch Padeh Medical Center, Poriya, Israel
| | - Chaya Broyer
- Chaya Broyer is a head nurse of the ICU at Shaare Zedek Medical Center, Jerusalem
| | - Marta Gelkop
- Marta Gelkop is a head nurse of the Cardiothoracic Surgery Department at Rabin Medical Center, Petah Tikva, Israel
| | - Slava Gezunterman
- Slava Gezunterman is an ECMO coordinator in the cardiac surgery ICU at Sheba Medical Center, Ramat Gan, Israel
| | - Tova David
- Tova David is a coordinator, Professional Guidelines and Standards Department, Nursing Division, Ministry of Health, Israel
| | - Limor Eisenberg
- Limor Eisenberg is a head of the Professional Guidelines and Standards Department, Nursing Division, Ministry of Health
| | - Esam Kadry
- Esam Kadry is a head nurse of the heart surgery ICU at Rambam Medical Center, Haifa, Israel
| | - Ruti Nave
- Ruti Nave is a registered nurse in the ICU at Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Edna Shalom
- Edna Shalom is a head nurse of the cardiothoracic surgery ICU at Sheba Medical Center
| | - Noga Shoval
- Noga Shoval is a lecturer and clinical coordinator at The Yezreel Valley Academic College of Emek Yezreel, Israel
| | - Gregory Traytel
- Gregory Traytel is a deputy head nurse of the Cardiothoracic Surgery Department at Rabin Medical Center
| | - Nagah Zaid
- Nagah Zaid is a head nurse of the pediatric cardiac ICU and pediatric cardiac catheterization unit at Sheba Medical Center
| | - Shoshy Goldberg
- Shoshy Goldberg is the National Head Nurse of Israel and the Director of the Nursing Department at Ministry of Health
| | - Amir Vardi
- Amir Vardi is the Head of the pediatric cardiac ICU and the Director of ECMO service at the Edmond and Lily Safra Children's hospital, Sheba Medical Center
| |
Collapse
|
19
|
Convertino VA, Koons NJ, Suresh MR. Physiology of Human Hemorrhage and Compensation. Compr Physiol 2021; 11:1531-1574. [PMID: 33577122 DOI: 10.1002/cphy.c200016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Hemorrhage is a leading cause of death following traumatic injuries in the United States. Much of the previous work in assessing the physiology and pathophysiology underlying blood loss has focused on descriptive measures of hemodynamic responses such as blood pressure, cardiac output, stroke volume, heart rate, and vascular resistance as indicators of changes in organ perfusion. More recent work has shifted the focus toward understanding mechanisms of compensation for reduced systemic delivery and cellular utilization of oxygen as a more comprehensive approach to understanding the complex physiologic changes that occur following and during blood loss. In this article, we begin with applying dimensional analysis for comparison of animal models, and progress to descriptions of various physiological consequences of hemorrhage. We then introduce the complementary side of compensation by detailing the complexity and integration of various compensatory mechanisms that are activated from the initiation of hemorrhage and serve to maintain adequate vital organ perfusion and hemodynamic stability in the scenario of reduced systemic delivery of oxygen until the onset of hemodynamic decompensation. New data are introduced that challenge legacy concepts related to mechanisms that underlie baroreflex functions and provide novel insights into the measurement of the integrated response of compensation to central hypovolemia known as the compensatory reserve. The impact of demographic and environmental factors on tolerance to hemorrhage is also reviewed. Finally, we describe how understanding the physiology of compensation can be translated to applications for early assessment of the clinical status and accurate triage of hypovolemic and hypotensive patients. © 2021 American Physiological Society. Compr Physiol 11:1531-1574, 2021.
Collapse
Affiliation(s)
- Victor A Convertino
- Battlefield Healthy & Trauma Center for Human Integrative Physiology, United States Army Institute of Surgical Research, JBSA San Antonio, Texas, USA
| | - Natalie J Koons
- Battlefield Healthy & Trauma Center for Human Integrative Physiology, United States Army Institute of Surgical Research, JBSA San Antonio, Texas, USA
| | - Mithun R Suresh
- Battlefield Healthy & Trauma Center for Human Integrative Physiology, United States Army Institute of Surgical Research, JBSA San Antonio, Texas, USA
| |
Collapse
|
20
|
Place of Polygeline in Fluid Resuscitation: Focus on Hypovolemic Shock. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02221-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
|
21
|
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
|
22
|
Quantitative Assessment of Blood Lactate in Shock: Measure of Hypoxia or Beneficial Energy Source. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2608318. [PMID: 33150168 PMCID: PMC7603544 DOI: 10.1155/2020/2608318] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/18/2020] [Indexed: 12/16/2022]
Abstract
Blood lactate concentration predicts mortality in critically ill patients and is clinically used in the diagnosis, grading of severity, and monitoring response to therapy of septic shock. This paper summarizes available quantitative data to provide the first comprehensive description and critique of the accepted concepts of the physiology of lactate in health and shock, with particular emphasis on the controversy of whether lactate release is simply a manifestation of tissue hypoxia versus a purposeful transfer ("shuttle") of lactate between tissues. Basic issues discussed include (1) effect of nonproductive lactate-pyruvate exchange that artifactually enhances flux measurements obtained with labeled lactate, (2) heterogeneous tissue oxygen partial pressure (Krogh model) and potential for unrecognized hypoxia that exists in all tissues, and (3) pathophysiology that distinguishes septic from other forms of shock. Our analysis suggests that due to exchange artifacts, the turnover rate of lactate and the lactate clearance are only about 60% of the values of 1.05 mmol/min/70 kg and 1.5 L/min/70 kg, respectively, determined from the standard tracer kinetics. Lactate turnover reflects lactate release primarily from muscle, gut, adipose, and erythrocytes and uptake by the liver and kidney, primarily for the purpose of energy production (TCA cycle) while the remainder is used for gluconeogenesis (Cori cycle). The well-studied physiology of exercise-induced hyperlactatemia demonstrates massive release from the contracting muscle accompanied by an increased lactate clearance that may occur in recovering nonexercising muscle as well as the liver. The very limited data on lactate kinetics in shock patients suggests that hyperlactatemia reflects both decreased clearance and increased production, possibly primarily in the gut. Our analysis of available data in health and shock suggests that the conventional concept of tissue hypoxia can account for most blood lactate findings and there is no need to implicate a purposeful production of lactate for export to other organs.
Collapse
|
23
|
Asim M, Amin F, El-Menyar A. Multiple organ dysfunction syndrome: Contemporary insights on the clinicopathological spectrum. Qatar Med J 2020; 2020:22. [PMID: 33628712 PMCID: PMC7884906 DOI: 10.5339/qmj.2020.22] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 03/03/2020] [Indexed: 12/27/2022] Open
Abstract
Multiorgan dysfunction syndrome (MODS) remains a major complication and challenge to treat patients with critical illness in different intensive care unit settings. The exact mechanism and pathophysiology of MODS is complex and remains unexplored. We reviewed the literature from January 2011 to August 2019 to analyze the underlying mechanisms, prognostic factors, MODS scoring systems, organ systems dysfunctions, and the management of MODS. We used the search engines PubMed, MEDLINE, Scopus, and Google Scholar with the keywords "multiple organ dysfunction syndrome," "intensive care units," "multiorgan failure," "MODS scoring system," and "MODS management." The initial search yielded 3550 abstracts, of which 91 articles were relevant to the scope of the present article. A better understanding of a disease course will help differentiate the signs of an intense inflammatory response from the early onset of sepsis and minimize the inappropriate use of medications. This, in turn, will promote organtargeted therapy and prevent occurrence and progression of MODS.
Collapse
Affiliation(s)
- Mohammad Asim
- Department of Surgery, Clinical Research, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar
| | - Farhana Amin
- Sri Ramaswamy Memorial Medical College Hospital & Research Center, Tamil Nadu, India
| | | |
Collapse
|
24
|
Bonanno FG. The Need for a Physiological Classification of Hemorrhagic Shock. J Emerg Trauma Shock 2020; 13:177-182. [PMID: 33304066 PMCID: PMC7717460 DOI: 10.4103/jets.jets_153_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 05/23/2020] [Accepted: 08/03/2020] [Indexed: 11/04/2022] Open
Abstract
Classifications mean to conceptualize in a cluster and rapidly summarize the assessment and management of a clinical scenario. In the specific case of a hemorrhagic shock (HS), a classification should serve the purpose of allowing a rapid clinical assessment of the shock level and the earliest or right timing of source control, possibly also on whether to apply damage control surgery (DCS) strategy or not. ATLS® classification of HS is not sensitive and specific enough to help decision-making in reference to the timing of management, based only on the amount of blood loss that may be or may not rightly estimated, for example, blood loss on the floor in penetrating injuries before theatre. Moreover, it focuses also on other parameters, which are taken singularly, instead of the individual generalized physiological response to hemorrhage, which is the core by definition of the derangement we call "shock." It is unhelpful, difficult, and impractical to apply as well. A new classification, which may well be called as the "physiological HS classification" or "therapeutic HS classification," was proposed since 2010, following the new developments on microcirculation and an already going-on sensible praxis among some trauma surgeons. It bases on some physiological considerations such as the significance of fluid-blood resistant hypotension, body natural hemostatic mechanisms, the right definition of shock, and the relevance that hemorrhage-triggered ischemia-reperfusion toxemia and systemic inflammatory response have in critical illness scenarios as secondary insults from ischemia, which is what we mean to prevented with DCS. The key factor remains the persistence of hypotension, following fluid challenge.
Collapse
Affiliation(s)
- Fabrizio Giuseppe Bonanno
- Department of Surgery, Polokwane-Mankweng Hospitals Complex, UNILIM, Polokwane, Limpopo, South Africa
| |
Collapse
|
25
|
Farina DA, Komanduri S, Aadam AA, Keswani RN. Endoscopic retrograde cholangiopancreatography (ERCP) in critically ill patients is safe and effective when performed in the endoscopy suite. Endosc Int Open 2020; 8:E1165-E1172. [PMID: 32904818 PMCID: PMC7458757 DOI: 10.1055/a-1194-4049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 02/12/2020] [Indexed: 01/30/2023] Open
Abstract
Background and study aims Critically ill patients may require endoscopic retrograde cholangiopancreatography (ERCP) but performing ERCP in the intensive care unit (ICU) poses logistic and technical challenges. There are no data on ICU patients undergoing ERCP in the endoscopy suite. The primary aim of this study was to report outcomes, including safety, when ERCP in critically ill patients is performed in the endoscopy suite. Patients and methods We queried our institutional endoscopy database to identify all ICU patients who underwent ERCP at a single academic medical center from 04/01/2010 to 11/30/2017. Only patients admitted to an ICU prior to ERCP were included. Results Of 7,218 ERCPs performed during the study period, 260 ERCPs (3.6 %) were performed in 231 ICU patients (mean age 61y; 53 % male); nearly all ICU patient ERCPs (n = 258; 99 %) occurred in the endoscopy suite. ERCP indications included cholangitis (50 %), post-liver transplant cholestasis (15 %), and bile leak (10 %). All ERCPs were performed with anesthesiology, most with general anesthesia (60 %) and in the prone position (60 %). Most patients (73 %) had sepsis. Prior to ERCP, 17 % of patients required vasopressors; vasopressors were begun during ERCP in 4 %. The cannulation success rate was 95 % (94 % in native papillae). Adverse events occurred in 9 % (n = 23) of cases with post-ERCP pancreatitis most common. No patients died during or within 24 hours of ERCP. Mortality at 30 days was 16 %, all attributed to underlying disease. Conclusions When advanced ventilatory and hemodynamic support is available, critically ill patients can safely and effectively undergo ERCP in the endoscopy suite.
Collapse
Affiliation(s)
- Domenico A. Farina
- Northwestern University, Department of Gastroenterology and Hepatology, Chicago, Illinois, United States
| | - Srinadh Komanduri
- Northwestern University, Department of Gastroenterology and Hepatology, Chicago, Illinois, United States
| | - A. Aziz Aadam
- Northwestern University, Department of Gastroenterology and Hepatology, Chicago, Illinois, United States
| | - Rajesh N. Keswani
- Northwestern University, Department of Gastroenterology and Hepatology, Chicago, Illinois, United States
| |
Collapse
|
26
|
Saxena A, Garan AR, Kapur NK, O’Neill WW, Lindenfeld J, Pinney SP, Uriel N, Burkhoff D, Kern M. Value of Hemodynamic Monitoring in Patients With Cardiogenic Shock Undergoing Mechanical Circulatory Support. Circulation 2020; 141:1184-1197. [DOI: 10.1161/circulationaha.119.043080] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The recent widespread availability and use of mechanical circulatory support is transforming the management and outcomes of cardiogenic shock (CS). Clinical decision-making regarding the optimization of therapies for patients with CS can be guided effectively by hemodynamic monitoring with a pulmonary artery catheter (PAC). Because several studies regarding the benefit of PACs are ambiguous, the use of PACs is variable among clinicians treating patients with CS. More notable is that PAC use has not been studied as part of a randomized, controlled trial in patients with CS with or without mechanical circulatory support. Standardized approaches to hemodynamic monitoring in these patients can improve decision-making and outcomes. In this review, we summarize the hemodynamics of CS and mechanical circulatory support with PAC-derived measurements, and provide a compelling rationale for the use of PAC monitoring in patients with CS receiving mechanical circulatory support.
Collapse
Affiliation(s)
| | - A. Reshad Garan
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (A.R.G.)
| | | | | | | | - Sean P. Pinney
- Zena and Michael Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (S.P.P.)
| | - Nir Uriel
- Columbia University Irving Medical Center, Weill Cornell Medicine, New York (N.U.)
| | | | - Morton Kern
- University of California Irvine and VA Long Beach Healthcare System (M.K.)
| |
Collapse
|
27
|
Tunctan B, Senol SP, Temiz-Resitoglu M, Guden DS, Sahan-Firat S, Falck JR, Malik KU. Eicosanoids derived from cytochrome P450 pathway of arachidonic acid and inflammatory shock. Prostaglandins Other Lipid Mediat 2019; 145:106377. [PMID: 31586592 DOI: 10.1016/j.prostaglandins.2019.106377] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 09/06/2019] [Accepted: 09/18/2019] [Indexed: 12/14/2022]
Abstract
Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock, the most common form of vasodilatory shock, is a subset of sepsis in which circulatory and cellular/metabolic abnormalities are severe enough to increase mortality. Inflammatory shock constitutes the hallmark of sepsis, but also a final common pathway of any form of severe long-term tissue hypoperfusion. The pathogenesis of inflammatory shock seems to be due to circulating substances released by pathogens (e.g., bacterial endotoxins) and host immuno-inflammatory responses (e.g., changes in the production of histamine, bradykinin, serotonin, nitric oxide [NO], reactive nitrogen and oxygen species, and arachidonic acid [AA]-derived eicosanoids mainly through NO synthase, cyclooxygenase, and cytochrome P450 [CYP] pathways, and proinflammatory cytokine formation). Therefore, refractory hypotension to vasoconstrictors with end-organ hypoperfusion is a life threatening feature of inflammatory shock. This review summarizes the current knowledge regarding the role of eicosanoids derived from CYP pathway of AA in animal models of inflammatory shock syndromes with an emphasis on septic shock in addition to potential therapeutic strategies targeting specific CYP isoforms responsible for proinflammatory/anti-inflammatory mediator production.
Collapse
Affiliation(s)
- Bahar Tunctan
- Department of Pharmacology, Faculty of Pharmacy, Mersin University, Mersin, Turkey.
| | - Sefika Pinar Senol
- Department of Pharmacology, Faculty of Pharmacy, Mersin University, Mersin, Turkey
| | | | - Demet Sinem Guden
- Department of Pharmacology, Faculty of Pharmacy, Mersin University, Mersin, Turkey
| | - Seyhan Sahan-Firat
- Department of Pharmacology, Faculty of Pharmacy, Mersin University, Mersin, Turkey
| | - John R Falck
- Department of Biochemistry, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kafait U Malik
- Department of Pharmacology, College of Medicine, University of Tennessee, Center for Health Sciences, Memphis, TN, USA
| |
Collapse
|
28
|
Smits M, Lin S, Rahme J, Bailey M, Bellomo R, Hardidge A. Blood Pressure and Early Mobilization After Total Hip and Knee Replacements: A Pilot Study on the Impact of Midodrine Hydrochloride. JB JS Open Access 2019; 4:e0048. [PMID: 31334462 PMCID: PMC6613856 DOI: 10.2106/jbjs.oa.18.00048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Early mobilization is an important therapeutic goal after total knee replacement and total hip replacement. Orthostatic hypotension and orthostatic intolerance can impede mobilization. Midodrine hydrochloride, an orally administered vasoconstrictor, may improve blood pressure and diminish the prevalence of adverse mobilization events. Methods We conducted a pilot change-of-practice study. Two cohorts, each comprising 10 patients managed with total knee replacement and 10 patients managed with total hip replacement, were managed with blood pressure-adjusted midodrine, which was administered 3 times daily for the first 72 hours postoperatively at either a low dose (2.5 or 5 mg) or a higher dose (5 or 10 mg). These patients were then matched with an equivalent preintervention cohort of patients. Results The midodrine protocol was instituted effectively and with high compliance. Hypotension was uncommon across all groups, with the mean lowest systolic blood pressure ranging from 110 to 121 mm Hg. Moreover, adverse mobilization events were uncommon across all groups (prevalence, 9.6% in the control group, 5.6% in the low-dose group, and 2.9% in the high-dose group) (p = 0.046 for the high-dose group versus the control group). A midodrine dose of 10 mg generated a significant mean dose-related systolic blood pressure increase of 14 mm Hg at 2 hours after administration (p < 0.001). There were no significant differences between the groups in terms of mean systolic blood pressure, biochemical markers, or intravenous therapy administration. Conclusions A dose of 10 mg was found to achieve a significant systolic blood pressure response at 2 hours after administration and, in patients who received higher-dose midodrine, adverse mobilization events appeared less common. Additional investigation with a blinded randomized controlled trial, utilizing 10 mg of midodrine 2 hours before mobilization, would be needed to confirm the efficacy of midodrine therapy. Level of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Michael Smits
- Departments of Surgery (M.S., S.L., and J.R.), Intensive Care (R.B.), and Orthopaedic Surgery (A.H.), Austin Health, Austin Hospital, Heidelberg, Victoria, Australia
| | - Sandra Lin
- Departments of Surgery (M.S., S.L., and J.R.), Intensive Care (R.B.), and Orthopaedic Surgery (A.H.), Austin Health, Austin Hospital, Heidelberg, Victoria, Australia
| | - Jessica Rahme
- Departments of Surgery (M.S., S.L., and J.R.), Intensive Care (R.B.), and Orthopaedic Surgery (A.H.), Austin Health, Austin Hospital, Heidelberg, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Departments of Surgery (M.S., S.L., and J.R.), Intensive Care (R.B.), and Orthopaedic Surgery (A.H.), Austin Health, Austin Hospital, Heidelberg, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,School of Medicine, The University of Melbourne, Melbourne, Australia
| | - Andrew Hardidge
- Departments of Surgery (M.S., S.L., and J.R.), Intensive Care (R.B.), and Orthopaedic Surgery (A.H.), Austin Health, Austin Hospital, Heidelberg, Victoria, Australia
| |
Collapse
|
29
|
Convertino VA, Lye KR, Koons NJ, Joyner MJ. Physiological comparison of hemorrhagic shock and V˙ O 2max: A conceptual framework for defining the limitation of oxygen delivery. Exp Biol Med (Maywood) 2019; 244:690-701. [PMID: 31042073 PMCID: PMC6552402 DOI: 10.1177/1535370219846425] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPACT STATEMENT Disturbance of normal homeostasis occurs when oxygen delivery and energy stores to the body's tissues fail to meet the energy requirement of cells. The work submitted in this review is important because it advances the understanding of inadequate oxygen delivery as it relates to early diagnosis and treatment of circulatory shock and its relationship to disturbance of normal functioning of cellular metabolism in life-threatening conditions of hemorrhage. We explored data from the clinical and exercise literature to construct for the first time a conceptual framework for defining the limitation of inadequate delivery of oxygen by comparing the physiology of hemorrhagic shock caused by severe blood loss to maximal oxygen uptake induced by intense physical exercise. We also provide a translational framework in which understanding the fundamental relationship between the body's reserve to compensate for conditions of inadequate oxygen delivery as a limiting factor to V ˙ O2max helps to re-evaluate paradigms of triage for improved monitoring of accurate resuscitation in patients suffering from hemorrhagic shock.
Collapse
Affiliation(s)
- Victor A Convertino
- Battlefield Health & Trauma Center for Human Integrative Physiology, U. S. Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
| | - Kristen R Lye
- Battlefield Health & Trauma Center for Human Integrative Physiology, U. S. Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
| | - Natalie J Koons
- Battlefield Health & Trauma Center for Human Integrative Physiology, U. S. Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
| | - Michael J Joyner
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA
| |
Collapse
|
30
|
Senatore F, Jagadeesh G, Rose M, Pillai VC, Hariharan S, Liu Q, McDowell TY, Sapru MK, Southworth MR, Stockbridge N. FDA Approval of Angiotensin II for the Treatment of Hypotension in Adults with Distributive Shock. Am J Cardiovasc Drugs 2019; 19:11-20. [PMID: 30144016 DOI: 10.1007/s40256-018-0297-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Distributive shock is a subset of shock marked by decreased systemic vascular resistance, organ hypoperfusion and altered oxygen extraction. Despite the use of intravenous fluids and either higher dose of catecholamines or other additional exogenous vasopressors to maintain blood pressure in the target range, the rate of mortality remains higher in patients with septic shock. Therefore, there is clearly an unmet need for additional safe and effective treatments. The use of angiotensin II to raise the mean arterial pressure (MAP) could provide additional therapy and the opportunity to evaluate a catecholamine-sparing effect by decreasing the dose of concomitant catecholamines while maintaining a target MAP. ATHOS-3 (Angiotensin II for the Treatment of High-Output Shock phase 3; ClinicalTrials.gov number, NCT02338843) was an adequate and well-controlled trial. The primary endpoint was the rate of MAP response at hour 3 of treatment with study drug, defined as either a 10-mmHg increase from baseline in MAP or a MAP of at least 75 mmHg. The secondary endpoints were changes from baseline in Sequential Organ Failure Assessment (SOFA) scores (total and cardiovascular). Mortality was an exploratory endpoint. The trial provided substantial evidence of the effectiveness of angiotensin II in raising blood pressure over placebo in patients with distributive shock, while keeping catecholamine levels constant. There was no change in the secondary endpoint of total SOFA scores relative to placebo when catecholamine use was reduced in lieu of angiotensin II treatment. There was a slight decrease in the secondary endpoint of cardiovascular SOFA score relative to placebo during the catecholamine-sparing phase, reflecting the catecholamine-sparing effect. There was a consistent trend in decreased mortality relative to placebo over the 28-day study period. Based on the agreements emanating from the special protocol assessment to assess blood pressure effects, the data from this single study supported approval of angiotensin II by the Food and Drug Administration for marketing in the USA.
Collapse
Affiliation(s)
- Fortunato Senatore
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, Food and Drug Administration, 10903 New Hampshire Ave, Bldg 22, Room #4128, Silver Spring, MD, USA
| | - Gowraganahalli Jagadeesh
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, Food and Drug Administration, 10903 New Hampshire Ave, Bldg 22, Room #4128, Silver Spring, MD, USA.
| | - Martin Rose
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, Food and Drug Administration, 10903 New Hampshire Ave, Bldg 22, Room #4128, Silver Spring, MD, USA
| | - Venkateswaran C Pillai
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Sudharshan Hariharan
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Ququan Liu
- Office of Biostatistics, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Tzu-Yun McDowell
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, Food and Drug Administration, 10903 New Hampshire Ave, Bldg 22, Room #4128, Silver Spring, MD, USA
| | - Mohan K Sapru
- The Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Mary Ross Southworth
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, Food and Drug Administration, 10903 New Hampshire Ave, Bldg 22, Room #4128, Silver Spring, MD, USA
| | - Norman Stockbridge
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, Food and Drug Administration, 10903 New Hampshire Ave, Bldg 22, Room #4128, Silver Spring, MD, USA
| |
Collapse
|
31
|
Herminghaus A, Eberhardt R, Truse R, Schulz J, Bauer I, Picker O, Vollmer C. Nitroglycerin and Iloprost Improve Mitochondrial Function in Colon Homogenate Without Altering the Barrier Integrity of Caco-2 Monolayers. Front Med (Lausanne) 2018; 5:291. [PMID: 30460235 PMCID: PMC6232762 DOI: 10.3389/fmed.2018.00291] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 09/24/2018] [Indexed: 12/26/2022] Open
Abstract
Locally applied nitroglycerin [nitric oxide (NO) donor] and iloprost (analog of prostacyclin PGI2) improve regional gastric oxygenation and nitroglycerin preserves gastric mucosal barrier integrity. This suggests direct effects of these substances on oxygenation and barrier function. The aim of this study was to analyze the effect of iloprost and nitroglycerin on intestinal mitochondrial function and on mucosal barrier function in vitro. Mitochondrial oxygen consumption (respirometry) was determined in colon homogenates from 16 healthy rats before (baseline) and 15 min after incubation with nitroglycerin (25 and 250 μg/ml) and iloprost (0.1 and 1 μg/ml). State 2 (substrate-dependent oxygen consumption) and state 3 respiration (ADP-dependent oxygen consumption) were assessed and ADP/O ratio (ADP added/oxygen consumed) for complex I and II were calculated. For permeability measurement we used the Caco-2 monolayer. Fluorescein sulfonic acid (FS) (200 μg/ml) and the drugs were administered into the apical compartment of the transwell chamber. After 48 h, FS translocation was assessed as basolateral/apical FS. Both concentrations of nitroglycerin and iloprost reduced state 3 by stimulation via both complexes. Iloprost increased ADP/O ratio after stimulation via both complexes at both concentrations. Nitroglycerin increased ADP/O ratio at the higher concentration (250 μg/ml) after stimulation via complex I and at the lower concentration (25 μg/ml) via complex II. Neither nitroglycerin nor iloprost influenced FS translocation. Iloprost and nitroglycerin reduce the maximal mitochondrial respiration and improve the efficacy of oxidative phosphorylation in colon homogenates. Both drugs have no direct influence on mucosal barrier integrity of Caco-2 monolayers.
Collapse
Affiliation(s)
- Anna Herminghaus
- Department of Anaesthesiology, University of Düsseldorf, Düsseldorf, Germany
| | - Rebecca Eberhardt
- Department of Anaesthesiology, University of Düsseldorf, Düsseldorf, Germany
| | - Richard Truse
- Department of Anaesthesiology, University of Düsseldorf, Düsseldorf, Germany
| | - Jan Schulz
- Department of Anaesthesiology, University of Düsseldorf, Düsseldorf, Germany
| | - Inge Bauer
- Department of Anaesthesiology, University of Düsseldorf, Düsseldorf, Germany
| | - Olaf Picker
- Department of Anaesthesiology, University of Düsseldorf, Düsseldorf, Germany
| | - Christian Vollmer
- Department of Anaesthesiology, University of Düsseldorf, Düsseldorf, Germany
| |
Collapse
|
32
|
fMLP-dependent activation of Akt and ERK1/2 through ROS/Rho A pathways is mediated through restricted activation of the FPRL1 (FPR2) receptor. Inflamm Res 2018; 67:711-722. [PMID: 29922854 DOI: 10.1007/s00011-018-1163-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 05/02/2018] [Accepted: 06/12/2018] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE AND DESIGN The objective of this study is to uncover the signal transduction pathways of N-formyl methionyl-leucyl-phenylalanine (fMLP) in monocyte. MATERIALS OR SUBJECTS Freshly isolated human peripheral blood monocytes (PBMC) were used for in vitro assessment of signal transduction pathways activated by fMLP. TREATMENT Time-course and dose-response experiments were used to evaluate the effect of fMLP along with the specific inhibitors/stimulators on the activation of downstream signaling kinases. METHODS Freshly isolated human PBMC were stimulated with fMLP for the desired time. Western blot and siRNA analysis were used to evaluate the activated intracellular signaling kinases, and flow analysis was performed to assess the levels of CD11b. Furthermore, luminescence spectrometry was performed to measure the levels of released hydrogen peroxide in the media. RESULTS fMLP strongly stimulated the activation of AKT and ERK1/2 through a RhoA-GTPase-dependent manner and also induced H2O2 release by monocytes. Furthermore, fMLP mediated its effects through restricted activation of formylpeptide receptor-like 1 (FPRL1/FPR2), but independently of either EGFR transactivation or intracellular calcium release. In addition, NAC reversed fMLP- and H2O2-induced activation of Akt and RhoA-GTPase. CONCLUSION Collectively, these data suggested that fMLP-activated ERK1/2 and Akt pathways through specific activation of the FPRL1/ROS/RoA-GTPase pathway.
Collapse
|
33
|
Abstract
Pheochromocytomas are rare endocrine tumors that can have a significant impact on a variety of organ systems, including the cardiovascular system. Although the pathophysiology is not completely understood, pheochromocytomas exert their effects through high levels of catecholamines, mainly epinephrine and norepinephrine, which stimulate adrenergic receptors, including those within the cardiovascular system. Although the most common cardiovascular manifestation is hypertension, patients with pheochromocytoma can present with arrhythmia, hypotension, shock, myocardial ischemia, cardiomyopathy, aortic dissection, and peripheral ischemia. The medical management of the cardiovascular effects of pheochromocytoma is via blockade of adrenergic receptors, usually through the use of alpha blockers, with the addition of beta blockers if needed. However, only surgical resection of the pheochromocytoma is potentially curative, and this tumor requires unique management perioperatively. Because of the variability of presentation and the significant morbidity and mortality of patients with an undiagnosed pheochromocytoma, this entity should not be overlooked in the evaluation of patients with a wide variety of cardiovascular disorders.
Collapse
|
34
|
Affiliation(s)
- Brian K Roberts
- Department of Clinical Sciences, School of Veterinary Medicine, St Matthew's University, PO Box 32330, Grand Cayman KY1-1209, Cayman Islands; Small Animal Medicine, School of Veterinary Medicine, St Matthew's University, PO Box 32330, Grand Cayman KY1-1209, Cayman Islands.
| |
Collapse
|
35
|
Thongprayoon C, Cheungpasitporn W, Harrison AM, Carrera P, Srivali N, Kittamongkolchai W, Erdogan A, Kashani KB. Temporal trends in the utilization of vasopressors in intensive care units: an epidemiologic study. BMC Pharmacol Toxicol 2016; 17:19. [PMID: 27154548 PMCID: PMC4859949 DOI: 10.1186/s40360-016-0063-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 04/14/2016] [Indexed: 12/13/2022] Open
Abstract
Background The choice of vasopressor use in the intensive care unit (ICU) depends primarily on provider preference. This study aims to describe the rate of vasopressor utilization and the trends of each vasoactive agent usage in the ICU over the span of 7 years in a tertiary referral center. Methods All adult ICU admissions, including medical, cardiac, and surgical ICUs from January 1st, 2007 through December 31st, 2013 were included in this study. Vasopressor use was defined as the continuous intravenous administration of epinephrine, norepinephrine, phenylephrine, dopamine, or vasopressin within a given ICU day. The vasopressor utilization index (VUI) was defined as the proportion of ICU days on each vasoactive agent divided by the total ICU days with vasopressor usage. Results During the study period, 72,005 ICU admissions and 272,271 ICU days were screened. Vasopressors were used in 19,575 ICU admissions (27 %) and 59,811 ICU days (22 %). Vasopressin was used in 24,496 (41 %), epinephrine in 23,229 (39 %), norepinephrine in 20,648 (34 %), dopamine in 9449 (16 %), and phenylephrine in 7508 (13 %) ICU days. The VUInorepinephrine increased from 0.24 in 2007 to 0.46 in 2013 and VUIphenylephrine decreased from 0.20 in 2007 to 0.08 in 2013 (p < 0.001 both). For epinephrine, dopamine, and vasopressin VUI did not change over the course of study. Conclusion Vasopressors were used in about one fourth of ICU admissions and about one-fifth of ICU days. Although vasopressin is the most commonly used vasopressor, the use of norepinephrine found to have an increasing trajectory. Electronic supplementary material The online version of this article (doi:10.1186/s40360-016-0063-z) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Perliveh Carrera
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Narat Srivali
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Wonngarm Kittamongkolchai
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Aysen Erdogan
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. .,Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
36
|
Carlile C, Wade CE, Baraniuk MS, Holcomb JB, Moore LJ. Evaluation of StO2 tissue perfusion monitoring as a tool to predict the need for lifesaving interventions in trauma patients. Am J Surg 2015; 210:1070-5; discussion 1075. [DOI: 10.1016/j.amjsurg.2015.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 08/27/2015] [Accepted: 08/27/2015] [Indexed: 10/23/2022]
|
37
|
Urgent ultrasound guided hemodynamic assessments by a pediatric medical emergency team: a pilot study. PLoS One 2013; 8:e66951. [PMID: 23825593 PMCID: PMC3692535 DOI: 10.1371/journal.pone.0066951] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 05/13/2013] [Indexed: 12/17/2022] Open
Abstract
Purpose To determine the feasibility of using the Ultrasound Cardiac Output Monitor (USCOM) as an adjunct during hemodynamic assessments by a pediatric medical emergency team (PMET). Methods Pediatric in-patients at McMaster Children’s Hospital aged under 18 years requiring urgent PMET consultation, were eligible. Patients with known cardiac outflow valve defects, Pediatric Critical Care Unit in-patients, and those in cardiorespiratory arrest, were excluded. The primary outcome was feasibility, and the ease of USCOM transport and application as assessed by a self-administered user questionnaire. Secondary outcomes included the quality of USCOM measurements, and agreement in clinical versus USCOM-derived assessments. Results Forty-one patients from 85 eligible PMET consultations were enrolled between March and August 2011. A total of 55 USCOM assessments were performed on 36 of 41 (87.8%) participants. USCOM could not be completed in 5 (12.2%) participants due to patient agitation (n = 4) and emergent care (n = 1). USCOM was reported as easy to transport and apply by 97.4% and 94.7% of respondents respectively, not obstructive to patient care by 94.7%, and yielded timely measurements by 84.2% respondents. USCOM tracings were of good quality in 41 (75.9%) assessments. Agreement between clinical and USCOM-derived hemodynamic assessments by two independent raters was poor (Rater 1: κ = 0.094; Rater 2: κ = 0.146). Conclusion USCOM can be applied by a PMET during urgent hemodynamic assessments in children. While USCOM has been validated in stable children, its role in guiding hemodynamic resuscitation and informing therapeutic goals in a hemodynamically unstable pediatric population requires further investigation.
Collapse
|
38
|
|