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Mergoum AM, Rhone AR, Larson NJ, Dries DJ, Blondeau B, Rogers FB. A Guide to the Use of Vasopressors and Inotropes for Patients in Shock. J Intensive Care Med 2024:8850666241246230. [PMID: 38613381 DOI: 10.1177/08850666241246230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
Shock is a life-threatening circulatory failure that results in inadequate tissue perfusion and oxygenation. Vasopressors and inotropes are vasoactive medications that are vital in increasing systemic vascular resistance and cardiac contractility, respectively, in patients presenting with shock. To be well versed in using these agents is an important skill to have in the critical care setting where patients can frequently exhibit symptoms of shock. In this review, we will discuss the pathophysiological mechanisms of shock and evaluate the current evidence behind the management of shock with an emphasis on vasopressors and inotropes.
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Affiliation(s)
| | | | | | - David J Dries
- Department of Surgery, Regions Hospital, Saint Paul, MN, USA
| | - Benoit Blondeau
- Department of Surgery, Regions Hospital, Saint Paul, MN, USA
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Liu SY, Kelly-Hedrick M, Temkin N, Barber J, Komisarow J, Hatfield J, Ohnuma T, Manley G, Treggiari MM, Colton K, Vavilala MS, Grandhi R, Laskowitz DT, Mathew JP, Hernandez A, James ML, Raghunathan K, Goldstein B, Krishnamoorthy V. Association of Early Dexmedetomidine Utilization With Clinical and Functional Outcomes Following Moderate-Severe Traumatic Brain Injury: A Transforming Clinical Research and Knowledge in Traumatic Brain Injury Study. Crit Care Med 2024; 52:607-617. [PMID: 37966330 PMCID: PMC10939970 DOI: 10.1097/ccm.0000000000006106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
OBJECTIVE To examine early sedation patterns, as well as the association of dexmedetomidine exposure, with clinical and functional outcomes among mechanically ventilated patients with moderate-severe traumatic brain injury (msTBI). DESIGN Retrospective cohort study with prospectively collected data. SETTING Eighteen Level-1 Trauma Centers, United States. PATIENTS Adult (age > 17) patients with msTBI (as defined by Glasgow Coma Scale < 13) who required mechanical ventilation from the Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Using propensity-weighted models, we examined the association of early dexmedetomidine exposure (within the first 5 d of ICU admission) with the primary outcome of 6-month Glasgow Outcomes Scale Extended (GOS-E) and the following secondary outcomes: length of hospital stay, hospital mortality, 6-month Disability Rating Scale (DRS), and 6-month mortality. The study population included 352 subjects who required mechanical ventilation within 24 hours of admission. The initial sedative medication was propofol for 240 patients (68%), midazolam for 59 patients (17%), ketamine for 6 patients (2%), dexmedetomidine for 3 patients (1%), and 43 patients (12%) never received continuous sedation. Early dexmedetomidine was administered in 77 of the patients (22%), usually as a second-line agent. Compared with unexposed patients, early dexmedetomidine exposure was not associated with better 6-month GOS-E (weighted odds ratio [OR] = 1.48; 95% CI, 0.98-2.25). Early dexmedetomidine exposure was associated with lower DRS (weighted OR = -3.04; 95% CI, -5.88 to -0.21). In patients requiring ICP monitoring within the first 24 hours of admission, early dexmedetomidine exposure was associated with higher 6-month GOS-E score (OR 2.17; 95% CI, 1.24-3.80), lower DRS score (adjusted mean difference, -5.81; 95% CI, -9.38 to 2.25), and reduced length of hospital stay (hazard ratio = 1.50; 95% CI, 1.02-2.20). CONCLUSION Variation exists in early sedation choice among mechanically ventilated patients with msTBI. Early dexmedetomidine exposure was not associated with improved 6-month functional outcomes in the entire population, although may have clinical benefit in patients with indications for ICP monitoring.
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Affiliation(s)
- Sunny Yang Liu
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Duke University School of Medicine, Durham, NC
| | - Margot Kelly-Hedrick
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Duke University School of Medicine, Durham, NC
| | - Nancy Temkin
- Department of Biostatistics, University of Washington. Seattle, WA
- Department of Neurosurgery, University of Washington. Seattle, WA
| | - Jason Barber
- Department of Neurosurgery, University of Washington. Seattle, WA
| | | | - Jordan Hatfield
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Duke University School of Medicine, Durham, NC
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
| | - Geoffrey Manley
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, CA
| | - Miriam M. Treggiari
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
| | | | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington. Seattle, WA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, UT
| | - Daniel T. Laskowitz
- Department of Neurosurgery, Duke University. Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
- Department Neurology, Duke University. Durham, NC
| | | | | | - Michael L. James
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
- Department Neurology, Duke University. Durham, NC
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
- Department of Population Health Sciences, Duke University. Durham, NC
| | - Ben Goldstein
- Departments of Biostatistics and Bioinformatics, Duke University. Durham, NC
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, NC
- Department of Anesthesiology, Duke University. Durham, NC
- Department of Population Health Sciences, Duke University. Durham, NC
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Sridharan K, Jassim A, Mohammed Qader A, Pasha SAA. Unraveling the Role of COMT Polymorphism in Dopamine-Mediated Vasopressor Effects: An Observational Cross-Sectional Study. Curr Drug Metab 2024; 25:CDM-EPUB-139294. [PMID: 38509678 DOI: 10.2174/0113892002293952240315064943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/28/2024] [Accepted: 03/06/2024] [Indexed: 03/22/2024]
Abstract
AIMS To evaluate the association between rs4680 polymorphism in the COMT gene and the vasoconstrictive effects of commonly used vasopressors. BACKGROUND Dopamine is a medication that is given intravenously to critically ill patients to help increase blood pressure. Catechol O-Methyl Transferase (COMT) breaks down dopamine and other catecholamines. There is a genetic variation in the COMT gene called rs4680 that can affect how well the enzyme works. Studies have shown that people with this genetic variation may have different blood pressure levels. However, no one has looked at how this genetic variation affects the way dopamine works to increase blood pressure. OBJECTIVES To investigate the impact of the rs4680 polymorphism in the COMT gene on the pharmacodynamic response to dopamine. METHODS Critically ill patients administered dopamine were included following the consent of their legally acceptable representatives. Details on their demographic characteristics, diagnosis, drug-related details, changes in the heart rate, blood pressure, and urinary output were obtained. The presence of rs4680 polymorphism in the COMT gene was evaluated using a validated method. RESULTS One hundred and seventeen patients were recruited, and we observed a prevalence of rs4680 polymorphism in 57.3% of our critically ill patients. Those with mutant genotypes were observed with an increase in the median rate of change in mean arterial pressure (mm Hg/hour) [wild: 8.9 (-22.6 to 49.1); heterozygous mutant: 5.9 (-34.1 to 61.6); and homozygous mutant: 19.5 (-2.5 to 129.2)] and lowered urine output (ml/day) [wild: 1080 (21.4 to 5900); heterozygous mutant: 380 (23.7 to 15800); and homozygous mutant: 316.7 (5.8 to 2308.3)]. CONCLUSION V158M (rs4680) polymorphism is widely prevalent in the population and was significantly associated with altered effects as observed clinically. This finding suggests valuable insights into the molecular basis of COMT function and its potential impact on neurotransmitter metabolism and related disorders. Large-scale studies delineating the effect of these polymorphisms on various vasopressors are the need of the hour.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology & Therapeutics, College of Medicine & Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
| | - Anfal Jassim
- Department of Molecular Medicine, College of Medicine & Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
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Kelly-Hedrick M, Liu SY, Komisarow J, Hatfield J, Ohnuma T, Treggiari MM, Colton K, Arulraja E, Vavilala MS, Laskowitz DT, Mathew JP, Hernandez A, James ML, Raghunathan K, Krishnamoorthy V. Early Beta-Blocker Utilization in Critically Ill Patients With Moderate-Severe Traumatic Brain Injury: A Retrospective Cohort Study. J Intensive Care Med 2024:8850666241236724. [PMID: 38449336 DOI: 10.1177/08850666241236724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
BACKGROUND There is limited evidence that beta-blockers may provide benefit for patients with moderate-severe traumatic brain injury (TBI) during the acute injury period. Larger studies on utilization patterns and impact on outcomes in clinical practice are lacking. OBJECTIVE The present study uses a large, national hospital claims-based dataset to examine early beta-blocker utilization patterns and its association with clinical outcomes among critically ill patients with moderate-severe TBI. METHODS We conducted a retrospective cohort study of the administrative claims Premier Healthcare Database of adults (≥17 years) with moderate-severe TBI admitted to the intensive care unit (ICU) from 2016 to 2020. The exposure was receipt of a beta-blocker during day 1 or 2 of ICU stay (BB+). The primary outcome was hospital mortality, and secondary outcomes were: hospital length of stay (LOS), ICU LOS, discharge to home, and vasopressor utilization. In a sensitivity analysis, we explored the association of beta-blocker class (cardioselective and noncardioselective) with hospital mortality. We used propensity weighting methods to address possible confounding by treatment indication. RESULTS A total of 109 665 participants met inclusion criteria and 39% (n = 42 489) were exposed to beta-blockers during the first 2 days of hospitalization. Of those, 42% received cardioselective only, 43% received noncardioselective only, and 14% received both. After adjustment, there was no association with hospital mortality in the BB+ group compared to the BB- group (adjusted odds ratio [OR] = 0.99, 95% confidence interval [CI] = 0.94, 1.04). The BB+ group had longer hospital stays, lower chance of discharged home, and lower risk of vasopressor utilization, although these difference were clinically small. Beta-blocker class was not associated with hospital mortality. CONCLUSION In this retrospective cohort study, we found variation in use of beta-blockers and early exposure was not associated with hospital mortality. Further research is necessary to understand the optimal type, dose, and timing of beta-blockers for this population.
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Affiliation(s)
- Margot Kelly-Hedrick
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Sunny Yang Liu
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Jordan Komisarow
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurosurgery, Duke University, Durham, NC, USA
| | - Jordan Hatfield
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurosurgery, Duke University, Durham, NC, USA
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Miriam M Treggiari
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | | | - Evangeline Arulraja
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | | | - Joseph P Mathew
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | | | - Michael L James
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Program, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
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Aragão NL, Zaranza MDS, Meneses GC, Lázaro APP, Guimarães ÁR, Martins AMC, Aragão NLP, Beliero AM, da Silva Júnior GB, Mota SMB, Albuquerque PLMM, Daher EDF, De Bruin VMS, de Bruin PFC. Syndecan-1 levels predict septic shock in critically ill patients with COVID-19. Trans R Soc Trop Med Hyg 2024; 118:160-169. [PMID: 37897240 DOI: 10.1093/trstmh/trad077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 09/27/2023] [Accepted: 10/11/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND The clinical picture of coronavirus disease 2019 (COVID-19)-associated sepsis is similar to that of sepsis of other aetiologies. The present study aims to analyse the role of syndecan-1 (SDC-1) as a potential predictor of septic shock in critically ill patients with COVID-19. METHODS This is a prospective study of 86 critically ill patients due to COVID-19 infection. Patients were followed until day 28 of hospitalization. Vascular biomarkers, such as vascular cell adhesion protein-1, SDC-1, angiopoietin-1 and angiopoietin-2, were quantified upon admission and associated with the need for vasopressors in the first 7 d of hospitalization. RESULTS A total of 86 patients with COVID-19 (mean age 60±16 y; 51 men [59%]) were evaluated. Thirty-six (42%) patients died during hospitalization and 50 (58%) survived. The group receiving vasopressors had higher levels of D-dimer (2.46 ng/ml [interquartile range {IQR} 0.6-6.1] vs 1.01 ng/ml [IQR 0.62-2.6], p=0.019) and lactate dehydrogenase (929±382 U/l vs 766±312 U/l, p=0.048). The frequency of deaths during hospitalization was higher in the group that received vasoactive amines in the first 24 h in the intensive care unit (70% vs 30%, p=0.002). SDC-1 levels were independently associated with the need for vasoactive amines, and admission values >269 ng/ml (95% CI 0.524 to 0.758, p=0.024) were able to predict the need for vasopressors during the 7 d following admission. CONCLUSIONS Syndecan-1 levels predict septic shock in critically ill patients with COVID-19.
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Affiliation(s)
- Nilcyeli Linhares Aragão
- Medical Sciences Postgraduate Program, Department of Internal Medicine, School of Medicine, Universidade Federal do Ceará. Fortaleza, Ceará, Brazil
- Instituto José Frota Hospital, Fortaleza, Ceará, Brazil
| | - Marza de Sousa Zaranza
- Medical Sciences Postgraduate Program, Department of Internal Medicine, School of Medicine, Universidade Federal do Ceará. Fortaleza, Ceará, Brazil
- Instituto José Frota Hospital, Fortaleza, Ceará, Brazil
| | - Gdayllon Cavalcante Meneses
- Medical Sciences Postgraduate Program, Department of Internal Medicine, School of Medicine, Universidade Federal do Ceará. Fortaleza, Ceará, Brazil
| | - Ana Paula Pires Lázaro
- Public Health Postgraduate Program, School of Medicine, Health Sciences Center, Universidade de Fortaleza, Fortaleza, Ceará, Brazil
- School of Medicine, Health Sciences Center, Universidade de Fortaleza, Fortaleza, Ceará, Brazil
| | - Álvaro Rolim Guimarães
- Medical Sciences Postgraduate Program, Department of Internal Medicine, School of Medicine, Universidade Federal do Ceará. Fortaleza, Ceará, Brazil
| | - Alice Maria Costa Martins
- Clinical and Toxicological Analysis Department, School of Pharmacy, Universidade Federal do Ceará, Fortaleza, Brazil
| | | | | | - Geraldo Bezerra da Silva Júnior
- Public Health Postgraduate Program, School of Medicine, Health Sciences Center, Universidade de Fortaleza, Fortaleza, Ceará, Brazil
- School of Medicine, Health Sciences Center, Universidade de Fortaleza, Fortaleza, Ceará, Brazil
| | - Sandra Mara Brasileiro Mota
- Medical Sciences Postgraduate Program, Department of Internal Medicine, School of Medicine, Universidade Federal do Ceará. Fortaleza, Ceará, Brazil
- Instituto José Frota Hospital, Fortaleza, Ceará, Brazil
| | | | - Elizabeth De Francesco Daher
- Medical Sciences Postgraduate Program, Department of Internal Medicine, School of Medicine, Universidade Federal do Ceará. Fortaleza, Ceará, Brazil
| | - Veralice Meireles Sales De Bruin
- Medical Sciences Postgraduate Program, Department of Internal Medicine, School of Medicine, Universidade Federal do Ceará. Fortaleza, Ceará, Brazil
| | - Pedro Felipe Carvalhedo de Bruin
- Medical Sciences Postgraduate Program, Department of Internal Medicine, School of Medicine, Universidade Federal do Ceará. Fortaleza, Ceará, Brazil
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Ishak B, Pulido JN, von Glinski A, Ansari D, Oskouian RJ, Chapman JR. Vasoplegia Following Complex Spine Surgery: Incidence and Risk. Global Spine J 2024; 14:400-406. [PMID: 35634908 PMCID: PMC10802555 DOI: 10.1177/21925682221105823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Vasoplegia is a life-threatening form of distributive or vasodilatory shock that is characterized by reduced systemic vascular resistance with resultant hypotension and normal to elevated cardiac output affecting morbidity and mortality. Vasoplegia in the context of Spine Surgery has not been described previously. The purpose of this case series is to determine incidence, risk factors, complications and postoperative outcome in patients with vasoplegia after complex multi-level thoraco-lumbar spine surgery. METHODS A retrospective review of the electronic medical records at our institution was conducted between January 2014 and June 2018. All patients undergoing multi-level spine surgery (>6 levels) were screened for intraoperative hypotension. Patient demographics, surgical characteristics, neurological status, blood loss, risk factors, medical treatment, complications, hospital course and mortality were collected. All patients included in this study had a minimum follow-up period of 3 months. RESULTS Out of 8521 surgically treated patients, 994 patients with multi-level thoraco-lumbar spine surgery were identified. A total of 41 patients had intraoperative hypotensive events. Of those, 5 patients with vasoplegia could be identified after elimination of all other potential contributing factors. Vasoplegia did not influence the neurological outcome. One major and three minor complications occurred. All patients showed full recovery. The risk factors identified for vasoplegia include prolonged surgery with osteotomies. CONCLUSIONS Vasoplegia is a rare condition with an incidence of .6%. Patients experiencing vasoplegia did not appear to experience worse surgical outcomes. The use of special intraoperative hemodynamic monitoring should be considered in selected cases.
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Affiliation(s)
- Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
| | - Juan N Pulido
- Swedish Medical Center, Cardiothoracic Anesthesiology and Critical Care Medicine, Seattle, WA, USA
| | - Alexander von Glinski
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
- BG University Hospital Bergmannsheil, Ruhr University, Bochum, Germany
| | - Darius Ansari
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
| | - Rod J Oskouian
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
| | - Jens R Chapman
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
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Kwon BK, Tetreault LA, Martin AR, Arnold PM, Marco RAW, Newcombe VFJ, Zipser CM, McKenna SL, Korupolu R, Neal CJ, Saigal R, Glass NE, Douglas S, Ganau M, Rahimi-Movaghar V, Harrop JS, Aarabi B, Wilson JR, Evaniew N, Skelly AC, Fehlings MG. A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on Hemodynamic Management. Global Spine J 2024; 14:187S-211S. [PMID: 38526923 DOI: 10.1177/21925682231202348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Abstract
STUDY DESIGN Clinical practice guideline development following the GRADE process. OBJECTIVES Hemodynamic management is one of the only available treatment options that likely improves neurologic outcomes in patients with acute traumatic spinal cord injury (SCI). Augmenting mean arterial pressure (MAP) aims to improve blood perfusion and oxygen delivery to the injured spinal cord in order to minimize secondary ischemic damage to neural tissue. The objective of this guideline was to update the 2013 AANS/CNS recommendations on the hemodynamic management of patients with acute traumatic SCI, acknowledging that much has been published in this area since its publication. Specifically, we sought to make recommendations on 1. The range of mean arterial pressure (MAP) to be maintained by identifying an upper and lower MAP limit; 2. The duration of such MAP augmentation; and 3. The choice of vasopressor. Additionally, we sought to make a recommendation on spinal cord perfusion pressure (SCPP) targets. METHODS A multidisciplinary guideline development group (GDG) was formed that included health care professionals from a wide range of clinical specialities, patient advocates, and individuals living with SCI. The GDG reviewed the 2013 AANS/CNS guidelines and voted on whether each recommendation should be endorsed or updated. A systematic review of the literature, following PRISMA standards and registered in PROSPERO, was conducted to inform the guideline development process and address the following key questions: (i) what are the effects of goal-directed interventions to optimize spinal cord perfusion on extent of neurological recovery and rates of adverse events at any time point of follow-up? and (ii) what are the effects of particular monitoring techniques, perfusion ranges, pharmacological agents, and durations of treatment on extent of neurological recovery and rates of adverse events at any time point of follow-up? The GDG combined the information from this systematic review with their clinical expertise in order to develop recommendations on a MAP target range (specifically an upper and lower limit to target), the optimal duration for MAP augmentation, and the use of vasopressors or inotropes. Using methods outlined by the GRADE working group, recommendations were formulated that considered the balance of benefits and harms, financial impact, acceptability, feasibility and patient preferences. RESULTS The GDG suggested that MAP should be augmented to at least 75-80 mmHg as the "lower limit," but not actively augmented beyond an "upper limit" of 90-95 mmHg in order to optimize spinal cord perfusion in acute traumatic SCI. The quality of the evidence around the "target MAP" was very low, and thus the strength of this recommendation is weak. For duration of hemodynamic management, the GDG "suggested" that MAP be augmented for a duration of 3-7 days. Again, the quality of the evidence around the duration of MAP support was very low, and thus the strength of this recommendation is also weak. The GDG felt that a recommendation on the choice of vasopressor or the use of SCPP targets was not warranted, given the dearth of available evidence. CONCLUSION We provide new recommendations for blood pressure management after acute SCI that acknowledge the limitations of the current evidence on the relationship between MAP and neurologic recovery. It was felt that the low quality of existing evidence and uncertainty around the relationship between MAP and neurologic recovery justified a greater range of MAP to target, and for a broader range of days post-injury than recommended in previous guidelines. While important knowledge gaps still remain regarding hemodynamic management, these recommendations represent current perspectives on the role of MAP augmentation for acute SCI.
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Affiliation(s)
- Brian K Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | | | - Allan R Martin
- Department of Neurological Surgery, University of California, Davis, CA, USA
| | - Paul M Arnold
- Department of Neurosurgery, University of Illinois Champaign-Urbana, Urbana, IL, USA
| | - Rex A W Marco
- Department of Orthopedic Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Virginia F J Newcombe
- University Division of Anaesthesia and PACE, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Carl M Zipser
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | | | - Radha Korupolu
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center, Houston, TX, USA
| | - Chris J Neal
- Department of Surgery, Uniformed Services University, Bethesda, MD, USA
| | - Rajiv Saigal
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Nina E Glass
- Department of Surgery, Rutgers, New Jersey Medical School, University Hospital, Newark, NJ
| | - Sam Douglas
- Praxis Spinal Cord Institute, Vancouver, BC, Canada
| | - Mario Ganau
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - James S Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jefferson R Wilson
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Nathan Evaniew
- McCaig Institute for Bone and Joint Health, Department of Surgery, Orthopaedic Surgery, Cumming School of Medicine, University of Calgary, AB, Canada
| | | | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
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8
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Blankenship CR, Betthauser KD, Hencken LN, Maamari JA, Goetz J, Giacomino BD, Gibson GA. Clinical Response to Third-Line Angiotensin-II vs Epinephrine in Septic Shock: A Propensity-Matched Cohort Study. Ann Pharmacother 2024:10600280231226132. [PMID: 38303571 DOI: 10.1177/10600280231226132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND The appropriate third-line vasopressor in septic shock patients receiving norepinephrine and vasopressin is unknown. Angiotensin-II (AT-II) offers a unique mechanism of action to traditionally used vasopressors in septic shock. OBJECTIVE The objective of this study was to compare the clinical efficacy and safety of third-line AT-II to epinephrine in patients with septic shock. METHODS A single-center, retrospective cohort study of critically ill patients was performed between April 1, 2019 and July 31, 2022. Propensity-matched (2:1) analysis compared adults with septic shock who received third-line AT-II to controls who received epinephrine following norepinephrine and vasopressin. The primary outcome was clinical response 24 hours after third-line vasopressor initiation. Additional efficacy and safety outcomes were investigated. RESULTS Twenty-three AT-II patients were compared with 46 epinephrine patients. 47.8% of AT-II patients observed a clinical response at hour 24 compared with 28.3% of epinephrine patients (P = 0.12). In-hospital mortality (65.2% vs 73.9%, P = 0.45), cardiac arrhythmias (26.1% vs 26.1%, P = 0.21), and thromboembolism (4.3% vs 2.2%, P = 0.61) were not observed to be statistically different between groups. CONCLUSIONS AND RELEVANCE Administration of AT-II as a third-line vasopressor agent in septic shock patients was not associated with significantly improved clinical response at hour 24 compared with epinephrine. Although underpowered to detect meaningful differences, the clinical observations of this study warrant consideration and further investigation of AT-II as a third-line vasopressor in septic shock.
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Affiliation(s)
| | - Kevin D Betthauser
- Department of Pharmacy Practice, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Laura N Hencken
- Department of Pharmacy Practice, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Julie A Maamari
- Department of Pharmacy Practice, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Jenna Goetz
- Department of Pharmacy Practice, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Bria D Giacomino
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Gabrielle A Gibson
- Department of Pharmacy Practice, Barnes-Jewish Hospital, St. Louis, MO, USA
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9
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DeMillard L, Thuyns M. Implementation and Evaluation of Weight-Based Vasopressors in Intensive Care Units. J Pharm Technol 2024; 40:23-29. [PMID: 38318260 PMCID: PMC10838541 DOI: 10.1177/87551225231217905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Abstract
Background: Vasopressors, including norepinephrine, epinephrine, and phenylephrine are commonly used to maintain mean arterial pressure (MAP) in critically ill patients. Despite their frequent use, the optimal dosing strategy for vasopressors remains understudied. Objective: The purpose of this study is to evaluate the implementation of a weight-based (WB) dosing strategy using ideal body weight compared to a non-weight-based (NWB) dosing strategy for vasopressors in critically ill patients. Methods: This is a retrospective chart review of patients admitted to intensive care units receiving vasopressor medications for greater than or equal to 4 hours. Patients received either an NWB or a WB vasopressor dosing strategy. The primary endpoint was the time to achieve goal MAP. Results: This study included 153 patients in the NWB vasopressor dosing group and 183 in the WB dosing group. The median time to achieve goal MAP in the NWB group was 24 minutes versus 21 minutes in the WB group (P = 0.1713). There were no significant differences in secondary outcomes including number of vasoactive agents required, hospital length of stay, and duration of mechanical ventilation. Subgroup analysis of patients with extremes of body mass index did not show a difference in time to achieve goal MAP. In a subgroup analysis of patients with septic shock, a higher percentage of patients in the WB group received corticosteroids than the NWB group patients (14% vs. 54%; P ≤ 0.001). Conclusion and relevance: There was no difference in time to achieve goal MAP when using a WB or NWB vasopressor dosing approach. Institutions should employ a consistent dosing strategy for vasopressors with either an NWB or WB approach.
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Affiliation(s)
- Laurie DeMillard
- Department of Pharmacy, Renown Regional Medical Center, Reno, NV, USA
| | - Michael Thuyns
- Department of Pharmacy, Renown Regional Medical Center, Reno, NV, USA
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10
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Salvagno M, Geraldini F, Coppalini G, Robba C, Gouvea Bogossian E, Annoni F, Vitali E, Sterchele ED, Balestra C, Taccone FS. The Impact of Inotropes and Vasopressors on Cerebral Oxygenation in Patients with Traumatic Brain Injury and Subarachnoid Hemorrhage: A Narrative Review. Brain Sci 2024; 14:117. [PMID: 38391692 PMCID: PMC10886736 DOI: 10.3390/brainsci14020117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 01/17/2024] [Accepted: 01/22/2024] [Indexed: 02/24/2024] Open
Abstract
Traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH) are critical neurological conditions that necessitate specialized care in the Intensive Care Unit (ICU). Managing cerebral perfusion pressure (CPP) and mean arterial pressure (MAP) is of primary importance in these patients. To maintain targeted MAP and CPP, vasopressors and/or inotropes are commonly used. However, their effects on cerebral oxygenation are not fully understood. The aim of this review is to provide an up-to date review regarding the current uses and pathophysiological issues related to the use of vasopressors and inotropes in TBI and SAH patients. According to our findings, despite achieving similar hemodynamic parameters and CPP, the effects of various vasopressors and inotropes on cerebral oxygenation, local CBF and metabolism are heterogeneous. Therefore, a more accurate understanding of the cerebral activity of these medications is crucial for optimizing patient management in the ICU setting.
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Affiliation(s)
- Michele Salvagno
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), 1070 Brussels, Belgium
| | - Federico Geraldini
- Department of Anesthesia and Intensive Care, Ospedale Università di Padova, 35128 Padova, Italy
| | - Giacomo Coppalini
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center, 20089 Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milano, Italy
| | - Chiara Robba
- Anaesthesia and Intensive Care, IRCCS Policlinico San Martino, 16132 Genova, Italy
- Dipartimento di Scienze Chirurgiche Diagnostiche e Integrate, Università di Genova, 16132 Genova, Italy
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), 1070 Brussels, Belgium
| | - Filippo Annoni
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), 1070 Brussels, Belgium
| | - Eva Vitali
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), 1070 Brussels, Belgium
| | - Elda Diletta Sterchele
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), 1070 Brussels, Belgium
| | - Costantino Balestra
- Department Environmental, Occupational, Aging (Integrative) Physiology Laboratory, Haute Ecole Bruxelles-Brabant (HE2B), 1160 Brussels, Belgium
- Anatomical Research and Clinical Studies, Vrije Universiteit Brussels (VUB), 1090 Brussels, Belgium
- DAN Europe Research Division (Roseto-Brussels), 1160 Brussels, Belgium
- Motor Sciences Department, Physical Activity Teaching Unit, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), 1070 Brussels, Belgium
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11
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Deniz M, Alişik M. Risk factors and prognosis for the development of acute kidney injury in patients using colistin in the intensive care unit: A retrospective cohort study. Medicine (Baltimore) 2024; 103:e36913. [PMID: 38215139 PMCID: PMC10783213 DOI: 10.1097/md.0000000000036913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/19/2023] [Indexed: 01/14/2024] Open
Abstract
Colistin, an antibiotic of polymyxin group, has recently been increasingly used in the treatment of multidrug resistant gram-negative bacteria. However, it has serious adverse effects such as acute kidney injury (AKI). We aimed to determine the factors affecting the development of AKI due to colistin, which has serious adverse effects, such as nephrotoxicity and neurotoxicity. We retrospectively analyzed the data of patients who received colistin for multidrug resistant gram-negative sepsis in adult intensive care units between January 2020 and December 2022. Demographic data, blood test results, concomitant drug use, need for renal replacement therapy, and mortality were recorded. Kidney damage was assessed according to the Kidney Disease Improving Global Outcomes criterion. We obtained data from 103 patients, 45 (43.7%) of whom were women. The most common comorbidity was a neurological disorder. Renal damage developed in 59.2% of patients. Renal replacement was required in 50.8% of the patients. Among patients who received colistin, 64.1% died. The use of vasopressors, diuretics, nephrotoxic agents with colistin, advanced age, and hypoalbuminemia were more common in patients with renal injury. Multivariate regression analysis showed that vasopressor use, prior creatinine elevation, and diuretic use were independent risk factors for colistin-induced AKI. Vasoactive agent use, previous kidney injury, and furosemide use were independent risk factors for colistin-induced nephrotoxicity. Considering these factors may be instructive for better monitoring of patients when colistin is required in intensive care units.
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Affiliation(s)
- Mustafa Deniz
- Intensive Care Unit, Izzet Baysal State Hospital, Bolu, Turkey
| | - Murat Alişik
- Medical Biochemistry, Bolu Abant Izzet Baysal University, Bolu, Turkey
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12
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Kogelmann K, Hübner T, Drüner M, Jarczak D. Impact of CytoSorb Hemoadsorption Therapy on Fluid Balance in Patients with Septic Shock. J Clin Med 2024; 13:294. [PMID: 38202301 PMCID: PMC10779563 DOI: 10.3390/jcm13010294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/20/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
Recent in vitro studies have investigated the effects of hemoadsorption therapy on endothelial function in sepsis showing a reduction in markers of endothelial dysfunction, but, to this day, there are no clinical studies proving whether this approach could actually positively influence the disturbed vascular barrier function in septic conditions. We retrospectively analyzed data on administered fluid volumes and catecholamines in 124 septic shock patients. We collected catecholamine and volume requirements and calculated the volume balance within different time periods to obtain an assumption on the stability of the vascular barrier. Regarding the entire study cohort, our findings revealed a significant reduction in fluid balance at 72 h (T72) compared to both baseline (T0) and the 24 h mark (T24). Fluid balances from T72-T0 were significantly lower in hospital survivors compared with non-survivors. Patients who received a second catecholamine had a significantly lower in-hospital mortality. Our findings suggest that the applied treatment regimen including hemoadsorption therapy is associated with a reduced positive fluid balance paralleled by reductions in vasopressor needs, suggesting a potential positive effect on endothelial integrity. These results, derived from a large cohort of patients, provide valuable insights on the multiple effects of hemoadsorption treatment in septic shock patients.
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Affiliation(s)
- Klaus Kogelmann
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Leer, Augustenstraße 35-37, 26789 Leer, Germany
| | - Tobias Hübner
- Department of Anesthesiology and Intensive Care, Kantonsspital Münsterlingen, Spitalcampus 1, 8596 Münsterlingen, Switzerland;
| | - Matthias Drüner
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Emden, 26721 Emden, Germany;
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
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13
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Peake SL, Delaney A, Finnis M, Hammond N, Knowles S, McDonald S, Williams PJ. Early sepsis in Australia and New Zealand: A point-prevalence study of haemodynamic resuscitation practices. Emerg Med Australas 2023; 35:953-959. [PMID: 37460093 DOI: 10.1111/1742-6723.14283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/04/2023] [Accepted: 06/12/2023] [Indexed: 11/18/2023]
Abstract
OBJECTIVE Optimal resuscitation of sepsis-induced hypotension is uncertain, particularly the role of restrictive fluid strategies, leading to variability in usual practice. The objective of this study is to understand resuscitation practices in patients presenting to ED with early sepsis. METHODS Design, participants and setting: Prospective, observational, multicentre, single-day, point-prevalence study enrolling adult patients present in 51 Australian and New Zealand ICUs at 10.00 hours, 8 June 2021. MAIN OUTCOME MEASURES Site-level data on sepsis policies and patient-level demographic data, presence of sepsis and fluid and vasopressor administration in the first 24 h post-ED presentation. RESULTS A total of 722 patients were enrolled. ED was the ICU admission source for 222 of 722 patients (31.2%) and 78 of 222 patients (35%) met the criteria for sepsis within 24 h of ED presentation. Median age of the sepsis cohort was 61 (48-72) years, 58% were male and respiratory infection was the commonest cause (53.8%). The sepsis cohort had a higher severity of illness than the non-sepsis cohort (144/222 patients) and chronic immunocompromise was more common. Of 78 sepsis patients, 55 (71%) received ≥1 fluid boluses with 500 and 1000 mL boluses equally common (both 49%). In the first 24 h, 2335 (1409-3125) mL (25.3 [13.2-42.9] mL/kg) was administered. Vasopressors were administered in 53 of 78 patients (68%) and for 25 patients (47%) administration was peripheral. CONCLUSIONS ICU patients presenting to the ED with sepsis receive less fluids than current international recommendations and peripheral vasopressor administration is common. This finding supports the conduct of clinical trials evaluating optimal fluid dose and vasopressor timing for early sepsis-induced hypotension.
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Affiliation(s)
- Sandra L Peake
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Anthony Delaney
- School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Critical Care Program, The George Institute for Global Health and The University of New South Wales, Sydney, New South Wales, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Mark Finnis
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Naomi Hammond
- Critical Care Program, The George Institute for Global Health and The University of New South Wales, Sydney, New South Wales, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Serena Knowles
- Critical Care Program, The George Institute for Global Health and The University of New South Wales, Sydney, New South Wales, Australia
| | - Stephen McDonald
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Patricia J Williams
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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14
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Serries M, Zenzen H, Heine M, Holderried T, Brossart P, Schwab K. Evaluation of factors associated with survival in allogeneic stem cell-transplanted patients admitted to the intensive care unit (ICU). Hematology 2023; 28:2256198. [PMID: 37737158 DOI: 10.1080/16078454.2023.2256198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 08/29/2023] [Indexed: 09/23/2023] Open
Abstract
INTRODUCTION There are conflicting results concerning the outcome of patients after an allogeneic hematopoietic stem cell transplantation (allo-HSCT) who required treatment in the intensive care unit (ICU). The aim of this study was to evaluate the outcome and prognostic parameters in terms of patient survival after allo-HSCT and admission to the ICU within the first 30 days after transplantation. METHODS Patients after allo-HSCT, who were ≥18 years and admitted to the ICU after the initiation of conditioning therapy and within the first 30 days after allo-HSCT at the University Hospital of Bonn between January 2017 and April 2021, were analysed retrospectively. Baseline data, laboratory parameters, established scoring systems, vital parameters, and outcome were collected. RESULTS 44 patients (median age of 63 years) were analysed. The 90-day survival rate was 50% (N = 22) and the 1-year survival rate was 27% (N = 12). The 90-day and 1-year survival rates of patients who required MV were 38% (N = 13) and 18% (N = 6). There was a significant correlation between increased mortality and an APACHE-Score ≥20 (p = 0.03), a SAPS-II-Score ≥60 (p = 0.04) and a SOFA-Score ≥9 (p = 0.03). Invasive mechanical ventilation (p = 0.05) and vasopressor support (p = 0.03) showed a negative correlation with the outcome. CONCLUSION This study found several parameters (APACHE-II-Score, SAPS-II-Score, SOFA-Score, MV and vasopressor support) associated with increased mortality after allo-HSCT and admission to the ICU. The outcome of allo-HSCT patients admitted to the ICU is not as poor as previously reported. Even older patients under long-term ventilation may benefit from intensive care therapy.
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Affiliation(s)
- Michael Serries
- Department of Internal Medicine 3, Hematology and Medical Oncology, Centre of Integrated Oncology Aachen-Bonn-Cologne-Duesseldorf, University Hospital of Bonn, Bonn, Germany
| | - Hannah Zenzen
- Department of Internal Medicine 3, Hematology and Medical Oncology, Centre of Integrated Oncology Aachen-Bonn-Cologne-Duesseldorf, University Hospital of Bonn, Bonn, Germany
| | - Mario Heine
- Department of Internal Medicine 3, Hematology and Medical Oncology, Centre of Integrated Oncology Aachen-Bonn-Cologne-Duesseldorf, University Hospital of Bonn, Bonn, Germany
| | - Tobias Holderried
- Department of Internal Medicine 3, Hematology and Medical Oncology, Centre of Integrated Oncology Aachen-Bonn-Cologne-Duesseldorf, University Hospital of Bonn, Bonn, Germany
| | - Peter Brossart
- Department of Internal Medicine 3, Hematology and Medical Oncology, Centre of Integrated Oncology Aachen-Bonn-Cologne-Duesseldorf, University Hospital of Bonn, Bonn, Germany
| | - Katjana Schwab
- Department of Internal Medicine 3, Hematology and Medical Oncology, Centre of Integrated Oncology Aachen-Bonn-Cologne-Duesseldorf, University Hospital of Bonn, Bonn, Germany
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15
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Valencia Morales DJ, Garbajs NZ, Tawfic SS, Jose T, Laporta ML, Schroeder DR, Weingarten TN, Sprung J. Intraoperative Blood Pressure Variability and Early Postoperative Stroke: A Case-Control Study. Am Surg 2023; 89:5191-5200. [PMID: 36426383 DOI: 10.1177/00031348221136578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND This study aims to assess the association of postoperative stroke with intraoperative hemodynamic variability and transfusion management. METHODS In this case-control study, adult patients (≥ 18 years) who had a stroke within 72 hours of a surgical procedure were matched to 2 control patients according to age, sex, and procedure type. Primary risk factors assessed were intraoperative fluid administration, blood product transfusion, vasopressor use, and measures of variability in systolic and diastolic blood pressure and heart rate: maximum, minimum, range, SD, and average real variability. The variables were analyzed with conditional logistic regression, which accounted for the 1:2 matched case-control study design. RESULTS Among 687 581 procedures, we identified 64 postoperative strokes (incidence, 9.3 [95% CI, 7.2-11.9] strokes per 100 000 procedures). These cases were matched with 128 controls. Stroke cases had higher Charlson cmorbidity index scores than did controls (P = .046). Blood pressure and heart rate variability measures were not associated with stroke. The risk of stroke was increased with red blood cell (RBC) transfusion (odds ratio [OR], 14.82; 95% CI, 3.40-64.66; P < .001), vasopressor use (OR, 3.91; 95% CI, 1.59-9.60; P = .003), and longer procedure duration (OR, 1.23/h; 95% CI, 1.01-1.51; P = .04). Multivariable analysis of procedure duration, RBC transfusion, and vasopressor use showed that only RBC transfusion was independently associated with an increased risk of stroke (OR, 10.10; 95% CI, 2.14-47.72; P = .004). CONCLUSIONS Blood pressure variability was not associated with an increased risk of postoperative stroke; however, RBC transfusion was an independent risk factor.
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Affiliation(s)
| | - Nika Zorko Garbajs
- Department of Vascular Neurology and Intensive Therapy, University Medical Centre, Ljubljana, Slovenia
| | - Sarah S Tawfic
- Department of Internal Medicine, Mayo Clinic Rochester, Minnesota
| | - Thulasee Jose
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mariana L Laporta
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Darrell R Schroeder
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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Sacha GL, Bauer SR. Optimizing Vasopressin Use and Initiation Timing in Septic Shock: A Narrative Review. Chest 2023; 164:1216-1227. [PMID: 37479058 PMCID: PMC10635838 DOI: 10.1016/j.chest.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 07/23/2023] Open
Abstract
TOPIC IMPORTANCE This review discusses the rationale for vasopressin use, summarizes the results of clinical trials evaluating vasopressin, and focuses on the timing of vasopressin initiation to provide clinicians guidance for optimal adjunctive vasopressin initiation in patients with septic shock. REVIEW FINDINGS Patients with septic shock require vasoactive agents to restore adequate tissue perfusion. After norepinephrine, vasopressin is the suggested second-line adjunctive agent in patients with persistent inadequate mean arterial pressure. Vasopressin use in practice is heterogeneous likely because of inconsistent clinical trial findings, the lack of specific recommendations for when it should be used, and the high drug acquisition cost. Despite these limitations, vasopressin has demonstrated price inelastic demand, and its use in the United States has continued to increase. However, questions remain regarding optimal vasopressin use in patients with septic shock, particularly regarding patient selection and the timing of vasopressin initiation. SUMMARY Experimental studies evaluating the initiation timing of vasopressin in patients with septic shock are limited, and recent observational studies have revealed an association between vasopressin initiation at lower norepinephrine-equivalent doses or lower lactate concentrations and lower mortality.
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Affiliation(s)
- Gretchen L Sacha
- Department of Pharmacy, Cleveland Clinic, Case Western Reserve University, Cleveland, OH.
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Case Western Reserve University, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
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Douglas N, Leslie K, Darvall JN. Vasopressors to treat postoperative hypotension after adult noncardiac, non-obstetric surgery: a systematic review. Br J Anaesth 2023; 131:813-822. [PMID: 37778937 DOI: 10.1016/j.bja.2023.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/31/2023] [Accepted: 08/08/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Postoperative hypotension is common after major surgery and is associated with patient harm. Vasopressors are commonly used to treat hypotension without clear evidence of benefit. We conducted a systematic review to better understand the use, impact, and rationale for vasopressor administration after noncardiac, non-obstetric surgery in adults. METHODS We conducted a prospectively registered systematic review. Cochrane CENTRAL, EMBASE, MEDBASE, and MEDLINE were searched for RCTs and cohort studies of adult patients receiving vasopressors after noncardiac, non-obstetric surgery. Study quality was critically appraised by two investigators. Findings from the review were synthesised, but formal meta-analysis was not performed because of significant variability in study populations and outcomes. RESULTS A total of 3201 articles were screened, of which seven RCTs, two prospective cohort studies, and 15 retrospective cohort studies were included in the analysis (24 in total). One study was graded as high quality, two as moderate quality, and the remaining 21 as low quality. Sixteen studies relied on clinical assessment alone to decide on therapeutic interventions. Vasodilation was the most common suggested physiological disturbance. The median proportion of patients receiving vasopressors was 42% (interquartile range: 11.5-74.7%). Norepinephrine was the most common vasopressor used. CONCLUSIONS The evidence supporting the use of vasopressors to treat postoperative hypotension is limited. Future research should focus on whether vasodilatation or other physiological disturbance is driving postoperative hypotension to allow rational decision-making.
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Affiliation(s)
- Ned Douglas
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia.
| | - Kate Leslie
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia
| | - Jai N Darvall
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia
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Bottari G, Guzzo I, Cappoli A, Labbadia R, Perdichizzi S, Serpe C, Creteur J, Cecchetti C, Taccone FS. Impact of CytoSorb and CKRT on hemodynamics in pediatric patients with septic shock: the PedCyto study. Front Pediatr 2023; 11:1259384. [PMID: 37780052 PMCID: PMC10540853 DOI: 10.3389/fped.2023.1259384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 08/21/2023] [Indexed: 10/03/2023] Open
Abstract
Background There is a lack of data to support the use of hemoadsorption in pediatric septic shock. The aim of our study was to assess the effectiveness and safety of CytoSorb therapy in this setting. Methods Phase II interventional single arm pilot study in which 17 consecutive children admitted with septic shock who required continuous kidney replacement therapy (CKRT) and weighed ≥10 kg were included. A CytoSorb (CytoSorbents Inc, New Jersey, USA) hemoadsorption cartridge was added to the CKRT every 24 h for a maximum of 96 h. A control group of 13 children with septic shock treated with CKRT but not hemoadsorption at Children's Hospital Bambino Gesù and enrolled in the EuroAKId register was selected as an historical cohort. The primary outcome of the study was a reduction in vasopressor or inotrope dose of >50% from baseline by the end of CytoSorb therapy. Secondary outcomes included hemodynamic and biological changes, changes in severity scores, and 28-day mortality. Results There were significant decreases in the Vasoactive Inotropic Score (VIS) and the Pediatric Logistic Organ Dysfunction 2 (PELOD-2) score at 72 and 96 h from the start of the CytoSorb therapy compared to baseline; the reductions were larger in the hemoadsorption group than in the control group (historical cohort). 28-day mortality was lower, although not significantly, in the hemoadsorption group when compared to the control group (5/17 [29%] vs. 8/13 [61%] OR 0.26 [95% CI: 0.05-1.2]; p = 0.08). Conclusions CytoSorb therapy may have some benefits in pediatric patients with septic shock. Future larger randomized trials are needed in this setting. Clinical Trial Registration https://clinicaltrials.gov/ct2/show/NCT05658588, identifier (Clinicaltrials.gov NCT05658588).
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Affiliation(s)
- Gabriella Bottari
- Pediatric Emergency Department, Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Isabella Guzzo
- Department of Pediatrics, Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Andrea Cappoli
- Department of Pediatrics, Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Raffaella Labbadia
- Department of Pediatrics, Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Salvatore Perdichizzi
- Pediatric Emergency Department, Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Carmela Serpe
- Pediatric Emergency Department, Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Jacques Creteur
- Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Corrado Cecchetti
- Pediatric Emergency Department, Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
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Kamath S, Hammad Altaq H, Abdo T. Management of Sepsis and Septic Shock: What Have We Learned in the Last Two Decades? Microorganisms 2023; 11:2231. [PMID: 37764075 PMCID: PMC10537306 DOI: 10.3390/microorganisms11092231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/20/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
Sepsis is a clinical syndrome encompassing physiologic and biological abnormalities caused by a dysregulated host response to infection. Sepsis progression into septic shock is associated with a dramatic increase in mortality, hence the importance of early identification and treatment. Over the last two decades, the definition of sepsis has evolved to improve early sepsis recognition and screening, standardize the terms used to describe sepsis and highlight its association with organ dysfunction and higher mortality. The early 2000s witnessed the birth of early goal-directed therapy (EGDT), which showed a dramatic reduction in mortality leading to its wide adoption, and the surviving sepsis campaign (SSC), which has been instrumental in developing and updating sepsis guidelines over the last 20 years. Outside of early fluid resuscitation and antibiotic therapy, sepsis management has transitioned to a less aggressive approach over the last few years, shying away from routine mixed venous oxygen saturation and central venous pressure monitoring and excessive fluids resuscitation, inotropes use, and red blood cell transfusions. Peripheral vasopressor use was deemed safe and is rising, and resuscitation with balanced crystalloids and a restrictive fluid strategy was explored. This review will address some of sepsis management's most important yet controversial components and summarize the available evidence from the last two decades.
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Affiliation(s)
| | | | - Tony Abdo
- Section of Pulmonary, Critical Care and Sleep Medicine, The University of Oklahoma Health Sciences Center, The Oklahoma City VA Health Care System, Oklahoma City, OK 73104, USA; (S.K.); (H.H.A.)
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Asher E, Karameh H, Nassar H, Yosefy C, Marmor D, Perel N, Taha L, Tabi M, Braver O, Shuvy M, Wiener-Well Y, Glikson M, Bruoha S. Safety and Outcomes of Peripherally Administered Vasopressor Infusion in Patients Admitted with Shock to an Intensive Cardiac Care Unit-A Single-Center Prospective Study. J Clin Med 2023; 12:5734. [PMID: 37685801 PMCID: PMC10488618 DOI: 10.3390/jcm12175734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/23/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Vasopressors are frequently utilized for blood pressure stabilization in patients with cardiogenic shock (CS), although with a questionable benefit. Obtaining central venous access is time consuming and may be associated with serious complications. Hence, we thought to evaluate whether the administration of vasopressors through a peripheral venous catheter (PVC) is a safe and effective alternative for the management of patients with CS presenting to the intensive cardiovascular care unit (ICCU). METHODS A prospective single-center study was conducted to compare the safety and outcomes of vasopressors administered via a PVC vs. a central venous catheter (CVC) in patients presenting with CS over a 12-month period. RESULTS A total of 1100 patients were included; of them, 139 (12.6%) required a vasopressor treatment due to shock, with 108 (78%) treated via a PVC and 31 (22%) treated via a CVC according to the discretion of the treating physician. The duration of the vasopressor administration was shorter in the PVC group compared with the CVC group (2.5 days vs. 4.2 days, respectively, p < 0.05). Phlebitis and the extravasation of vasopressors occurred at similar rates in the PVC and CVC groups (5.7% vs. 3.3%, respectively, p = 0.33; 0.9% vs. 3.3%, respectively, p = 0.17). Nevertheless, the bleeding rate was higher in the CVC group compared with the PVC group (3% vs. 0%, p = 0.03). CONCLUSIONS The administration of vasopressor infusions via PVC for the management of patients with CS is feasible and safe in patients with cardiogenic shock. Further studies are needed to establish this method of treatment.
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Affiliation(s)
- Elad Asher
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Hani Karameh
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Hamed Nassar
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Chaim Yosefy
- Department of Cardiology, Barzilai Medical Center, The Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel; (C.Y.); (O.B.)
| | - David Marmor
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Nimrod Perel
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Louay Taha
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Meir Tabi
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Omri Braver
- Department of Cardiology, Barzilai Medical Center, The Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel; (C.Y.); (O.B.)
| | - Mony Shuvy
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Yonit Wiener-Well
- Infectious Diseases Unit, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel;
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Sharon Bruoha
- Department of Cardiology, Barzilai Medical Center, The Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel; (C.Y.); (O.B.)
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Baykuziyev T, Khan MJ, Karmakar A, Baloch MA. Closed-Loop Pharmacologic Control of Blood Pressure: A Review of Existing Systems. Cureus 2023; 15:e45188. [PMID: 37842385 PMCID: PMC10576018 DOI: 10.7759/cureus.45188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 10/17/2023] Open
Abstract
Blood pressure management is a critical aspect of patient care, particularly in surgical and critical care settings. Closed-loop systems, which utilize real-time data and feedback to adjust treatment interventions, have gained attention for their potential to enhance blood pressure control. This review explores the application of closed-loop systems in blood pressure management. We discuss various closed-loop approaches, including their mechanisms, benefits, and limitations. By harnessing real-time patient data and feedback, closed-loop systems can tailor interventions dynamically, thus enhancing blood pressure regulation. Additionally, we examine the integration of advanced monitoring technologies and artificial intelligence algorithms in closed-loop systems. The review highlights recent studies and their findings, emphasizing the evolving landscape of closed-loop blood pressure management across different clinical scenarios. From the perioperative period to critical care settings, closed-loop systems hold the potential to optimize patient outcomes by precisely adjusting vasopressor administration in response to continuous blood pressure fluctuations. By providing insights into the current state of closed-loop systems for blood pressure control, this review offers a comprehensive overview of their potential contributions to improved patient outcomes and future directions for research and implementation.
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Affiliation(s)
- Temur Baykuziyev
- Anesthesiology and Critical Care, Hamad Medical Corporation, Doha, QAT
| | | | - Arunabha Karmakar
- Anesthesiology and Critical Care, Hamad Medical Corporation, Doha, QAT
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Sharpe AR, Richardson K, Stanton M, Dang C, Feih J, Brazauskas R, Teng BQ, Feldman R. Lack of Association of Initial Vasopressor Dosing with Survival and Cardiac Re-Arrest Likelihood After Return of Spontaneous Circulation. J Emerg Med 2023; 65:e209-e220. [PMID: 37635036 DOI: 10.1016/j.jemermed.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 04/26/2023] [Accepted: 05/26/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Cardiac arrest occurs in approximately 350,000 patients outside the hospital and approximately 30,000 patients in the emergency department (ED) annually in the United States. When return of spontaneous circulation (ROSC) is achieved, hypotension is a common complication. However, optimal dosing of vasopressors is not clear. OBJECTIVE The objective of this study was to determine if initial vasopressor dosing was associated with cardiac re-arrest in patients after ROSC. METHODS This was a retrospective, single-center analysis of adult patients experiencing cardiac arrest prior to arrival or within the ED. Patients were assigned to one of four groups based on starting dose of vasopressor: low dose (LD; < 0.25 µg/kg/min), medium dose (MD; 0.25-0.49 µg/kg/min), high dose (HD; 0.5-0.99 µg/kg/min), and very high dose (VHD; ≥ 1 µg/kg/min). Data collection was performed primarily via manual chart review of medical records. The primary outcome was incidence of cardiac re-arrest within 1 h of vasopressor initiation. Multivariate logistic regression analysis was conducted to identify any covariates strongly associated with the primary outcome. RESULTS No difference in cardiac re-arrest incidence was noted between groups. The VHD group was significantly more likely to require a second vasopressor (p = 0.003). The HD group had lower survival rates to hospital discharge compared with the LD and MD groups (p = 0.0033 and p = 0.0147). In the multivariate regression, longer duration of pre-vasopressor re-arrests and hyperkalemic cardiac arrest etiology were significant predictors of cardiac re-arrest after vasopressor initiation. CONCLUSIONS Initial vasopressor dosing was not found to be associated with risk of cardiac re-arrest or, conversely, risk of adverse events.
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Affiliation(s)
- Abigail R Sharpe
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kelly Richardson
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Matthew Stanton
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cathyyen Dang
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jessica Feih
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ruta Brazauskas
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Bi Qing Teng
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ryan Feldman
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin
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Shields AD, Plante LA, Pacheco LD, Louis JM. Society for Maternal-Fetal Medicine Consult Series #67: Maternal sepsis. Am J Obstet Gynecol 2023; 229:B2-B19. [PMID: 37236495 DOI: 10.1016/j.ajog.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Maternal sepsis is a significant cause of maternal morbidity and mortality, and is a potentially preventable cause of maternal death. This Consult aims to summarize what is known about sepsis and provide guidance for the management of sepsis during pregnancy and the postpartum period. Most studies cited are from the nonpregnant population, but where available, pregnancy data are included. The following are the Society for Maternal-Fetal Medicine recommendations: (1) we recommend that clinicians consider the diagnosis of sepsis in pregnant or postpartum patients with otherwise unexplained end-organ damage in the presence of a suspected or confirmed infectious process, regardless of the presence of fever (GRADE 1C); (2) we recommend that sepsis and septic shock in pregnancy be considered medical emergencies and that treatment and resuscitation begin immediately (Best Practice); (3) we recommend that hospitals and health systems use a performance improvement program for sepsis in pregnancy with sepsis screening tools and metrics (GRADE 1B); (4) we recommend that institutions develop their own procedures and protocols for the detection of maternal sepsis, avoiding the use of a single screening tool alone (GRADE 1B); (5) we recommend obtaining tests to evaluate for infectious and noninfectious causes of life-threatening organ dysfunction in pregnant and postpartum patients with possible sepsis (Best Practice); (6) we recommend that an evaluation for infectious causes in pregnant or postpartum patients in whom sepsis is suspected or identified includes appropriate microbiologic cultures, including blood, before starting antimicrobial therapy, as long as there are no substantial delays in timely administration of antibiotics (Best Practice); (7) we recommend obtaining a serum lactate level in pregnant or postpartum patients in whom sepsis is suspected or identified (GRADE 1B); (8) in pregnant or postpartum patients with septic shock or a high likelihood of sepsis, we recommend administration of empiric broad-spectrum antimicrobial therapy, ideally within 1 hour of recognition (GRADE 1C); (9) after a diagnosis of sepsis in pregnancy is made, we recommend rapid identification or exclusion of an anatomic source of infection and emergency source control when indicated (Best Practice); (10) we recommend early intravenous administration (within the first 3 hours) of 1 to 2 L of balanced crystalloid solutions in sepsis complicated by hypotension or suspected organ hypoperfusion (GRADE 1C); (11) we recommend the use of a balanced crystalloid solution as a first-line fluid for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1B); (12) we recommend against the use of starches or gelatin for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1A); (13) we recommend ongoing, detailed evaluation of the patient's response to fluid resuscitation guided by dynamic measures of preload (GRADE 1B); (14) we recommend the use of norepinephrine as the first-line vasopressor during pregnancy and the postpartum period with septic shock (GRADE 1C); (15) we suggest using intravenous corticosteroids in pregnant or postpartum patients with septic shock who continue to require vasopressor therapy (GRADE 2B); (16) because of an increased risk of venous thromboembolism in sepsis and septic shock, we recommend the use of pharmacologic venous thromboembolism prophylaxis in pregnant and postpartum patients in septic shock (GRADE 1B); (17) we suggest initiating insulin therapy at a glucose level >180 mg/dL in critically ill pregnant patients with sepsis (GRADE 2C); (18) if a uterine source for sepsis is suspected or confirmed, we recommend prompt delivery or evacuation of uterine contents to achieve source control, regardless of gestational age (GRADE 1C); and (19) because of an increased risk of physical, cognitive, and emotional problems in survivors of sepsis and septic shock, we recommend ongoing comprehensive support for pregnant and postpartum sepsis survivors and their families (Best Practice).
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Elamin A, Sinan L, Tari SPH, Ahmad BI. Analysis of Variables Influencing Short-Term Complications in Geriatric Patients Undergoing Emergency General Surgery (EGS): A Retrospective Cohort Study. Cureus 2023; 15:e44031. [PMID: 37746435 PMCID: PMC10517432 DOI: 10.7759/cureus.44031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Emergency general surgery (EGS) encompasses a wide range of acute surgical conditions that pose significant risks to patient life and well-being. Understanding the factors that contribute to short-term complications in geriatric patients undergoing EGS is crucial for improving patient outcomes. This retrospective single-center cohort study aimed to evaluate the impact of various variables on short-term complications in geriatric patients undergoing EGS. METHODS A total of 212 patients aged 65 and above who underwent emergency abdominal surgery between 2017 and 2018 were included in the study. The analysis focused on several variables, including age, sex, body mass index (BMI), beta-blocker use, open abdomen treatment, blood transfusions, anticoagulant therapy, and vasopressor use. Univariate and multivariate analyses were conducted to assess the association between these variables and short-term complications. RESULTS Among the analyzed variables, blood transfusions and vasopressor use demonstrated a statistically significant association with short-term complications. Patients who received blood transfusions had a significantly higher risk of complications, with an odds ratio (OR) of 3.01 (95% confidence interval, CI: 1.28-7.06, p-value = 0.011). Similarly, the use of vasopressors was strongly correlated with increased short-term complications, with an OR of 14.61 (95% CI: 4.86-43.89, p-value < 0.001). CONCLUSION These findings emphasize the importance of minimizing blood transfusions and careful consideration of vasopressor use in geriatric patients undergoing EGS to reduce the risk of short-term complications. Further research is warranted to explore additional factors and optimize perioperative management strategies to improve outcomes in this vulnerable patient population.
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Affiliation(s)
- Abubaker Elamin
- General Surgery, Humanitas University, Milan, ITA
- Otolaryngology, Nottingham University Hospitals, Nottingham, GBR
| | - Laith Sinan
- Orthopaedic Surgery, Nottingham University Hospitals, Nottingham, GBR
| | | | - Bilal I Ahmad
- Orthopaedic Surgery, United Lincolnshire Hospitals, Lincoln, GBR
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Ratnani I, Ochani RK, Shaikh A, Jatoi HN. Vasoplegia: A Review. Methodist Debakey Cardiovasc J 2023; 19:38-47. [PMID: 37547893 PMCID: PMC10402787 DOI: 10.14797/mdcvj.1245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 05/03/2023] [Indexed: 08/08/2023] Open
Abstract
Vasoplegia is a condition characterized by persistent low systemic vascular resistance despite a normal or high cardiac index, resulting in profound and uncontrolled vasodilation. Vasoplegia may occur due to various conditions, including cardiac failure, sepsis, and post-cardiac surgery. In the cardiac cohort, multiple risk factors for vasoplegia have been identified. Several factors contribute to the pathophysiology of this condition, and various mechanisms have been proposed, including nitric oxide, adenosine, prostanoids, endothelins, the renin-angiotensin-aldosterone system, and hydrogen sulfide. Early identification and prompt management of vasoplegia is crucial to prevent development of shock. This review expands upon the different vasopressors used in management of vasoplegia, including catecholamines such as norepinephrine, dopamine, epinephrine, phenylephrine, and other agents including vasopressin, methylene blue, angiotensin II, hydroxocobalamin, vitamin C, thiamine, and corticosteroids (ie, hydrocortisone). It also emphasizes the importance of conducting further research and making advancements in treatment regimens for vasoplegia.
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Affiliation(s)
- Iqbal Ratnani
- Methodist DeBakey Heart & Vascular Center, Houston Methodist, Houston, Texas, US
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Hamzaoui O, Goury A, Teboul JL. The Eight Unanswered and Answered Questions about the Use of Vasopressors in Septic Shock. J Clin Med 2023; 12:4589. [PMID: 37510705 PMCID: PMC10380663 DOI: 10.3390/jcm12144589] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/05/2023] [Accepted: 07/08/2023] [Indexed: 07/30/2023] Open
Abstract
Septic shock is mainly characterized-in addition to hypovolemia-by vasoplegia as a consequence of a release of inflammatory mediators. Systemic vasodilatation due to depressed vascular tone results in arterial hypotension, which induces or worsens organ hypoperfusion. Accordingly, vasopressor therapy is mandatory to correct hypotension and to reverse organ perfusion due to hypotension. Currently, two vasopressors are recommended to be used, norepinephrine and vasopressin. Norepinephrine, an α1-agonist agent, is the first-line vasopressor. Vasopressin is suggested to be added to norepinephrine in cases of inadequate mean arterial pressure instead of escalating the doses of norepinephrine. However, some questions about the bedside use of these vasopressors remain. Some of these questions have been well answered, some of them not clearly addressed, and some others not yet answered. Regarding norepinephrine, we firstly reviewed the arguments in favor of the choice of norepinephrine as a first-line vasopressor. Secondly, we detailed the arguments found in the recent literature in favor of an early introduction of norepinephrine. Thirdly, we reviewed the literature referring to the issue of titrating the doses of norepinephrine using an individualized resuscitation target, and finally, we addressed the issue of escalation of doses in case of refractory shock, a remaining unanswered question. For vasopressin, we reviewed the rationale for adding vasopressin to norepinephrine. Then, we discussed the optimal time for vasopressin administration. Subsequently, we addressed the issue of the optimal vasopressin dose, and finally we discussed the best strategy to wean these two vasopressors when combined.
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Affiliation(s)
- Olfa Hamzaoui
- Service de Médecine intensive réanimation polyvalente, Hôpital Robert Debré, CHU de Reims Université de Reims, 51092 Reims, France
- "Hémostase et Remodelage Vasculaire Post-Ischémie"-EA 3801, Unité HERVI, 51100 Reims, France
| | - Antoine Goury
- Service de Médecine intensive réanimation polyvalente, Hôpital Robert Debré, CHU de Reims Université de Reims, 51092 Reims, France
| | - Jean-Louis Teboul
- Service de médecine intensive-réanimation, Hôpital de Bicêtre, AP-HP, Université Paris-Saclay, DMU CORREVE, FHU SEPSIS, 94270 Le Kremlin-Bicêtre, France
- INSERM-UMR_S999 LabEx-LERMIT, Hôpital Marie-Lannelongue, 92350 Le Plessis Robinson, France
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Arfaras-Melainis A, Ventoulis I, Polyzogopoulou E, Boultadakis A, Parissis J. The current and future status of inotropes in heart failure management. Expert Rev Cardiovasc Ther 2023; 21:573-585. [PMID: 37458248 DOI: 10.1080/14779072.2023.2237869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 07/08/2023] [Accepted: 07/14/2023] [Indexed: 07/25/2023]
Abstract
INTRODUCTION Heart failure (HF) is a complex syndrome with a wide range of presentations and acuity, ranging from outpatient care to inpatient management due to acute decompensated HF, cardiogenic shock or advanced HF. Frequently, the etiology of a patient's decompensation is diminished cardiac output and peripheral hypoperfusion. Consequently, there is a need for use of inotropes, agents that increase cardiac contractility, optimize hemodynamics and ensure adequate perfusion. AREAS COVERED Inotropes are divided into 3 major classes: beta agonists, phosphodiesterase III inhibitors and calcium sensitizers. Additionally, as data from prospective studies accumulates, novel agents are emerging, including omecamtiv mecarbil and istaroxime. The aim of this review is to summarize current data on the optimal use of inotropes and to provide an expert opinion regarding their current and future use in the management of HF. EXPERT OPINION The use of inotropes has long been linked to worsening mortality, tachyarrhythmias, increased myocardial oxygen consumption and ischemia. Therefore, individualized and evidence-based treatment plans for patients who require inotropic support are necessary. Also, better quality data on the use of existing inotropes is imperative, while the development of newer and safer agents will lead to more effective management of patients with HF in the future.
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Affiliation(s)
- Angelos Arfaras-Melainis
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ioannis Ventoulis
- Department of Occupational Therapy, University of Western Macedonia, Ptolemaida, Greece
| | - Effie Polyzogopoulou
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonios Boultadakis
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - John Parissis
- Emergency Department, Heart Failure Unit, Attikon University Hospital, Athens, Greece
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Ayasa LA, Azar J, Odeh A, Ayyad M, Shbaita S, Zidan T, Awwad NAD, Kawa NM, Awad W. Hydroxocobalamin as Rescue Therapy in a Patient With Refractory Amlodipine-Induced Vasoplegia. Cureus 2023; 15:e38400. [PMID: 37265888 PMCID: PMC10231868 DOI: 10.7759/cureus.38400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2023] [Indexed: 06/03/2023] Open
Abstract
Vasoplegic syndrome is a type of distributive shock characterized by mean arterial pressure of less than 65 mmHg, with normal to high cardiac output and often refractory to fluid resuscitation, high doses of intravenous vasopressors, and inotropes. It is usually observed after cardiac and solid organ transplantation surgeries. Here, we report a 56-year-old female patient who presented with a profound vasoplegia manifesting as lethargy and confusion in the setting of amlodipine toxicity. This case of severe vasoplegia was refractory to all conditional lines of medical management reported in the literature. The mainstay treatment modalities for vasoplegia include volume resuscitation, catecholamines, vasopressin, angiotensin II, and possibly methylene blue in unresponsive cases. Our patient was given hydroxocobalamin in favor of methylene blue, given the history of serotonin reuptake inhibitors use, which would have caused a life-threatening serotonin syndrome. Hydroxycobolamine resulted in a dramatic clinical recovery, suggesting its potentially significant role in refractory vasoplegia.
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Affiliation(s)
- Laith A Ayasa
- Internal Medicine, Al-Quds University, Jerusalem, PSE
| | - Jehad Azar
- Respiratory Institute, Cleveland Clinic, Cleveland, USA
| | - Anas Odeh
- Faculty of Medicine, An Najah National University, Nablus, PSE
| | | | - Sara Shbaita
- Faculty of Medicine, An Najah National University, Nablus, PSE
| | - Thabet Zidan
- Faculty of Medicine, An Najah National University, Nablus, PSE
| | | | - Nagham M Kawa
- Faculty of Medicine, An Najah National University, Nablus, PSE
| | - Wafaa Awad
- Pediatrics, Al Makassed Hospital, Jerusalem, PSE
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Rietjens SJ, van Riemsdijk TE, Sikma MA, de Lange DW. High-dose insulin should NOT be used without vasopressors in calcium channel blocker toxicity. Br J Clin Pharmacol 2023; 89:1275-1278. [PMID: 36604782 DOI: 10.1111/bcp.15642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/05/2022] [Indexed: 01/07/2023] Open
Affiliation(s)
- Saskia J Rietjens
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Tessa E van Riemsdijk
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Maaike A Sikma
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands.,Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Dylan W de Lange
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands.,Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Agarwal N, Blitstein J, Lui A, Torres-Espin A, Vasnarungruengkul C, Burke J, Mummaneni PV, Dhall SS, Weinstein PR, Duong-Fernandez X, Chou A, Pan J, Singh V, Ferguson AR, Hemmerle DD, Kyritsis N, Talbott JF, Whetstone WD, Bresnahan JC, Beattie MS, Manley GT, DiGiorgio A. Hypotension requiring vasopressor treatment and increased cardiac complications in elderly spinal cord injury patients: a prospective TRACK-SCI registry study. J Neurosurg Spine 2023:1-9. [PMID: 36933260 DOI: 10.3171/2023.2.spine221043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/10/2023] [Indexed: 03/19/2023]
Abstract
OBJECTIVE Increasing life expectancy has led to an older population. In this study, the authors analyzed complications and outcomes in elderly patients following spinal cord injury (SCI) using the established multi-institutional prospective study Transforming Research and Clinical Knowledge in SCI (TRACK-SCI) database collected in the Department of Neurosurgical Surgery at the University of California, San Francisco. METHODS TRACK-SCI was queried for elderly individuals (≥ 65 years of age) with traumatic SCI from 2015 to 2019. Primary outcomes of interest included total hospital length of stay, perioperative complications, postoperative complications, and in-hospital mortality. Secondary outcomes included disposition location, and neurological improvement based on the American Spinal Injury Association Impairment Scale (AIS) grade at discharge. Descriptive analysis, Fisher's exact test, univariate analysis, and multivariable regression analysis were performed. RESULTS The study cohort consisted of 40 elderly patients. The in-hospital mortality rate was 10%. Every patient in this cohort experienced at least 1 complication, with a mean of 6.6 separate complications (median 6, mode 4). The most common complication categories were cardiovascular, with a mean of 1.6 complications (median 1, mode 1), and pulmonary, with a mean of 1.3 (median 1, mode 0) complications, with 35 patients (87.5%) having at least 1 cardiovascular complication and 25 (62.5%) having at least 1 pulmonary complication. Overall, 32 patients (80%) required vasopressor treatment for mean arterial pressure (MAP) maintenance goals. The use of norepinephrine correlated with increased cardiovascular complications. Only 3 patients (7.5%) of the total cohort had an improved AIS grade compared with their acute level at admission. CONCLUSIONS Given the increased frequency of cardiovascular complications associated with vasopressor use in elderly SCI patients, caution is warranted when targeting MAP goals in these patients. A downward adjustment of blood pressure maintenance goals and prophylactic cardiology consultation to select the most appropriate vasopressor agent may be advisable for SCI patients ≥ 65 years of age.
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Affiliation(s)
| | - Jacob Blitstein
- 2College of Osteopathic Medicine, Touro University California, Vallejo
| | - Austin Lui
- 2College of Osteopathic Medicine, Touro University California, Vallejo
| | - Abel Torres-Espin
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | | | | | - Praveen V Mummaneni
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Sanjay S Dhall
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Philip R Weinstein
- 1Departments of Neurological Surgery.,5Radiology and Biomedical Imaging.,6Neurology
| | - Xuan Duong-Fernandez
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Austin Chou
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Jonathan Pan
- 1Departments of Neurological Surgery.,7Anesthesia and Perioperative Care, and
| | | | - Adam R Ferguson
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco.,8San Francisco Veterans Affairs Healthcare System, San Francisco, California; and
| | - Debra D Hemmerle
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Nikos Kyritsis
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Jason F Talbott
- 4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco.,5Radiology and Biomedical Imaging
| | | | - Jacqueline C Bresnahan
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Michael S Beattie
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco.,8San Francisco Veterans Affairs Healthcare System, San Francisco, California; and
| | - Geoffrey T Manley
- 1Departments of Neurological Surgery.,10Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - Anthony DiGiorgio
- 1Departments of Neurological Surgery.,3Weill Institute for Neurosciences, Brain and Spinal Injury Center, University of California, San Francisco.,4Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco.,10Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
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Kim DD, DeSnyder SM, Dougherty PM, Cata JP. Effect of neoadjuvant chemotherapy on intraoperative core temperature in patients with breast cancer: a retrospective cohort study. BJA Open 2023; 5:100119. [PMID: 37587989 PMCID: PMC10430839 DOI: 10.1016/j.bjao.2022.100119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 12/06/2022] [Accepted: 12/12/2022] [Indexed: 08/18/2023]
Abstract
Background Clinical evidence suggests that chemotherapeutic agents are associated with neuropathy and peripheral autonomic dysfunction. However, the possible effects of neoadjuvant chemotherapy on intraoperative temperature remain poorly characterised. Methods We evaluated patients who underwent a mastectomy for breast cancer between April 2016 and July 2020. Propensity scores were used to match patients who received neoadjuvant chemotherapy with those who did not, and intraoperative core temperature patterns were analysed in the matched cohort. The independent associations between vasopressor use and heart rate during general anaesthesia in the matched cohort were also analysed. Results Data from 1764 patients were analysed (882 patients in each group). Both groups presented a similar pattern of heat redistribution and subsequent rewarming; however, the neoadjuvant chemotherapy group did not reach the same intraoperative plateau temperature as the group that did not receive prior chemotherapy, with differences of up to 0.4°C (95% confidence interval: 0.11-0.63°C; P=0.005). In a subgroup analysis, neuropathy in patients who received neoadjuvant chemotherapy was associated with increased use of vasopressors and higher heart rate. Conclusions In patients with breast cancer, neoadjuvant chemotherapy is associated with lower plateau core temperatures, increased vasopressor use, and higher heart rates during general anaesthesia, which is more severe in the presence of neuropathy.
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Affiliation(s)
- Daniel D. Kim
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Sarah M. DeSnyder
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patrick M. Dougherty
- Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Juan P. Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
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Schmitt CJ, Mattson AE, Brown CS, Mara KC, Cabrera D, Sandefur BJ, Wieruszewski ED. The incidence of cardiovascular instability in patients receiving various vasopressor strategies for peri-intubation hypotension. Am J Emerg Med 2023; 65:104-108. [PMID: 36603354 DOI: 10.1016/j.ajem.2022.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/10/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Patients frequently experience hypotension in the peri-intubation period. This can be due to the underlying disease process, physiologic response to the intervention, or adverse effect from medications. With the heterogeneity in cause for hypotension, the duration can also be short or prolonged. Initiation of vasopressors for peri-intubation hypotension includes various strategies using continuous infusion norepinephrine (NE) or push-dose phenylephrine (PDPE) to obtain goal mean arterial pressure. There is a paucity of data describing cardiovascular stability outcomes in patients receiving vasopressors for peri-intubation hypotension. METHODS This is a retrospective cohort study including emergency department patients across three academic medical centers and smaller health system sites who received vasopressors for hypotension within 30 min of intubation. Patients were matched based on factors likely to influence vasopressor selection and were divided into groups if they received PDPE alone, continuous infusion NE alone, or PDPE followed by continuous infusion NE. The primary outcome was a composite of the incidence of hypotension (systolic blood pressure < 90 mmHg), bradycardia (HR < 60 beats per minute), and cardiac arrest within 2 h following initiation of vasopressors. RESULTS Screening occurred for 2518 patients, with 105 patients undergoing matching. Mean time to vasopressor initiation was 10 min following intubation. The composite primary outcome was not statistically different between groups and occurred 88.6%, 80.0%, and 88.6% in the NE, PDPE, and PDPE+NE groups, respectively. A subgroup analysis of patients with an ED diagnosis of sepsis or septic shock were more likely to receive PDPE before starting continuous infusion NE (41.3% vs. 27.1%, p = 0.075) and more frequently experienced the primary composite outcome (p = 0.045) but was not correlated with vasopressor strategy (p = 0.55). DISCUSSION Cardiovascular instability following vasopressor initiation for peri-intubation hypotension was no different depending on the selected vasopressor strategy. This held true in patients with a sepsis or septic shock diagnosis. Selection of vasopressors should continue to include patient specific factors and product availability.
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Affiliation(s)
- Cassandra J Schmitt
- Department of Pharmacy Services, Mayo Clinic Rochester, United States of America.
| | - Alicia E Mattson
- Department of Pharmacy Services, Mayo Clinic Rochester, United States of America.
| | - Caitlin S Brown
- Department of Pharmacy Services, Mayo Clinic Rochester, United States of America.
| | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic Rochester, United States of America.
| | - Daniel Cabrera
- Department of Emergency Medicine, Mayo Clinic Rochester, United States of America.
| | - Benjamin J Sandefur
- Department of Emergency Medicine, Mayo Clinic Rochester, United States of America.
| | - Erin D Wieruszewski
- Department of Pharmacy Services, Mayo Clinic Rochester, United States of America.
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Selby AR, Khan NS, Dadashian T, Hall 2nd RG. Evaluation of Dose Requirements Using Weight-Based versus Non-Weight-Based Dosing of Norepinephrine to Achieve a Goal Mean Arterial Pressure in Patients with Septic Shock. J Clin Med 2023; 12:jcm12041344. [PMID: 36835880 PMCID: PMC9964536 DOI: 10.3390/jcm12041344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 01/27/2023] [Accepted: 02/05/2023] [Indexed: 02/11/2023] Open
Abstract
No consensus exists regarding optimal dosing of norepinephrine in septic shock. We aimed to evaluate if weight-based dosing (WBD) lead to higher norepinephrine doses when achieving goal mean arterial pressure (MAP) than non-weight-based dosing (non-WBD). This was a retrospective cohort study conducted after standardization of norepinephrine dosing within a cardiopulmonary ICU. Patients received non-WBD prior to standardization (November 2018-October 2019) and WBD afterwards (November 2019-October 2020). The primary outcome was the norepinephrine dose needed to attain goal MAP. Secondary outcomes included time to goal MAP, duration of norepinephrine therapy, duration of mechanical ventilation, and treatment-related adverse effects. A total of 189 patients were included (WBD 97; non-WBD 92). There was a significantly lower norepinephrine dose at goal MAP (WBD 0.05, IQR 0.02, 0.07; non-WBD 0.07, IQR 0.05, 0.14; p < 0.005) and initial norepinephrine dose (WBD 0.02, IQR 0.01, 0.05; non-WBD 0.06, 0.04, 0.12; p < 0.005) in the WBD group. No difference was observed in achievement of goal MAP (WBD 73%; non-WBD 78%; p = 0.09) or time until goal MAP (WBD 18, IQR 0, 60; non-WBD 30, IQR 14, 60; p = 0.84). WBD may lead to lower norepinephrine doses. Both strategies achieved goal MAP with no significant difference in time to goal.
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Richards-Belle A, Hylands M, Muttalib F, Taran S, Rochwerg B, Day A, Mouncey PR, Radermacher P, Couban R, Asfar P, Adhikari NKJ, Lamontagne F. Lower Versus Higher Exposure to Vasopressor Therapy in Vasodilatory Hypotension: A Systematic Review With Meta-Analysis. Crit Care Med 2023; 51:254-266. [PMID: 36398968 PMCID: PMC9848218 DOI: 10.1097/ccm.0000000000005736] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Balancing the risks of hypotension and vasopressor-associated adverse effects is a daily challenge in ICUs. We conducted a systematic review with meta-analysis to examine the effect of lower versus higher exposure to vasopressor therapy on mortality among adult ICU patients with vasodilatory hypotension. DATA SOURCES We searched Ovid Medline, Embase, and the Cochrane Central Register of Controlled Trials for studies published from inception to October 15, 2021. STUDY SELECTION We included randomized controlled trials of lower versus higher exposure to vasopressor therapy in adult ICU patients with vasodilatory hypotension without language or publication status limits. DATA EXTRACTION The primary outcome was 90-day all-cause mortality, with seven prespecified subgroups. Secondary outcomes included shorter- and longer-term mortality, use of life-sustaining therapies, vasopressor-related complications, neurologic outcome, and quality of life at longest reported follow-up. We conducted random-effects meta-analyses to calculate summary effect measures across individual studies (risk ratio [RR] for dichotomous variables, mean difference for continuous variables, both with 95% CIs). The certainty of the evidence was assessed using Grading of Recommendations, Assessment, Development, and Evaluation. We registered this review on the International Prospective Register of Systematic Reviews (CRD42021224434). DATA SYNTHESIS Of 3,403 records retrieved, 68 full-text articles were reviewed and three eligible studies included. Lower exposure to vasopressors probably lowers 90-day mortality but this is based on moderate-certainty evidence, lowered for imprecision (RR, 0.94; 95% CI, 0.87-1.02). There was no credible subgroup effect. Lower vasopressor exposure may also decrease the risk of supraventricular arrhythmia (odds ratio, 0.55; 95% CI, 0.36-0.86; low certainty). CONCLUSIONS In patients with vasodilatory hypotension who are started on vasopressors, moderate-certainty evidence from three randomized trials showed that lower vasopressor exposure probably lowers mortality. However, additional trial data are needed to reach an optimal information size to detect a clinically important 10% relative reduction in mortality with this approach.
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Affiliation(s)
- Alvin Richards-Belle
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | | | - Fiona Muttalib
- Center for Global Child Health, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Shaurya Taran
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | - Bram Rochwerg
- Departments of Medicine, Critical Care Medicine, Pediatrics and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Andrew Day
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Helmholtzstrasse 8-1, Ulm, Germany
| | - Rachel Couban
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Pierre Asfar
- Department of Medical Intensive Care, University Hospital of Angers, Angers, France
| | - Neill K J Adhikari
- Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, ON, Canada
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Abstract
BACKGROUND Phenylephrine is a selective α1-receptor agonist used to manage shock. Current guidelines for septic shock recommend limited utilization of phenylephrine due to the lack of evidence available. This deviates from previous guidelines, which had recommendations of when utilization may be appropriate. OBJECTIVE The primary objective of this study was to evaluate mortality in patients receiving phenylephrine for the management of septic shock. METHODS This was a retrospective chart review from September 2015 to September 2017 evaluating all adult patients admitted to an intensive care unit (ICU) on vasopressors for management of septic shock. Patients were divided into 2 groups, those treated with phenylephrine and those treated without phenylephrine. The primary outcome was mortality. Secondary objectives included days on vasopressors and ICU length of stay. Two subgroup analyses were performed: 1 for phenylephrine as first-line therapy and 1 for patients with tachycardia at initiation of vasopressors. Patients started on phenylephrine for salvage therapy were excluded from this study. RESULTS 499 patients enrolled in the study. 148 (32%) were enrolled in the phenylephrine group. Phenylephrine was associated with an increase in mortality (56% vs 41%; p = 0.003). There was no difference in the days on vasopressors or ICU length of stay. Patients who had ongoing tachycardia were associated with increased mortality with phenylephrine (54% vs 36%, p = 0.02). There was no difference in mortality when phenylephrine was started as the initial vasopressor. CONCLUSION Utilization of phenylephrine in septic shock patients, especially those with ongoing tachycardia, was associated with an increased rate of mortality.
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Affiliation(s)
- Vishal V Patel
- 518097Idaho College of Osteopathic Medical School, Meridian, ID, USA.,Community Medical Center, Toms River, NJ, USA
| | - Jesse B Sullivan
- 7856Fairleigh Dickinson University School of Pharmacy & Health Sciences, Florham Park, NJ, USA
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Ranjan AK, Gulati A. Controls of Central and Peripheral Blood Pressure and Hemorrhagic/Hypovolemic Shock. J Clin Med 2023; 12. [PMID: 36769755 DOI: 10.3390/jcm12031108] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/17/2023] [Accepted: 01/23/2023] [Indexed: 02/04/2023] Open
Abstract
The pressure exerted on the heart and blood vessels because of blood flow is considered an essential parameter for cardiovascular function. It determines sufficient blood perfusion, and transportation of nutrition, oxygen, and other essential factors to every organ. Pressure in the primary arteries near the heart and the brain is known as central blood pressure (CBP), while that in the peripheral arteries is known as peripheral blood pressure (PBP). Usually, CBP and PBP are correlated; however, various types of shocks and cardiovascular disorders interfere with their regulation and differently affect the blood flow in vital and accessory organs. Therefore, understanding blood pressure in normal and disease conditions is essential for managing shock-related cardiovascular implications and improving treatment outcomes. In this review, we have described the control systems (neural, hormonal, osmotic, and cellular) of blood pressure and their regulation in hemorrhagic/hypovolemic shock using centhaquine (Lyfaquin®) as a resuscitative agent.
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Lazarovits G, Ofek Shlomai N, Kheir R, Bdolah Abram T, Eventov Friedman S, Volovelsky O. Acute Kidney Injury in Very Low Birth Weight Infants: A Major Morbidity and Mortality Risk Factor. Children (Basel) 2023; 10. [PMID: 36832371 DOI: 10.3390/children10020242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/13/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND OBJECTIVES Very low birth weight (VLBW) infants are at high risk of developing acute kidney injury (AKI), presumably secondary to low kidney reserves, stressful postnatal events, and drug exposures. Our study aimed to identify the prevalence, risk factors, and outcomes associated with AKI in VLBW infants. STUDY DESIGN Records of all VLBW infants admitted to two medical campuses between January 2019 and June 2020 were retrospectively reviewed. AKI was classified using the modified KDIGO definition to include only serum creatinine. Risk factors and composite outcomes were compared between infants with and without AKI. We evaluated the main predictors of AKI and death with forward stepwise regression analysis. RESULTS 152 VLBW infants were enrolled. 21% of them developed AKI. Based on the multivariable analysis, the most significant predictors of AKI were the use of vasopressors, patent ductus arteriosus, and bloodstream infection. AKI had a strong and independent association with neonatal mortality. CONCLUSIONS AKI is common in VLBW infants and is a significant risk factor for mortality. Efforts to prevent AKI are necessary to prevent its harmful effects.
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Fernando SM, Mathew R, Sadeghirad B, Brodie D, Belley-Côté EP, Thiele H, van Diepen S, Fan E, Di Santo P, Simard T, Russo JJ, Tran A, Lévy B, Combes A, Hibbert B, Rochwerg B. Inotropes, vasopressors, and mechanical circulatory support for treatment of cardiogenic shock complicating myocardial infarction: a systematic review and network meta-analysis. Can J Anaesth 2022; 69:1537-53. [PMID: 36195825 DOI: 10.1007/s12630-022-02337-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/08/2022] [Accepted: 07/07/2022] [Indexed: 11/05/2022] Open
Abstract
PURPOSE To compare the relative efficacy of supportive therapies (inotropes, vasopressors, and mechanical circulatory support [MCS]) for adult patients with cardiogenic shock complicating acute myocardial infarction. SOURCE We conducted a systematic review and network meta-analysis and searched six databases from inception to December 2021 for randomized clinical trials (RCTs). We evaluated inotropes, vasopressors, and MCS in separate networks. Two reviewers performed screening, full-text review, and extraction. We used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to rate the certainty in findings. The critical outcome of interest was 30-day all-cause mortality. PRINCIPAL FINDINGS We included 17 RCTs. Among inotropes (seven RCTs, 1,145 patients), levosimendan probably reduces mortality compared with placebo (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.33 to 0.87; moderate certainty), but primarily in lower severity shock. Milrinone (OR, 0.52; 95% CI, 0.19 to 1.39; low certainty) and dobutamine (OR, 0.67, 95% CI, 0.30 to 1.49; low certainty) may have no effect on mortality compared with placebo. With regard to MCS (eight RCTs, 856 patients), there may be no effect on mortality with an intra-aortic balloon pump (IABP) (OR, 0.94; 95% CI, 0.69 to 1.28; low certainty) or percutaneous MCS (pMCS) (OR, 0.96; 95% CI, 0.47 to 1.98; low certainty), compared with a strategy involving no MCS. Intra-aortic balloon pump use was associated with less major bleeding compared with pMCS. We found only two RCTs evaluating vasopressors, yielding insufficient data for meta-analysis. CONCLUSION The results of this systematic review and network meta-analysis indicate that levosimendan reduces mortality compared with placebo among patients with low severity cardiogenic shock. Intra-aortic balloon pump and pMCS had no effect on mortality compared with a strategy of no MCS, but pMCS was associated with higher rates of major bleeding. STUDY REGISTRATION Center for Open Science ( https://osf.io/ky2gr ); registered 10 November 2020.
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Muacevic A, Adler JR, Garvanovic SH, Lupu SI, Gow-Lee E, Sanner DA. Central Versus Peripheral Invasive Arterial Blood Pressure Monitoring in Liver Transplant Surgery. Cureus 2022; 14:e33095. [PMID: 36721557 PMCID: PMC9884124 DOI: 10.7759/cureus.33095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2022] [Indexed: 12/30/2022] Open
Abstract
Introduction Invasive blood pressure monitoring is essential in liver transplant surgery due to expected major hemodynamic shifts. The use of central versus peripheral arterial access, however, is institution-dependent, which can affect clinical decisions regarding vasopressor therapy. Although there are studies that demonstrate inconsistencies based on arterial cannulation sites, few studies have compared femoral and radial artery blood pressures in patients undergoing liver transplant surgery. To our knowledge, there are no studies investigating the differences between continuous minute-to-minute femoral and radial artery measurements during all three phases of liver transplant surgery. Objective The main objective of this study was to evaluate for any differences between central and peripheral blood pressure measurements in liver transplant surgery and to assess for any correlation between vasopressor infusion dose and femoral-arterial pressure differences. Methods In this retrospective study, we reviewed and studied the data of 61 patients with American Society of Anesthesiologists (ASA) grade 4 who underwent liver transplant surgery at Loma Linda University Medical Center between January and December of 2019. All patients had both femoral and radial arterial lines placed for liver transplant surgery. Femoral and radial arterial blood pressure values were obtained continuously over 60 minutes in the pre-anhepatic phase, 45 minutes during the anhepatic phase, and 60 minutes into the neo-hepatic phase. Vasopressor infusion doses were also recorded for each patient during these time frames. Results This pilot study found statistically significant differences between the mean femoral and radial systolic blood pressure (SBP; p < 0.0001), diastolic blood pressure (DBP; p < 0.0001), and mean arterial pressure (MAP; p < 0.0001) during all phases of liver transplantation. The meanSBP and MAP differences between femoral and radial arteries were highest (femoral blood pressure reading higher than radial blood pressure measurements) in the late anhepatic and early neo-hepatic phases with SBP differences of 20.8 ± 0.8 mmHg and 22.8 ± 0.8 mmHg, respectively, and MAP differences of 10.0 ± 0.4 mmHg and 9.8 ± 0.4 mmHg, respectively. Higher vasopressor infusion doses were strongly associated with greater differences in femoral-radial SBP and MAP measurements (r = 0.69 for vasopressin, 0.68 for norepinephrine, and 0.68 for epinephrine; p < 0.0001) during the anhepatic phase. Conclusions Peripheral invasive blood pressure monitoring may result in underestimation of the central blood pressure, as was seen in all phases of liver transplantation. This may lead to excessive vasopressor use with potentially adverse effects. Although the cause for the difference between femoral and radial artery measurements is unclear, increasing vasopressor infusion dosages appears to contribute. Femoral artery blood pressure monitoring allows clinicians to interpret hemodynamic status and administer appropriate vasopressors more accurately.
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Owen P, Sherriff M. Is there an association between 30-day mortality and adrenaline infusion rates in post-ROSC patients? A retrospective observational analysis. Br Paramed J 2022; 7:1-7. [PMID: 36531796 PMCID: PMC9730193 DOI: 10.29045/14784726.2022.12.7.3.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023] Open
Abstract
Introduction Revised guidelines for the management of cardiac arrest have placed greater emphasis on early defibrillation and closed chest compressions; subsequently there has been a significant rise in the number of patients gaining a return of spontaneous circulation (ROSC). As a consequence, emergency medical services have realised the importance of therapies delivered during this phase of care. In some Trusts this includes the use of inotropic agents to augment the cardiovascular system and maintain adequate cerebral and coronary perfusion pressures to mitigate the effects of post-cardiac arrest syndrome. Currently, limited evidence exists with regards to the efficacy of such treatments in the pre-hospital phase. Methods Retrospective observational analysis of out-of-hospital cardiac arrest patients who received an adrenaline infusion by critical care paramedics. Infusion rates, time of call (ToC) to ROSC and 30-day mortality were compared. Results Over a 2-year period, 202 patients were recorded as having an adrenaline infusion commenced. Of these, 25 were excluded as they did not meet criteria or had incomplete data and 22 were excluded as the infusion was stopped at scene; 155 patients were admitted to hospital. There were no survivors in the non-shockable group and three survivors in the shockable group at 30 days. A rare events analysis found no relationship between infusion rate, ToC to ROSC and 30-day mortality (Wald chi2, 1.37). Conclusion Commencement of adrenaline infusions in post-ROSC was associated with significant 30-day mortality, especially in non-shockable rhythms. Further research is needed to elucidate whether this intervention has any benefit in the post-ROSC patient.
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Affiliation(s)
- Peter Owen
- South East Coast Ambulance Service NHS Foundation Trust
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Macdonald S, Peake SL, Corfield AR, Delaney A. Fluids or vasopressors for the initial resuscitation of septic shock. Front Med (Lausanne) 2022; 9:1069782. [PMID: 36507525 PMCID: PMC9729725 DOI: 10.3389/fmed.2022.1069782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/07/2022] [Indexed: 11/25/2022] Open
Abstract
Intravenous fluid resuscitation is recommended first-line treatment for sepsis-associated hypotension and/or hypoperfusion. The rationale is to restore circulating volume and optimize cardiac output in the setting of shock. Nonetheless, there is limited high-level evidence to support this practice. Over the past decade emerging evidence of harm associated with large volume fluid resuscitation among patients with septic shock has led to calls for a more conservative approach. Specifically, clinical trials undertaken in Africa have found harm associated with initial fluid resuscitation in the setting of infection and hypoperfusion. While translating these findings to practice in other settings is problematic, there has been a re-appraisal of current practice with some recommending earlier use of vasopressors rather than repeated fluid boluses as an alternative to restore perfusion in septic shock. There is consequently uncertainty and variation in practice. The question of fluids or vasopressors for initial resuscitation in septic shock is the subject of international multicentre clinical trials.
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Affiliation(s)
- Stephen Macdonald
- Medical School, University of Western Australia, Perth, WA, Australia
- Department of Emergency Medicine, Royal Perth Hospital, Perth, WA, Australia
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia
| | - Sandra L. Peake
- Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, SA, Australia
- Department of Critical Care Research, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Alasdair R. Corfield
- Consultant Emergency Medicine, Royal Alexandra Hospital, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, United Kingdom
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
- Division of Critical Care, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Faculty of Medicine, Northern Clinical School, University of Sydney, Sydney, NSW, Australia
- Department of Epidemiology and Preventative Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
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Ryu R, Hauschild C, Bahjri K, Tran H. The Usage of Concomitant Beta-Blockers with Vasopressors and Inotropes in Cardiogenic Shock. Med Sci (Basel) 2022; 10:medsci10040064. [PMID: 36412905 PMCID: PMC9680500 DOI: 10.3390/medsci10040064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/13/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022]
Abstract
Vasopressors and inotropes (Vs/Is) are widely used in the treatment of cardiogenic shock (CS). Despite improvements in hemodynamic variables and end-organ perfusion, these agents have been associated with an increase in mortality, potentially due to the increased risk of tachyarrhythmias-which we hypothesize may be mitigated by beta-blockers (BBs). We conducted a retrospective chart review of patients who received a V/I (dobutamine, milrinone, dopamine, and norepinephrine) for CS. The primary objective was to assess the effect of BB in patients receiving Vs/Is for CS. In our final analysis of 227 patients, those in the BB group were younger, were more likely to have acute coronary syndrome as the reason for admission, had more reduced left ventricular ejection fraction, were more likely to have coronary artery disease and atrial fibrillation as pre-existing co-morbidities, and had a lower rate of in-hospital mortality. Nevertheless, in our multivariable logistic regression analysis, concurrent BB usage with a V/I was not associated with a reduction in in-hospital mortality. Our present study sheds light on the importance and urgency of large, carefully designed clinical studies to optimize inpatient medical therapy, particularly evaluating the combination of V/I and BB, in this high-risk patient population.
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Affiliation(s)
- Rachel Ryu
- College of Pharmacy, Western University of Health Sciences, 309 E. Second Street, Pomona, CA 91766, USA
- Correspondence:
| | - Christopher Hauschild
- Loma Linda University Medical Center, 11223 Campus Street, Loma Linda, CA 92350, USA
| | - Khaled Bahjri
- School of Pharmacy, Loma Linda University, 24745 Stewart Street, Loma Linda, CA 92350, USA
| | - Huyentran Tran
- School of Pharmacy, Loma Linda University, 24745 Stewart Street, Loma Linda, CA 92350, USA
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Muacevic A, Adler JR. Perfusion Index and Its Correlation With Intraoperative Hypotension in Lower-Segment Cesarean Section Under Spinal Anesthesia: A Prospective Observational Study in a Tertiary Care Hospital in Eastern India. Cureus 2022; 14:e30431. [PMID: 36276602 PMCID: PMC9579516 DOI: 10.7759/cureus.30431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 11/07/2022] Open
Abstract
Background Hypotension is commonly encountered in patients undergoing lower-segment cesarean section (LSCS) under the subarachnoid block (SAB) owing to decreased vascular resistance caused by the sympathetic blockade and decreased cardiac output because of blood pooling in blocked areas of the body. Perfusion index (PI) is a good indicator of systemic vascular resistance and can foretell hypotension. This study aimed to associate baseline PI with intraoperative hypotension after SAB in LSCS. Methodology This was a prospective observational study with a sample size of 50. The baseline PI was recorded every 10 seconds for one minute in a supine position on the right index finger at room temperature of 26°C to 28°C. The blood pressure (BP) and heart rate (HR) were recorded at an interval of one minute for three minutes. The mean of PI, BP, and HR were taken as the preoperative value. Spinal anesthesia was administered as per institutional protocol. Hypotension, defined as mean arterial pressure (MAP) <20% of baseline or MAP <60 mmHg was treated with vasopressors. Regression analysis with the Spearman correlation coefficient was done to correlate PI and hypotension. Results The incidence of hypotension in parturients with PI <2.85 was 28.6% (5/20) and in parturients with PI >2.85 was 82.8% (p < 0.001). The requirement of sympathomimetics was higher in parturients with PI >2.85.The area under the receiver operating characteristic curve was 0.8883. A cut-off PI value of 2.85 can identify parturients at risk for central neuraxial block-induced hypotension with a sensitivity of 80% and a specificity of 75% (p < 0.001). Conclusions The PI is a useful tool for predicting hypotension in healthy parturients undergoing elective cesarean section under SAB.
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Morkane CM, Sapisochin G, Mukhtar AM, Reyntjens KMEM, Wagener G, Spiro M, Raptis DA, Klinck JR. Perioperative fluid management and outcomes in adult deceased donor liver transplantation - A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14651. [PMID: 35304919 DOI: 10.1111/ctr.14651] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/28/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Fluid management practices during and after liver transplantation vary widely among centers despite better understanding of the pathophysiology of end-stage liver disease and of the effects of commonly used fluids. This reflects a lack of high quality trials in this setting, but also provides a rationale for both systematic review of all relevant studies in liver recipients and evaluation of new evidence from closely related domains, including hepatology, non-transplant abdominal surgery, and critical care. OBJECTIVES To develop evidence-based recommendations for perioperative fluid management to optimize immediate and short-term outcomes following liver transplantation. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Studies included those evaluating the following postoperative outcomes: acute kidney injury, respiratory complications, operative blood loss/red cell units required, and intensive care length of stay. PROSPERO protocol ID: CRD42021241392 RESULTS: Following expert panel review, 18 of 1624 screened studies met eligibility criteria for inclusion in the final quantitative synthesis. These included six single center RCTs, 11 single center observational studies, and one observational study comparing centers with different fluid management techniques. Definitions of interventions and outcomes varied between studies. Recommendations are therefore based substantially on expert opinion and evidence from other clinical settings. CONCLUSIONS A moderately restrictive or "replacement only" fluid regime is recommended, especially during the dissection phase of the transplant procedure. Sustained hypervolemia, based on absence of fluid responsiveness, elevated filling pressures and/or echocardiographic findings, should be avoided (Quality of Evidence: Moderate | Grade of Recommendation: Weak for restrictive fluid regime. Strong for avoidance of hypervolemia). Mean Arterial Pressure (MAP) should be maintained at >60-65 mmHg in all cases (Quality of Evidence: Low | Grade of Recommendation: Strong). There is insufficient evidence in this population to support preferential use of any specific colloid or crystalloid for routine volume replacement. However, we recommend against the use of 130/.4 HES given the high incidence of AKI in this population.
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Affiliation(s)
- Clare M Morkane
- Department of Intensive Care Medicine, Kings College Hospital, London, UK
| | - Gonzalo Sapisochin
- Multio-Organ Transplant & HPB Surgical Oncology, Division of General Surgery, University Health Network, University of Toronto, Toronto, Canada
| | | | - Koen M E M Reyntjens
- Department of Anesthesiology, Rijksuniversiteit, University Medical Center Groningen, Groningen, The Netherlands
| | - Gebhard Wagener
- Department of Anesthesiology, Columbia University Medical Center, New York, USA
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri A Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - John R Klinck
- Division of Perioperative Care, Addenbrooke's Hospital, Cambridge, UK
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- Department of Intensive Care Medicine, Kings College Hospital, London, UK
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Rinehart J, Desebbe O, Berna A, Lam I, Coeckelenbergh S, Cannesson M, Joosten A. Systolic Arterial Pressure Control Using an Automated Closed-Loop System for Vasopressor Infusion during Intermediate-to-High-Risk Surgery: A Feasibility Study. J Pers Med 2022; 12:jpm12101554. [PMID: 36294696 PMCID: PMC9604572 DOI: 10.3390/jpm12101554] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/18/2022] [Accepted: 09/20/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction: Vasopressor infusions are essential in treating and preventing intraoperative hypotension. Closed-loop vasopressor therapy outperforms clinicians when the target is set at a mean arterial pressure (MAP) baseline, but little is known on the performance metrics of closed-loop vasopressor infusions when systolic arterial pressure (SAP) is the controlled variable. Methods: Patients undergoing intermediate- to high-risk abdominal surgery were included in this prospective cohort feasibility study. All patients received norepinephrine infusion through a computer controlled closed-loop system that targeted SAP at 130 mmHg. The primary objective was to determine the percent of case time in hypotension or under target defined as SAP below 10% of the target (SAP < 117 mmHg). Secondary objectives were the percent of case time “above target” (SAP > 10% of the target or >143 mmHg) and “in target” (within 10% of the SAP target or SAP between 117 and 143 mmHg). Results: A total of 12 patients were included. The closed-loop system infused norepinephrine for a median of 94.6% (25−75th percentile: 90.0−98.0%) of case time. The percentage of case time in hypotension or under target was only 1.8% (0.9−3.6%). The percentages of case time “above target” and “in target” were 4.7% (3.2−7.5%) and 92.4% (90.1−96.3%), respectively. Conclusions: This closed-loop vasopressor system minimizes intraoperative hypotension and maintains SAP within 10% of the target range for >90% of the case time in patients undergoing intermediate- to high-risk abdominal surgery.
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Affiliation(s)
- Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California Irvine, 101 The City Drive South, Irvine, CA 92868, USA
| | - Olivier Desebbe
- Department of Anesthesiology and Perioperative Medicine, Sauvegarde Clinic, Ramsay Santé, 69009 Lyon, France
| | - Antoine Berna
- Department of Anesthesiology and Perioperative Medicine, Sauvegarde Clinic, Ramsay Santé, 69009 Lyon, France
| | - Isaac Lam
- Department of Anesthesiology & Perioperative Care, University of California Irvine, 101 The City Drive South, Irvine, CA 92868, USA
| | - Sean Coeckelenbergh
- Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, 1070 Brussels, Belgium
- Department of Anesthesiology and Intensive Care, Groupe Universitaire Paris-Saclay, Paul Brousse Hospital, Assistance Publique-Hôpitaux de Paris (APHP), 94800 Villejuif, France
| | - Maxime Cannesson
- Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Alexandre Joosten
- Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, 1070 Brussels, Belgium
- Department of Anesthesiology and Intensive Care, Groupe Universitaire Paris-Saclay, Paul Brousse Hospital, Assistance Publique-Hôpitaux de Paris (APHP), 94800 Villejuif, France
- Correspondence:
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Kuniavsky M, Doenyas-Barak K, Goldschmidt N, Huppert A, Bronshtein O, Rosenfelder C, Freedman LS, Niv Y. COVID-19 and Renal Failure - Adding Insult to Injury? Israel's Experience Based on Nationwide Retrospective Cohort Study. J Gen Intern Med 2022; 37:3128-33. [PMID: 35794306 DOI: 10.1007/s11606-022-07722-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/17/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Renal failure (RF) is a risk factor for mortality among hospitalized patients. However, its role in COVID-19-related morbidity and mortality is inconclusive. The aim of the study was to determine whether RF is a significant predictor of clinical outcomes in COVID-19 hospitalized patients based on a retrospective, nationwide, cohort study. METHODS The study sample consisted of patients hospitalized in Israel for COVID-19 in two periods. A random sample of these admissions was selected, and experienced nurses extracted the data from the electronic files. The group with RF on admission was compared to the group of patients without RF. The association of RF with 30-day mortality was investigated using a logistic regression model. RESULTS During the two periods, 19,308 and 2994 patients were admitted, from which a random sample of 4688 patients was extracted. The 30-day mortality rate for patients with RF was 30% (95% confidence interval (CI): 27-33%) compared to 8% (95% CI: 7-9%) among patients without RF. The estimated OR for 30-day mortality among RF versus other patients was 4.3 (95% CI: 3.7-5.1) and after adjustment for confounders was 2.2 (95% CI: 1.8-2.6). Furthermore, RF patients received treatment by vasopressors and invasive mechanical ventilation (IMV) more frequently than those without RF (vasopressors: 17% versus 6%, OR = 2.8, p<0.0001; IMV: 17% versus 7%, OR = 2.6, p<0.0001). DISCUSSION RF is an independent risk factor for mortality, IMV, and the need for vasopressors among patients hospitalized for COVID-19 infection. Therefore, this condition requires special attention when considering preventive tools, monitoring, and treatment.
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Iovine JA, Villanueva RD, Werth CM, Hlavacek NL, Rollstin AD, Tawil I, Sarangarm P. Contemporary hemodynamic management of acute spinal cord injuries with intravenous and enteral vasoactive agents: A narrative review. Am J Health Syst Pharm 2022; 79:1521-1530. [PMID: 35677966 DOI: 10.1093/ajhp/zxac164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE The pathophysiology and hemodynamic management of acute spinal cord injuries, including the use of intravenous and enteral vasoactive agents, are reviewed. SUMMARY Spinal cord injuries are devastating neurological insults that in the acute setting lead to significant hemodynamic disturbances, including hypotension and bradycardia, that are influenced by the level of injury. High thoracic (usually defined as at or above T6) and cervical injuries often manifest with hypotension and bradycardia due to destruction of sympathetic nervous system activity and unopposed vagal stimulation to the myocardium, whereas lower thoracic injuries tend to result in hypotension alone due to venous pooling. Initial management includes maintaining euvolemia with crystalloids and maintaining or augmenting mean arterial pressure with the use of intravenous vasoactive agents to improve neurological outcomes. Choice of vasopressor should be based on patient-specific factors, particularly level of injury and presenting hemodynamics. This review includes the most recent literature on intravenous vasopressors as well as the limited evidence supporting the use of enteral vasoactive agents. Enteral vasoactive agents may be considered, when clinically appropriate, as a strategy to wean patients off of intravenous agents and facilitate transfer outside of the intensive care unit. CONCLUSION The hemodynamic management of acute spinal cord injuries often requires the use of vasoactive agents to meet mean arterial pressure goals and improve neurological outcomes. Patient-specific factors must be considered when choosing intravenous and enteral vasoactive agents.
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Affiliation(s)
- Joseph A Iovine
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Ruben D Villanueva
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Christopher M Werth
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Nicole L Hlavacek
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Amber D Rollstin
- Department of Critical Care and Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Isaac Tawil
- Department of Critical Care and Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM, USA
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Scheibner A, Betthauser KD, Bewley AF, Juang P, Lizza B, Micek S, Lyons PG. Machine learning to predict vasopressin responsiveness in patients with septic shock. Pharmacotherapy 2022; 42:460-471. [PMID: 35426141 DOI: 10.1002/phar.2683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 03/15/2022] [Accepted: 04/01/2022] [Indexed: 12/19/2022]
Abstract
STUDY OBJECTIVES The objective of this study was to develop and externally validate a model to predict adjunctive vasopressin response in patients with septic shock being treated with norepinephrine for bedside use in the intensive care unit. DESIGN This was a retrospective analysis of two adult tertiary intensive care unit septic shock populations. SETTING Barnes-Jewish Hospital (BJH) from 2010 to 2017 and Beth Israel Deaconess Medical Center (BIDMC) from 2001 to 2012. PATIENTS Two septic shock populations (548 BJH patients and 464 BIDMC patients) that received vasopressin as second-line vasopressor. INTERVENTION Patients who were vasopressin responsive were compared with those who were nonresponsive. Vasopressin response was defined as survival with at least a 20% decrease in maximum daily norepinephrine requirements by one calendar day after vasopressin initiation, without a third-line vasopressor. MEASUREMENTS Two supervised machine learning models (gradient-boosting machine [XGBoost] and elastic net penalized logistic regression [EN]) were trained in 1000 bootstrap replications of the BJH data and externally validated in the BIDMC data to predict vasopressin responsiveness. MAIN RESULTS Vasopressin responsiveness was similar among each cohort (BJH 45% and BIDMC 39%). Mortality was lower for vasopressin responders compared with nonresponders in the BJH (51% vs. 73%) and BIDMC (45% vs. 83%) cohorts, respectively. Both models demonstrated modest discrimination in the training (XGBoost area under receiver operator curve [AUROC] 0.61 [95% confidence interval (CI) 0.61-0.61], EN 0.59 [95% CI 0.58-0.59]) and external validation (XGBoost 0.68 [95% CI 0.63-0.73], EN 0.64 [95% CI 0.59-0.69]) datasets. CONCLUSION Vasopressin nonresponsiveness is common and associated with increased mortality. The models' modest performances highlight the complexity of septic shock and indicate that more research will be required before clinical decision support tools can aid in anticipating patient-specific responsiveness to vasopressin.
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Affiliation(s)
- Aileen Scheibner
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Kevin D Betthauser
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Alice F Bewley
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Paul Juang
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA.,Department of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, Missouri, USA
| | - Bryan Lizza
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Scott Micek
- Department of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, Missouri, USA
| | - Patrick G Lyons
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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Frenkel A, Hassan L, Glick A, Pikovsky O, Boyko M, Binyamin Y, Novack V, Klein M. Potassium Level Variation Following Packed Cell Transfusion in Critically Ill Adult Patients-How Alert Should We Be? J Clin Med 2022; 11. [PMID: 35683501 DOI: 10.3390/jcm11113117] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/02/2022] [Accepted: 05/04/2022] [Indexed: 02/01/2023] Open
Abstract
One of the most clinically important effects following the administration of packed cell transfusion (PCT) is hyperkalemia, which can cause severe life-threatening cardiac arrhythmias. This retrospective population-based cohort study included adults hospitalized between January 2007 and December 2019 in a general intensive care unit for 24 h or more, with normal levels of serum potassium on admission. We assessed changes in serum potassium levels after administration of one unit of packed cells and sought to identify clinical parameters that may affect these changes. We applied adjusted linear mixed models to assess changes in serum potassium. The mean increase in serum potassium was 0.09 mEq/L (C.U 0.04−0.14, p-value < 0.001) among the 366 patients who were treated with a single PCT compared to those not treated with PCT. Increased serum potassium levels were also found in patients who required mechanical ventilation, and to a lesser degree in those treated with vasopressors. Hypertension, the occurrence of a cerebrovascular accident, and increased creatinine levels were all associated with reduced serum potassium levels. Due to the small rise in serum potassium levels following PCT, we do not suggest any particular follow-up measures for critically ill patients who receive PCT.
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Jozwiak M, Geri G, Laghlam D, Boussion K, Dolladille C, Nguyen LS. Vasopressors and Risk of Acute Mesenteric Ischemia: A Worldwide Pharmacovigilance Analysis and Comprehensive Literature Review. Front Med (Lausanne) 2022; 9:826446. [PMID: 35677822 PMCID: PMC9168038 DOI: 10.3389/fmed.2022.826446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 04/21/2022] [Indexed: 12/03/2022] Open
Abstract
Vasodilatory shock, such as septic shock, requires personalized management which include adequate fluid therapy and vasopressor treatments. While these potent drugs are numerous, they all aim to counterbalance the vasodilatory effects of a systemic inflammatory response syndrome. Their specific receptors include α- and β-adrenergic receptors, arginine-vasopressin receptors, angiotensin II receptors and dopamine receptors. Consequently, these may be associated with severe adverse effects, including acute mesenteric ischemia (AMI). As the risk of AMI depends on drug class, we aimed to review the evidence of plausible associations by performing a worldwide pharmacovigilance analysis based on the World Health Organization database, VigiBase®. Among 24 million reports, 104 AMI events were reported, and disproportionality analyses yielded significant association with all vasopressors, to the exception of selepressin. Furthermore, in a comprehensive literature review, we detailed mechanistic phenomena which may enhance vasopressor selection, in the course of treating vasodilatory shock.
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Affiliation(s)
- Mathieu Jozwiak
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire l'Archet 1, Nice, France
- Equipe 2 CARRES UR2CA—Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur UCA, Nice, France
| | - Guillaume Geri
- Service de Médecine Intensive Réanimation, Centre Médico-Chirurgical Ambroise Paré, Neuilly-sur-Seine, France
| | - Driss Laghlam
- Service de Médecine Intensive Réanimation, Centre Médico-Chirurgical Ambroise Paré, Neuilly-sur-Seine, France
- Faculté de Médecine, Université de Paris, Paris, France
| | - Kevin Boussion
- Service de Médecine Intensive Réanimation, Centre Médico-Chirurgical Ambroise Paré, Neuilly-sur-Seine, France
| | | | - Lee S. Nguyen
- Service de Médecine Intensive Réanimation, Centre Médico-Chirurgical Ambroise Paré, Neuilly-sur-Seine, France
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