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McCully BH, Kozuma K, Pommier S, Pommier RF. Comparison of Octreotide and Vasopressors as First-Line Treatment for Intraoperative Carcinoid Crisis. Ann Surg Oncol 2024; 31:2996-3002. [PMID: 38227166 DOI: 10.1245/s10434-023-14876-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/21/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND Intraoperative carcinoid crisis is typically sudden onset of profound hypotension during operations on patients with neuroendocrine tumors. The crisis was thought to be due to massive release of hormones, and perioperative octreotide was recommended as a prophylaxis against the crisis and as first-line treatment. Recent studies show that octreotide does not prevent the crisis and that no massive release of hormones occurs. Therefore, the authors hypothesized that octreotide is not effective for treating the crisis. METHODS A prospective carcinoid anesthesia database was analyzed for occurrences of crisis. Outcomes were compared between protocols when first-line therapy was bolus octreotide and when it was vasopressors without octreotide. Significance was determined by Student's t test, the Mann-Whitney U test, and Fisher's exact test. RESULTS Among operations performed with octreotide as first-line treatment (n = 150), crisis occurred for 45 (30 %) patients, the median crisis duration was 6 min, 12 (27 %) patients had crises longer than 10 min, 42 patients (93 %) required subsequent vasopressor administration to resolve the crisis, and 3 (2 %) operations were aborted. Among operations performed with vasopressors as the first-line treatment (n = 195), crisis occurred for 49 (25 %) patients (p = 0.31), the median crisis duration was 3 min (p < 0.001), and no crisis lasted longer than 10 min (p = 0.001). Patients treated with vasopressors were less likely to have multiple crises and had a shorter total time in crisis, a shorter anesthesia time, and no aborted operations (p < 0.05 for all). CONCLUSIONS First-line octreotide was ineffective treatment for carcinoid crisis, with patients requiring vasopressors to resolve the crisis, and many crises lasting longer than 10 min. First-line vasopressor treatment resulted in significantly shorter crisis durations, fewer crises and aborted operations, and shorter anesthesia times. Vasopressors should be used as first-line treatment for intraoperative crisis, and treatment guidelines should be changed.
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Affiliation(s)
- Belinda H McCully
- Department of Basic Medical Sciences, College of Osteopathic Medicine of the Pacific-Northwest, Western University of Health Sciences, Lebanon, OR, USA
| | - Kaiya Kozuma
- Division of Surgical Oncology, Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - SuEllen Pommier
- Division of Surgical Oncology, Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Rodney F Pommier
- Division of Surgical Oncology, Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
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Abstract
PURPOSE OF REVIEW The definition and diagnostic criteria of hepatorenal syndrome-acute kidney injury (HRS-AKI) has undergone recent changes. A major vasoconstrictor, terlipressin, has recently been approved as pharmacotherapy for HRS-AKI in the United States. The purpose of this review is to familiarize the readers with these new diagnostic criteria of HRS-AKI, and how best to use terlipressin. RECENT FINDINGS Terlipressin is effective either as bolus dosing or continuous infusion and can achieve reversal of HRS-AKI in approximately 40% of patients. Continuous infusion allows lower daily dose with equal efficacy and less side effects but not an approved mode of administration in the United States. Response to terlipressin in the randomized controlled trials was defined as repeat reduction of serum creatinine to less than 1.5 mg/dl. Newer studies will likely require response to treatment to be defined as a repeat serum creatinine to be less than 0.3 mg/dl from baseline. Terlipressin use is associated with ischemic side effects and potential for respiratory failure development. SUMMARY Careful patient selection and close monitoring are necessary for its use. Response to terlipressin with HRS-AKI reversal is associated with improved outcomes with better survival and less requirement for renal replacement therapy.
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Affiliation(s)
- Florence Wong
- Division of Gastroenterology & Hepatology, Department of Medicine, Toronto General Hospital, University of Toronto, Ontario, Canada
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Alshehri AM, Kovacevic MP, Dube KM, Lupi KE, DeGrado JR. Comparison of Early Versus Late Adjunctive Vasopressin and Corticosteroids in Patients With Septic Shock. Ann Pharmacother 2024; 58:461-468. [PMID: 37542417 DOI: 10.1177/10600280231191131] [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: 08/07/2023] Open
Abstract
BACKGROUND Vasopressin (VP) and hydrocortisone (HC) have been shown to improve outcomes in patients with septic shock. However, there is very little literature addressing the impact of the timing of the combination. OBJECTIVE This study was conducted to evaluate the impact of early versus late initiation of both VP and HC on time to shock reversal in septic shock patients. METHODS This was a retrospective study conducted at a tertiary academic medical center. Data were collected from system-generated reports, which were used to identify patients with septic shock who were admitted to an intensive care unit (ICU) and received both VP and HC. The primary endpoint was time to shock reversal. Patients were divided into the "early" group if both VP and HC were initiated within 12 hours of vasopressor initiation or into the "late" group if either VP or HC (or both agents) were initiated after 12 hours of vasopressor initiation. RESULTS A total of 122 patients were included in the analysis. Early initiation was associated with a shorter time to shock reversal (34 hours vs 65 hours; P = 0.012) compared to late initiation. There were no differences in ICU length of stay, mortality, the number patients requiring renal replacement therapy, or the duration of mechanical ventilation in either group. CONCLUSION AND RELEVANCE Our study addressed a major gap in the literature and suggests that adding the combination of VP and HC within 12 hours of septic shock may be associated with improved patient outcomes.
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Affiliation(s)
| | - Mary P Kovacevic
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Kevin M Dube
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Kenneth E Lupi
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Jeremy R DeGrado
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
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Revelli L, Dirchwolf M. Editorial: Terlipressin and MDRO colonisation in cirrhosis-Is there a causal link? Aliment Pharmacol Ther 2024; 59:1284-1285. [PMID: 38652777 DOI: 10.1111/apt.17940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
LINKED CONTENTThis article is linked to Mücke et al paper. To view this article, visit https://doi.org/10.1111/apt.17899
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Affiliation(s)
- Luciano Revelli
- Liver Unit, Hospital Privado de Rosario, Santa Fe, Argentina
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Premkumar M, Kajal K, Reddy KR, Izzy M, Kulkarni AV, Duseja AK, Sihag KB, Divyaveer S, Gupta A, Taneja S, De A, Verma N, Rathi S, Bhujade H, Chaluvashetty SB, Roy A, Kumar V, Siddhartha V, Singh V, Bahl A. Evaluation of terlipressin-related patient outcomes in hepatorenal syndrome-acute kidney injury using point-of-care echocardiography. Hepatology 2024; 79:1048-1064. [PMID: 37976391 DOI: 10.1097/hep.0000000000000691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/27/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND AND AIMS Treatment of hepatorenal syndrome-acute kidney injury (HRS-AKI), with terlipressin and albumin, provides survival benefits, but may be associated with cardiopulmonary complications. We analyzed the predictors of terlipressin response and mortality using point-of-care echocardiography (POC-Echo) and cardiac and renal biomarkers. APPROACH Between December 2021 and January 2023, patients with HRS-AKI were assessed with POC-Echo and lung ultrasound within 6 hours of admission, at the time of starting terlipressin (48 h), and at 72 hours. Volume expansion was done with 20% albumin, followed by terlipressin infusion. Clinical data, POC-Echo data, and serum biomarkers were prospectively collected. Cirrhotic cardiomyopathy (CCM) was defined per 2020 criteria. RESULTS One hundred and forty patients were enrolled (84% men, 59% alcohol-associated disease, mean MELD-Na 25±SD 5.6). A median daily dose of infused terlipressin was 4.3 (interquartile range: 3.9-4.6) mg/day; mean duration 6.4 ± SD 1.9 days; the complete response was in 62% and partial response in 11%. Overall mortality was 14% and 16% at 30 and 90 days, respectively. Cutoffs for prediction of terlipressin nonresponse were cardiac variables [ratio of early mitral inflow velocity and mitral annular early diastolic tissue doppler velocity > 12.5 (indicating increased left filling pressures, C-statistic: 0.774), tissue doppler mitral velocity < 7 cm/s (indicating impaired relaxation; C-statistic: 0.791), > 20.5% reduction in cardiac index at 72 hours (C-statistic: 0.885); p < 0.001] and pretreatment biomarkers (CysC > 2.2 mg/l, C-statistic: 0.640 and N-terminal proBNP > 350 pg/mL, C-statistic: 0.655; p <0.050). About 6% of all patients with HRS-AKI and 26% of patients with CCM had pulmonary edema. The presence of CCM (adjusted HR 1.9; CI: 1.8-4.5, p = 0.009) and terlipressin nonresponse (adjusted HR 5.2; CI: 2.2-12.2, p <0.001) were predictors of mortality independent of age, sex, obesity, DM-2, etiology, and baseline creatinine. CONCLUSIONS CCM and reduction in cardiac index, reliably predict terlipressin nonresponse. CCM is independently associated with poor survival in HRS-AKI.
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kamal Kajal
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - K Rajender Reddy
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Manhal Izzy
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University, Nashville, Tennessee, USA
| | - Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Ajay Kumar Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - K Bhupendra Sihag
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Smita Divyaveer
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ankur Gupta
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arka De
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nipun Verma
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahaj Rathi
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harish Bhujade
- Radiodiagnosis and Interventional Radiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sreedhara B Chaluvashetty
- Radiodiagnosis and Interventional Radiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Akash Roy
- Department of Hepatology, Apollo Hospital, Kolkata, India
| | - Vishesh Kumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vuppada Siddhartha
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Virendra Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Bahl
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Roozbeh J, Ezzatzadegan Jahromi S, Rezazadeh MH, Hamidianjahromi A, Malekmakan L. Management of hepatorenal syndrome and associated outcomes: a systematic reviews. BMJ Open Gastroenterol 2024; 11:e001319. [PMID: 38631807 PMCID: PMC11033346 DOI: 10.1136/bmjgast-2023-001319] [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: 12/02/2023] [Accepted: 03/11/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Hepatorenal syndrome (HRS), a multiorgan condition of acute kidney injury, is seen in advanced liver disease. This study aims to evaluate the current treatment for HRS. METHODS The authors searched PubMed, Scopus and Google Scholar literature. After quality assessment, 31 studies were included in this review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology and the population, intervention, comparison and outcome scheme were used. We included human-controlled trials that evaluate the current treatment for HRS. Two authors independently screened articles for inclusion, extracted data and assessed the quality of included studies. RESULTS This study investigated the studies conducted on the effects of different treatments on follow-up of HRS patients. We gathered 440 articles, so 31 articles remained in our study. Of which 24 articles were conducted on terlipressin versus placebo or other treatments (midodrine/octreotide, norepinephrine, etc) that showed the higher rate of HRS reversal was detected for terlipressin in 17 studies (10 of them were significant), 2 studies achieved an insignificant lower rate of the model for end-stage liver disease score for terlipressin, 15 studies showed a decreased mortality rate in the terlipressin group (4 of them were significant). CONCLUSION This review showed that terlipressin has a significantly higher reversal rate of HRS than the other treatments. Even the results showed that terlipressin is more efficient than midodrine/octreotide and norepinephrine as a previous medication, in reverse HRS, increasing patient survival.
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Affiliation(s)
- Jamshid Roozbeh
- Shiraz University of Medical Sciences, shiraz, Iran (the Islamic Republic of)
- Shiraz Nephro-Urology Research Center, Shiraz, Iran
| | - Shahrokh Ezzatzadegan Jahromi
- Shiraz University of Medical Sciences, shiraz, Iran (the Islamic Republic of)
- Shiraz Nephro-Urology Research Center, Shiraz, Iran
| | - Mohamad Hossein Rezazadeh
- Shiraz University of Medical Sciences, shiraz, Iran (the Islamic Republic of)
- Shiraz Nephro-Urology Research Center, Shiraz, Iran
| | - Anahid Hamidianjahromi
- Shiraz University of Medical Sciences, shiraz, Iran (the Islamic Republic of)
- Shiraz Nephro-Urology Research Center, Shiraz, Iran
| | - Leila Malekmakan
- Shiraz University of Medical Sciences, shiraz, Iran (the Islamic Republic of)
- Shiraz Nephro-Urology Research Center, Shiraz, Iran
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Mikkonen E, Blixt J, Ercole A, Alpkvist P, Sköldbring R, Bellander BM, Weitzberg E, Nelson DW. A Solution to the Cerebral Perfusion Pressure Transducer Placement Conundrum in Neurointensive Care? The Dual Transducer. Neurocrit Care 2024; 40:391-394. [PMID: 37697130 PMCID: PMC10959835 DOI: 10.1007/s12028-023-01829-8] [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: 04/21/2023] [Accepted: 08/04/2023] [Indexed: 09/13/2023]
Abstract
Intracranial pressure is routinely monitored in most intensive care units caring for patients with severe neurological insults and, together with continuous arterial blood pressure measurement, allows for monitoring of cerebral perfusion pressure (CPP). CPP is the driving pressure of blood flow to the brain and is used to guide therapy. However, there is considerable inconsistency in the literature regarding how CPP is technically measured and, more specifically, the appropriate placement of the arterial pressure transducer. Depending on patient positioning and where the arterial pressure transducer is placed, the mean arterial pressure used for CPP calculation can vary widely by up to 15 mm Hg, which is greater than the acceptable variation in target ranges used clinically. Physiologically, the arterial pressure transducer should be placed at the level of the foramen of Monro for CPP measurement, but it is commonly set at the level of the right atrium for systematic measurement. Mean arterial pressure measurement at the level of the right atrium can lead to overestimation and potentially critically low actual CPP levels when the head is elevated, and measurement at the level of the foramen of Monro will underestimate systemic pressures, increasing the risk of excessive and unnecessary use of vasopressors and fluid. At the Karolinska University Hospital neurointensive care unit, we have used a split dual-transducer system, measuring arterial pressure both at the level of the foramen of Monro and at the level of the right atrium from a single arterial source. In doing so, we work with constants and can monitor and target optimum arterial pressures to better secure perfusion to all organs, with potentially less risk of cerebral ischemia or overuse of vasopressors and fluids, which may affect outcome.
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Affiliation(s)
- Era Mikkonen
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.
| | - Jonas Blixt
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Peter Alpkvist
- Section for Neurosurgery, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Robert Sköldbring
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Bo-Michael Bellander
- Section for Neurosurgery, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Eddie Weitzberg
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - David W Nelson
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Munroe ES, Weinstein J, Gershengorn HB, Karlic KJ, Seelye S, Sjoding MW, Valley TS, Prescott HC. Understanding How Clinicians Personalize Fluid and Vasopressor Decisions in Early Sepsis Management. JAMA Netw Open 2024; 7:e247480. [PMID: 38639934 PMCID: PMC11031682 DOI: 10.1001/jamanetworkopen.2024.7480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/21/2024] [Indexed: 04/20/2024] Open
Abstract
Importance Recent sepsis trials suggest that fluid-liberal vs fluid-restrictive resuscitation has similar outcomes. These trials used generalized approaches to resuscitation, and little is known about how clinicians personalize fluid and vasopressor administration in practice. Objective To understand how clinicians personalize decisions about resuscitation in practice. Design, Setting, and Participants This survey study of US clinicians in the Society of Critical Care Medicine membership roster was conducted from November 2022 to January 2023. Surveys contained 10 vignettes of patients with sepsis where pertinent clinical factors (eg, fluid received and volume status) were randomized. Respondents selected the next steps in management. Data analysis was conducted from February to September 2023. Exposure Online Qualtrics clinical vignette survey. Main Outcomes and Measures Using multivariable logistic regression, the associations of clinical factors with decisions about fluid administration, vasopressor initiation, and vasopressor route were tested. Results are presented as adjusted proportions with 95% CIs. Results Among 11 203 invited clinicians, 550 (4.9%; 261 men [47.5%] and 192 women [34.9%]; 173 with >15 years of practice [31.5%]) completed at least 1 vignette and were included. A majority were physicians (337 respondents [61.3%]) and critical care trained (369 respondents [67.1%]). Fluid volume already received by a patient was associated with resuscitation decisions. After 1 L of fluid, an adjusted 82.5% (95% CI, 80.2%-84.8%) of respondents prescribed additional fluid and an adjusted 55.0% (95% CI, 51.9%-58.1%) initiated vasopressors. After 5 L of fluid, an adjusted 17.5% (95% CI, 15.1%-19.9%) of respondents prescribed more fluid while an adjusted 92.7% (95% CI, 91.1%-94.3%) initiated vasopressors. More respondents prescribed fluid when the patient examination found dry vs wet (ie, overloaded) volume status (adjusted proportion, 66.9% [95% CI, 62.5%-71.2%] vs adjusted proportion, 26.5% [95% CI, 22.3%-30.6%]). Medical history, respiratory status, lactate trend, and acute kidney injury had small associations with fluid and vasopressor decisions. In 1023 of 1127 vignettes (90.8%) where the patient did not have central access, respondents were willing to start vasopressors through a peripheral intravenous catheter. In cases where patients were already receiving peripheral norepinephrine, respondents were more likely to place a central line at higher norepinephrine doses of 0.5 µg/kg/min (adjusted proportion, 78.0%; 95% CI, 74.7%-81.2%) vs 0.08 µg/kg/min (adjusted proportion, 25.2%; 95% CI, 21.8%-28.5%) and after 24 hours (adjusted proportion, 59.5%; 95% CI, 56.6%-62.5%) vs 8 hours (adjusted proportion, 47.1%; 95% CI, 44.0%-50.1%). Conclusions and Relevance These findings suggest that fluid volume received is the predominant factor associated with ongoing fluid and vasopressor decisions, outweighing many other clinical factors. Peripheral vasopressor use is common. Future studies aimed at personalizing resuscitation must account for fluid volumes and should incorporate specific tools to help clinicians personalize resuscitation.
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Affiliation(s)
- Elizabeth S. Munroe
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor
| | - Julien Weinstein
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Hayley B. Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
| | | | - Sarah Seelye
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Michael W. Sjoding
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor
| | - Thomas S. Valley
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Hallie C. Prescott
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor
- VA Center for Clinical Management Research, Ann Arbor, Michigan
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de Martino N, Belghiti Alaoui M, Loreau C, Caruselli M, Michel F. Use of norepinephrine for intraoperative hypotension in pediatric surgery. Minerva Anestesiol 2024; 90:339-340. [PMID: 38270921 DOI: 10.23736/s0375-9393.23.17800-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Affiliation(s)
- Noémie de Martino
- Department of Pediatric Anesthesia and Intensive Care Unit, University Hospitals of Marseille, La Timone Hospital, Marseille, France
| | - Myriem Belghiti Alaoui
- Department of Pediatric Anesthesia and Intensive Care Unit, University Hospitals of Marseille, La Timone Hospital, Marseille, France
| | - Chine Loreau
- Department of Pediatric Anesthesia and Intensive Care Unit, University Hospitals of Marseille, La Timone Hospital, Marseille, France
| | - Marco Caruselli
- Department of Pediatric Anesthesia and Intensive Care Unit, University Hospitals of Marseille, La Timone Hospital, Marseille, France -
| | - Fabrice Michel
- Department of Pediatric Anesthesia and Intensive Care Unit, University Hospitals of Marseille, La Timone Hospital, Marseille, France
- Aix Marseille University, Marseille, France
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Ragoonanan D, Nickelsen P, Tran N, Allen B, Emborski R, Legare A, Villela A, Hampson L, Busey K, Shomo E, Broomfield A, Hailu K. Vasopressin Initiation as a Second-Line Vaso Pressor in Early Septic Shock (VISPSS). J Intensive Care Med 2024; 39:306-312. [PMID: 37715634 DOI: 10.1177/08850666231201364] [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: 09/18/2023]
Abstract
BACKGROUND Vasopressin is recommended as a second-line vasoactive agent for the management of septic shock; however, a paucity of data to guide its optimal use remains. The aim was to evaluate the effect of time-to vasopressin initiation and norepinephrine (NE) dose at vasopressin initiation on clinical outcomes in patients presenting with septic shock. METHODS This was a multi-centered, retrospective, observational study conducted in patients with septic shock. Patients were divided into 2 groups: patients initiated on vasopressin when NE-equivalent dose (NEE) < 0.25 mcg/kg/min or ≥ 0.25 mcg/kg/min. The primary outcome was time-to-vasopressor discontinuation (hours). Secondary outcomes included 28-day in-hospital mortality, intensive care unit (ICU) length of stay (LOS), fluid balance after 72 hours, and the change in NEE at 12 hours. RESULTS A total of 302 patients were included in this study. After propensity-score matching, 73 patients in each group were identified for analysis. There was no significant difference in the time-to-vasopressor discontinuation (hours) between the groups (88.8 [55-187.5] vs 86.7 [47-172]); p = 0.7815). Fluid balance (mL) at 72 hours was significantly lower when vasopressin was initiated at NEE < 0.25 mcg/kg/min (1769 [71-7287] vs 5762 [1463-8813]; p = 0.0077). A multivariable linear regression showed shorter time to shock resolution with earlier vasopressin initiation, defined as within 4 hours (p < 0.05). CONCLUSION In this propensity-score matched cohort, vasopressin initiation at NEE < 0.25 mcg/kg/min was not associated with shorter vasopressor duration. There was a lower fluid balance at 72 hours when vasopressin was initiated at lower NE doses.
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Affiliation(s)
- David Ragoonanan
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Paige Nickelsen
- Department of Pharmacy Services, University of California San Diego, San Diego, CA, USA
| | - Nicolas Tran
- Department of Pharmacy Services, Tampa General Hospital, Tampa, FL, USA
| | - Bryan Allen
- Department of Pharmacy Services, Ascension St. Vincent's, Jacksonville, FL, USA
| | - Rebecca Emborski
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Anit Legare
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Antonia Villela
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Lauryn Hampson
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Kirsten Busey
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Eileen Shomo
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Abby Broomfield
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Kirubel Hailu
- Department of Pharmacy Services, Ascension St. Vincent's, Jacksonville, FL, USA
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Wieruszewski PM, Leone M, Khanna AK. Commentary: The never-ending quest to equate vasopressor dosages. J Crit Care 2024; 80:154460. [PMID: 37925243 DOI: 10.1016/j.jcrc.2023.154460] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 10/27/2023] [Indexed: 11/06/2023]
Affiliation(s)
- Patrick M Wieruszewski
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, United States of America; Department of Pharmacy, Mayo Clinic, Rochester, MN, United States of America.
| | - Marc Leone
- Department of Anesthesiology and Intensive Care Unit, North Hospital, Aix Marseille Université, Assistance Publique Hôpitaux Universitaires de Marseille, Marseille, France
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States of America; Outcomes Research Consortium, Cleveland, OH, United States of America
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12
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Foth A, Stewart D, Tingay DG. Neonatal resuscitation with vasopressin instead of epinephrine: are we ready to challenge the status quo? Pediatr Res 2024; 95:1174-1176. [PMID: 38071278 DOI: 10.1038/s41390-023-02961-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 04/24/2024]
Affiliation(s)
- Anna Foth
- Department of Neonatology, Royal Children's Hospital, Melbourne, VIC, Australia
| | - David Stewart
- Department of Neonatology, Royal Children's Hospital, Melbourne, VIC, Australia
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - David G Tingay
- Department of Neonatology, Royal Children's Hospital, Melbourne, VIC, Australia.
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.
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13
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Barbash IJ. Real World Data on Peripheral Vasopressors in Septic Shock. Chest 2024; 165:762-763. [PMID: 38599747 DOI: 10.1016/j.chest.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 04/12/2024] Open
Affiliation(s)
- Ian J Barbash
- University of Pittsburgh School of Medicine, Pittsburgh, PA.
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Munroe ES, Heath ME, Eteer M, Gershengorn HB, Horowitz JK, Jones J, Kaatz S, Tamae Kakazu M, McLaughlin E, Flanders SA, Prescott HC. Use and Outcomes of Peripheral Vasopressors in Early Sepsis-Induced Hypotension Across Michigan Hospitals: A Retrospective Cohort Study. Chest 2024; 165:847-857. [PMID: 37898185 DOI: 10.1016/j.chest.2023.10.027] [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: 08/18/2023] [Revised: 10/09/2023] [Accepted: 10/17/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND Vasopressors traditionally are administered via central access, but newer data suggest that peripheral administration may be safe and may avoid delays and complications associated with central line placement. RESEARCH QUESTION How commonly are vasopressors initiated through peripheral IV lines in routine practice? Is vasopressor initiation route associated with in-hospital mortality? STUDY DESIGN AND METHODS This retrospective cohort study included adults hospitalized with sepsis (November 2020-September 2022) at 29 hospitals in the Michigan Hospital Medicine Safety Consortium, a Collaborative Quality Initiative sponsored by Blue Cross Blue Shield of Michigan. We assessed route of early vasopressor initiation, factors and outcomes associated with peripheral initiation, and timing of central line placement. RESULTS Five hundred ninety-four patients received vasopressors within 6 h of hospital arrival and were included in this study. Peripheral vasopressor initiation was common (400/594 [67.3%]). Patients with peripheral vs central initiation were similar; BMI was the only patient factor associated independently with initiation route (adjusted OR [aOR] of peripheral initiation [per 1-kg/m2 increase], 0.98; 95% CI, 0.97-1.00; P = .015). The specific hospital showed a large impact on initiation route (median OR, 2.19; 95% CI, 1.31-3.07). Compared with central initiation, peripheral initiation was faster (median, 2.5 h vs 2.7 h from hospital arrival; P = .002), but was associated with less initial norepinephrine use (84.3% vs 96.8%; P = .001). We found no independent association between initiation route and in-hospital mortality (32.3% vs 42.2%; aOR, 0.66; 95% CI, 0.39-1.12). No tissue injury from peripheral vasopressors was documented. Of patients with peripheral initiation, 135 of 400 patients (33.8%) never received a central line. INTERPRETATION Peripheral vasopressor initiation was common across Michigan hospitals and had practical benefits, including expedited vasopressor administration and avoidance of central line placement in one-third of patients. However, the findings of wide practice variation that was not explained by patient case mix and lower use of first-line norepinephrine with peripheral administration suggest that additional standardization may be needed.
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Affiliation(s)
- Elizabeth S Munroe
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI.
| | - Megan E Heath
- Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI; The Michigan Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, MI
| | - Mousab Eteer
- Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health, Detroit, MI
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL; Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Jennifer K Horowitz
- Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI; The Michigan Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, MI
| | - Jessica Jones
- Department of Pharmacy, Corewell Health, Dearborn, MI
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Health, Detroit, MI
| | | | - Elizabeth McLaughlin
- Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI; The Michigan Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, MI
| | - Scott A Flanders
- Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Hallie C Prescott
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI; VA Center for Clinical Management Research, Ann Arbor, MI
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15
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Juanola A, Cárdenas A. Terlipressin plus albumin in patients with HRS listed for liver transplant: Treat early and avoid RRT. Liver Transpl 2024; 30:335-336. [PMID: 38100174 DOI: 10.1097/lvt.0000000000000316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/07/2023] [Indexed: 01/06/2024]
Affiliation(s)
- Adrià Juanola
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomediques August Pi i Sunyer, Barcelona, Spain
- Centro de Investigacion Biomedica en Red Enfermedades Hepaticas y Digestivas, Barcelona, Spain
| | - Andrés Cárdenas
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomediques August Pi i Sunyer, Barcelona, Spain
- Centro de Investigacion Biomedica en Red Enfermedades Hepaticas y Digestivas, Barcelona, Spain
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16
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Ramsie M, Cheung PY, Lee TF, O'Reilly M, Schmölzer GM. Comparison of various vasopressin doses to epinephrine during cardiopulmonary resuscitation in asphyxiated neonatal piglets. Pediatr Res 2024; 95:1265-1272. [PMID: 37940664 PMCID: PMC11035119 DOI: 10.1038/s41390-023-02858-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/22/2023] [Accepted: 09/24/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Current neonatal resuscitation guidelines recommend epinephrine for cardiac arrest. Vasopressin might be an alternative during asphyxial cardiac arrest. We aimed to compare vasopressin and epinephrine on incidence and time to return of spontaneous circulation (ROSC) in asphyxiated newborn piglets. DESIGN/METHODS Newborn piglets (n = 8/group) were anesthetized, intubated, instrumented, and exposed to 30 min of normocapnic hypoxia, followed by asphyxia and asystolic cardiac arrest. Piglets were randomized to 0.2, 0.4, or 0.8IU/kg vasopressin, or 0.02 mg/kg epinephrine. Hemodynamic parameters were continuously measured. RESULTS Median (IQR) time to ROSC was 172(103-418)s, 157(100-413)s, 122(93-289)s, and 276(117-480)s for 0.2, 0.4, 0.8IU/kg vasopressin, and 0.02 mg/kg epinephrine groups, respectively (p = 0.59). The number of piglets that achieved ROSC was 6(75%), 6(75%), 7(88%), and 5(63%) for 0.2, 0.4, 0.8IU/kg vasopressin, and 0.02 mg/kg epinephrine, respectively (p = 0.94). The epinephrine group had a 60% (3/5) rate of post-ROSC survival compared to 83% (5/6), 83% (5/6), and 57% (4/7) in the 0.2, 0.4, and 0.8IU/kg vasopressin groups, respectively (p = 0.61). CONCLUSION Time to and incidence of ROSC were not different between all vasopressin dosages and epinephrine. However, non-significantly lower time to ROSC and higher post-ROSC survival in vasopressin groups warrant further investigation. IMPACT Time to and incidence of ROSC were not statistically different between all vasopressin dosages and epinephrine. Non-significantly lower time to ROSC and higher post-ROSC survival in vasopressin-treated piglets. Overall poorer hemodynamic recovery following ROSC in epinephrine piglets compared to vasopressin groups. Human neonatal clinical trials examining the efficacy of vasopressin during asphyxial cardiac arrest will begin recruitment soon.
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Affiliation(s)
- Marwa Ramsie
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Tze-Fun Lee
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Megan O'Reilly
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada.
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.
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17
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Kattan E, Ibarra-Estrada M, Jung C. Knowing the ropes of vasopressor dosing: a focus on norepinephrine. Intensive Care Med 2024; 50:587-589. [PMID: 38498164 PMCID: PMC11018687 DOI: 10.1007/s00134-024-07374-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 02/25/2024] [Indexed: 03/20/2024]
Affiliation(s)
- Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Miguel Ibarra-Estrada
- Unidad de Terapia Intensiva, Hospital Civil Fray Antonio Alcalde, Universidad de Guadalajara. Guadalajara, Jalisco, México
| | - Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225, Duesseldorf, Germany.
- CARID (Cardiovascular Research Institute Düsseldorf), Düsseldorf, Germany.
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18
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Weinberg EM, Wong F, Vargas HE, Curry MP, Jamil K, Pappas SC, Sharma P, Reddy KR. Decreased need for RRT in liver transplant recipients after pretransplant treatment of hepatorenal syndrome-type 1 with terlipressin. Liver Transpl 2024; 30:347-355. [PMID: 37801553 DOI: 10.1097/lvt.0000000000000277] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/25/2023] [Indexed: 10/08/2023]
Abstract
Hepatorenal syndrome-acute kidney injury (HRS-AKI), a serious complication of decompensated cirrhosis, has limited therapeutic options and significant morbidity and mortality. Terlipressin improves renal function in some patients with HRS-1, while liver transplantation (LT) is a curative treatment for advanced chronic liver disease. Renal failure post-LT requiring renal replacement therapy (RRT) is a major risk factor for graft and patient survival. A post hoc analysis with a 12-month follow-up of LT recipients from a placebo-controlled trial of terlipressin (CONFIRM; NCT02770716) was conducted to evaluate the need for RRT and overall survival. Patients with HRS-1 were treated with terlipressin plus albumin or placebo plus albumin for up to 14 days. RRT was defined as any type of procedure that replaced kidney function. Outcomes compared between groups included the incidence of HRS-1 reversal, the need for RRT (pretransplant and posttransplant), and overall survival. Of the 300 patients in CONFIRM (terlipressin n = 199; placebo, n = 101), 70 (23%) underwent LT alone (terlipressin, n = 43; placebo, n = 27) and 5 had simultaneous liver-kidney transplant (terlipressin, n = 3, placebo, n = 2). The rate of HRS reversal was significantly higher in the terlipressin group compared with the placebo group (37%, n = 16 vs. 15%, n = 4; p = 0.033). The pretransplant need for RRT was significantly lower among those who received terlipressin ( p = 0.007). The posttransplant need for RRT, at 12 months, was significantly lower among those patients who received terlipressin and were alive at Day 365, compared to placebo ( p = 0.009). Pretransplant treatment with terlipressin plus albumin in patients with HRS-1 decreased the need for RRT pretransplant and posttransplant.
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Affiliation(s)
| | | | | | - Michael P Curry
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Khurram Jamil
- Mallinckrodt Pharmaceuticals, Bridgewater, New Jersey, USA
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Ma H, Ahrens E, Wachtendorf LJ, Suleiman A, Shay D, Munoz-Acuna R, Tartler TM, Teja B, Wagner S, Subramaniam B, Rhee J, Schaefer MS. Intraoperative Use of Phenylephrine versus Ephedrine and Postoperative Delirium: A Multicenter Retrospective Cohort Study. Anesthesiology 2024; 140:657-667. [PMID: 37725759 DOI: 10.1097/aln.0000000000004774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
BACKGROUND The treatment of intraoperative hypotension with phenylephrine may impair cerebral perfusion through vasoconstriction, which has been linked to postoperative delirium. The hypothesis was that intraoperative administration of phenylephrine, compared to ephedrine, is associated with higher odds of postoperative delirium. METHODS A total of 103,094 hospitalized adults undergoing general anesthesia for noncardiac, non-neurosurgical procedures between 2008 and 2020 at two tertiary academic healthcare networks in Massachusetts were included in this multicenter hospital registry study. The primary exposure was the administration of phenylephrine versus ephedrine during surgery, and the primary outcome was postoperative delirium within 7 days. Multivariable logistic regression analyses adjusted for a priori defined confounding variables including patient demographics, comorbidities, and procedural factors including magnitude of intraoperative hypotension were applied. RESULTS Between the two healthcare networks, 78,982 (76.6%) patients received phenylephrine, and 24,112 (23.4%) patients received ephedrine during surgery; 770 patients (0.8%) developed delirium within 7 days. The median (interquartile range) total intraoperative dose of phenylephrine was 1.0 (0.2 to 3.3) mg and 10.0 (10.0 to 20.0) mg for ephedrine. In adjusted analyses, the administration of phenylephrine, compared to ephedrine, was associated with higher odds of developing postoperative delirium within 7 days (adjusted odds ratio, 1.35; 95% CI, 1.06 to 1.71; and adjusted absolute risk difference, 0.2%; 95% CI, 0.1 to 0.3%; P = 0.015). A keyword and manual chart review-based approach in a subset of 45,465 patients further validated these findings (delirium incidence, 3.2%; adjusted odds ratio, 1.88; 95% CI, 1.49 to 2.37; P < 0.001). Fractional polynomial regression analysis further indicated a dose-dependent effect of phenylephrine (adjusted coefficient, 0.08; 95% CI, 0.02 to 0.14; P = 0.013, per each μg/kg increase in the cumulative phenylephrine dose). CONCLUSIONS The administration of phenylephrine compared to ephedrine during general anesthesia was associated with higher odds of developing postoperative delirium. Based on these data, clinical trials are warranted to determine whether favoring ephedrine over phenylephrine for treatment of intraoperative hypotension can reduce delirium after surgery. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Haobo Ma
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Elena Ahrens
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Luca J Wachtendorf
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Aiman Suleiman
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts; and Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Denys Shay
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts; and Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ricardo Munoz-Acuna
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Tim M Tartler
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Bijan Teja
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Soeren Wagner
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Balachundhar Subramaniam
- Department of Anesthesia, Critical Care and Pain Medicine and Sadhguru Center for a Conscious Planet, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - James Rhee
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, Massachusetts; and Department of Anesthesiology, University Hospital Duesseldorf, Düsseldorf, Germany
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20
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Wedemire C, Samavat H, Newkirk M, Parker A. Treatment of refractory shock with vitamin B 12 : A narrative review. Nutr Clin Pract 2024; 39:356-365. [PMID: 38030578 DOI: 10.1002/ncp.11095] [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: 07/26/2023] [Revised: 10/17/2023] [Accepted: 10/28/2023] [Indexed: 12/01/2023] Open
Abstract
High-dose vitamin B12 is a potential treatment for patients with vasodilatory shock that is refractory to other therapies. Vasodilatory shock is characterized by low blood pressure and low systemic vascular resistance. Nitric oxide and hydrogen sulfide, two potential targets of high-dose vitamin B12 given as hydroxocobalamin, facilitate this syndrome. This review explores the relationship between high-dose vitamin B12 and hemodynamic outcomes in adults with vasodilatory shock and provides an update on the literature since a 2019 review on this topic. A literature search of studies published in the past 5 years was conducted in the CINAHL, PubMed, Cochrane, and EMBASE databases in May 2023. After assessing for eligibility, eight studies met this review's inclusion criteria. Seven of the eight studies reported decreased vasopressor requirements for part or all of the study samples after receiving a hydroxocobalamin infusion. However, not all patients responded to hydroxocobalamin. These findings are limited by patient selection and differences in the timing of vasopressor requirement and blood pressure outcome assessments. The current evidence is promising as to whether vitamin B12 , given as a hydroxocobalamin infusion, may improve hemodynamic outcomes in vasodilatory shock, but the evidence is of low quality. The use of hydroxocobalamin to treat refractory, vasodilatory shock remains investigative. Larger randomized controlled trials are required to elucidate the role of vitamin B12 in treating refractory, vasodilatory shock, including in conjunction with other alternative therapies such as methylene blue and corticosteroids.
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Affiliation(s)
- Courtney Wedemire
- Department of Dietitian Services, Abbotsford Regional Hospital, Abbotsford, British Columbia, Canada
| | - Hamed Samavat
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Newark, New Jersey, USA
| | - Melanie Newkirk
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Newark, New Jersey, USA
| | - Anna Parker
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Newark, New Jersey, USA
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21
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Jeon Y, Kim S, Ahn S, Park JH, Cho H, Moon S, Lee S. Predicting septic shock in patients with sepsis at emergency department triage using systolic and diastolic shock index. Am J Emerg Med 2024; 78:196-201. [PMID: 38301370 DOI: 10.1016/j.ajem.2024.01.029] [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: 07/11/2023] [Revised: 12/19/2023] [Accepted: 01/15/2024] [Indexed: 02/03/2024] Open
Abstract
INTRODUCTION Identifying patients with at a high risk of progressing to septic shock is essential. Due to systemic vasodilation in the pathophysiology of septic shock, the use of diastolic blood pressure (DBP) has emerged. We hypothesized that the initial shock index (SI) and diastolic SI (DSI) at the emergency department (ED) triage can predict septic shock. METHOD This observational study used the prospectively collected sepsis registry. The primary outcome was progression to septic shock. Secondary outcomes were the time to vasopressor requirement, vasopressor dose, and severity according to SI and DSI. Patients were classified by tertiles according to the first principal component of shock index and diastolic shock index. RESULTS A total of 1267 patients were included in the analysis. The area under the receiver operating characteristic curve (AUC) for predicting progression to septic shock for DSI was 0.717, while that for SI was 0.707. The AUC for predicting progression to septic shock for DSI and SI were significantly higher than those for conventional early warning scores. Middle tertile showed adjusted Odd ratio (aOR) of 1.448 (95% CI 1.074-1.953), and that of upper tertile showed 3.704 (95% CI 2.299-4.111). CONCLUSION The SI and DSI were significant predictors of progression to septic shock. Our findings suggest an association between DSI and vasopressor requirement. We propose stratifying lower tertile as being at low risk, middle tertile as being at intermediate risk, and upper tertile as being at high risk of progression to septic shock. This system can be applied simply at the ED triage.
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Affiliation(s)
- Yumin Jeon
- Department of Emergency Medicine, Korea University Ansan Hospital, 15355, Ansan-si, Republic of Korea
| | - Sungjin Kim
- Department of Emergency Medicine, Korea University Ansan Hospital, 15355, Ansan-si, Republic of Korea
| | - Sejoong Ahn
- Department of Emergency Medicine, Korea University Ansan Hospital, 15355, Ansan-si, Republic of Korea
| | - Jong-Hak Park
- Department of Emergency Medicine, Korea University Ansan Hospital, 15355, Ansan-si, Republic of Korea
| | - Hanjin Cho
- Department of Emergency Medicine, Korea University Ansan Hospital, 15355, Ansan-si, Republic of Korea
| | - Sungwoo Moon
- Department of Emergency Medicine, Korea University Ansan Hospital, 15355, Ansan-si, Republic of Korea
| | - Sukyo Lee
- Department of Emergency Medicine, Korea University Ansan Hospital, 15355, Ansan-si, Republic of Korea.
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22
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Wu W, Zheng Q, Zhou J, Li X, Zhou H. Norepinephrine versus phenylephrine on cerebral tissue oxygen saturation during prophylactic infusion to prevent spinal hypotension for Caesarean birth. Medicine (Baltimore) 2024; 103:e37454. [PMID: 38457564 PMCID: PMC10919502 DOI: 10.1097/md.0000000000037454] [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: 12/05/2023] [Revised: 01/08/2024] [Accepted: 02/09/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Phenylephrine may cause a reduction in maternal cerebral tissue oxygen saturation (SctO2) during Caesarean birth to prevent spinal hypotension; however, the effect of norepinephrine has not been assessed. We hypothesized that norepinephrine was more effective than phenylephrine in maintaining SctO2 when preventing spinal hypotension during Caesarean birth. METHODS We conducted a randomized, double-blind, controlled study. Sixty patients were randomly assigned to prophylactic norepinephrine or phenylephrine to maintain blood pressure during spinal anesthesia for Caesarean birth. SctO2, systolic blood pressure, and heart rate were recorded. The primary outcome was the incidence of a 10% reduction of intraoperative SctO2 from baseline or more during Caesarean birth. RESULTS The norepinephrine group had a lower incidence of more than 10% reduction of intraoperative SctO2 from baseline than that of the phenylephrine group (13.3% vs 40.0%, P = .02). The change in SctO2 after 5 minutes of norepinephrine infusion was higher than that after phenylephrine infusion (-3.4 ± 4.7 vs -6.2 ± 5.6, P = .04). The change in SctO2 after 10 minutes of norepinephrine infusion was higher than that after phenylephrine infusion (-2.5 ± 4.4 vs -5.4 ± 4.6, P = .006). The norepinephrine group showed greater left- and right-SctO2 values than the phenylephrine group at 5 to 10 minutes. However, the change in systolic blood pressure was comparable between the 2 groups. CONCLUSION Norepinephrine was more effective than phenylephrine in maintaining SctO2 when preventing spinal hypotension during Caesarean birth. However, the changes in clinical outcomes caused by differences in SctO2 between the 2 medications warrant further studies.
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Affiliation(s)
- Weiguo Wu
- Department of Anaesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, P. R. China
| | - Qiang Zheng
- Department of Anaesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, P. R. China
| | - Jinfeng Zhou
- Department of Anaesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, P. R. China
| | - Xiujuan Li
- Department of Anaesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, P. R. China
| | - Haipeng Zhou
- Department of Anaesthesiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, P. R. China
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23
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Ko CC, Lee PH, Lee JS, Lee KZ. Spinal decompression surgery may alleviate vasopressor-induced spinal hemorrhage and extravasation during acute cervical spinal cord injury in rats. Spine J 2024; 24:519-533. [PMID: 37793474 DOI: 10.1016/j.spinee.2023.09.021] [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: 06/19/2023] [Revised: 09/19/2023] [Accepted: 09/26/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Cervical spinal injury often disrupts the supraspinal vasomotor pathways projecting to the thoracic sympathetic preganglionic neurons, leading to cardiovascular dysfunction. The current guideline is to maintain the mean arterial blood pressure at 85 to 90 mmHg using a vasopressor during the first week of the injury. Some studies have demonstrated that this treatment might be beneficial to alleviate secondary injury and improve neurological outcomes; however, elevation of blood pressure may exacerbate spinal hemorrhage, extravasation, and edema, exacerbating the initial injury. PURPOSE The present study was designed to (1) examine whether vasopressor administration exacerbates spinal hemorrhage and extravasation; (2) evaluate whether spinal decompression surgery relieves vasopressor-induced spinal hemorrhage and extravasation. STUDY DESIGN In vivo animal study. METHODS Animals received a saline solution or a vasopressor (phenylephrine hydrochloride, 500 or 1000 μg/kg, 7 mL/kg/h) after mid-cervical contusion with or without spinal decompression (ie, incision of the dura and arachnoid mater). Spinal cord hemorrhage and extravasation were examined by expression of Evans blue within the spinal cord section. RESULTS The results demonstrated that cervical spinal contusion significantly reduced the mean arterial blood pressure and induced spinal hemorrhage and extravasation. Phenylephrine infusion significantly elevated the mean arterial blood pressure to the preinjury level within 15 to 60 minutes postcontusion; however, spinal hemorrhage and extravasation were more extensive in animals that received phenylephrine than in those that received saline. Notably, spinal decompression mitigated spinal hemorrhage and extravasation in contused rats who received phenylephrine. CONCLUSIONS These data indicate that, although phenylephrine can prevent hypotension after cervical spinal injury, it also causes excess spinal hemorrhage and extravasation. CLINICAL SIGNIFICANCE Spinal decompressive surgery seemed to minimize the side effect of phenylephrine as vasopressor treatment during acute spinal cord injury.
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Affiliation(s)
- Chia-Chen Ko
- Department of Biological Sciences, National Sun Yat-sen University, No. 70, Lien-Hai Rd., Kaohsiung city 804, Taiwan
| | - Po-Hsuan Lee
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, No. 138, Sheng-Li Rd., Tainan city 704, Taiwan
| | - Jung-Shun Lee
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, No. 138, Sheng-Li Rd., Tainan city 704, Taiwan; Department of Cell Biology and Anatomy, College of Medicine, National Cheng Kung University, No.1, University Rd., Tainan city 701, Taiwan; Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, No.1, University Rd., Tainan city 701, Taiwan
| | - Kun-Ze Lee
- Department of Biological Sciences, National Sun Yat-sen University, No. 70, Lien-Hai Rd., Kaohsiung city 804, Taiwan; Department of Biomedical Science and Environmental Biology, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Rd., Kaohsiung city 807, Taiwan.
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24
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Johnson D, Hensler JG, O'Sullivan J, Blouin D, de la Garza MA, Yauger Y. Effects of Endotracheal Epinephrine on Pharmacokinetics and Survival in a Swine Pediatric Cardiac Arrest Model. Pediatr Emerg Care 2024; 40:197-202. [PMID: 38416651 DOI: 10.1097/pec.0000000000003142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2024]
Abstract
OBJECTIVES The aim of this study was to compare the endotracheal tube (ET) and intravenous (IV) administration of epinephrine relative to concentration maximum, time to maximum concentration, mean concentration over time (MC), area under the curve, odds, and time to return of spontaneous circulation (ROSC) in a normovolemic pediatric cardiac arrest model. METHODS Male swine weighing 24-37 kg were assigned to 4 groups: ET (n = 8), IV (n = 7), cardiopulmonary resuscitation (CPR) + defibrillation (CPR + Defib) (n = 5), and CPR only (n = 3). Swine were placed arrest for 2 minutes, and then CPR was initiated for 2 minutes. Epinephrine (0.1 mg/kg) for the ET group or 0.01 mg/kg for the IV was administered every 4 minutes or until ROSC. Defibrillation started at 3 minutes and continued every 2 minutes for 30 minutes or until ROSC for all groups except the CPR-only group. Blood samples were collected over a period of 5 minutes. RESULTS The MC of plasma epinephrine for the IV group was significantly higher at the 30- and 60-second time points (P = 0.001). The ET group had a significantly higher MC of epinephrine at the 180- and 240-second time points (P < 0.05). The concentration maximum of plasma epinephrine was significantly lower for the ET group (195 ± 32 ng/mL) than for the IV group (428 ± 38 ng/mL) (P = 0.01). The time to maximum concentration was significantly longer for the ET group (145 ± 26 seconds) than for the IV group (42 ± 16 seconds) (P = 0.01). No significant difference existed in area under the curve between the 2 groups (P = 0.62). The odds of ROSC were 7.7 times greater for the ET versus IV group. Time to ROSC was not significantly different among the IV, ET, and CPR + Defib groups (P = 0.31). CONCLUSIONS Based on the results of this study, the ET route of administration should be considered a first-line intervention.
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Affiliation(s)
- Don Johnson
- From the US Army Graduate Program in Anesthesia Nursing, US Army Medical Center of Excellence, Fort Sam Houston, TX
| | - Julie G Hensler
- From the US Army Graduate Program in Anesthesia Nursing, US Army Medical Center of Excellence, Fort Sam Houston, TX
| | | | | | | | - Young Yauger
- TriService Nursing Research Program, Uniformed Services University, Bethesda, MD
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25
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Levy B, Lescroart M, Combes A. Use of vasopressors and inotropes in ECMO. Intensive Care Med 2024; 50:463-466. [PMID: 38372746 DOI: 10.1007/s00134-024-07338-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/27/2024] [Indexed: 02/20/2024]
Affiliation(s)
- Bruno Levy
- Médecine Intensive et Réanimation, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Vandoeuvre-les-Nancy, France.
- INSERM U1116, Faculté de Médecine, Vandoeuvre-les-Nancy, France.
- Université de Lorraine, Nancy, France.
| | - Mickael Lescroart
- Médecine Intensive et Réanimation, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Vandoeuvre-les-Nancy, France
- INSERM U1116, Faculté de Médecine, Vandoeuvre-les-Nancy, France
- Université de Lorraine, Nancy, France
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
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26
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Slim MA, Turgman O, van Vught LA, van der Poll T, Wiersinga WJ. Non-conventional immunomodulation in the management of sepsis. Eur J Intern Med 2024; 121:9-16. [PMID: 37919123 DOI: 10.1016/j.ejim.2023.10.032] [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: 10/17/2023] [Accepted: 10/24/2023] [Indexed: 11/04/2023]
Abstract
Sepsis remains a critical global health issue, demanding novel therapeutic strategies. Traditional immunomodulation treatments such as corticosteroids, specific modifiers of cytokines, complement or coagulation, growth factors or immunoglobulins, have so far fallen short. Meanwhile the number of studies investigating non-conventional immunomodulatory strategies is expanding. This review provides an overview of adjunctive treatments with herbal-based medicine, immunonutrition, vasopressors, sedative treatments and targeted temperature management, used to modulate the immune response in patients with sepsis. Herbal-based medicine, notably within traditional Chinese medicine, shows promise. Xuebijing injection and Shenfu injection exhibit anti-inflammatory and immune-modulatory effects, and the potential to lower 28-day mortality in sepsis. Selenium supplementation has been reported to reduce the occurrence of ventilator-associated pneumonia among sepsis patients, but study results are conflicting. Likewise, the immune-suppressive effects of omega-3 fatty acids have been associated with improved clinical outcomes in sepsis. The immunomodulating properties of supportive treatments also gain interest. Vasopressors like norepinephrine exhibit dual dosage-dependent roles, potentially promoting both pro- and anti-inflammatory effects. Dexmedetomidine, a sedative, demonstrates anti-inflammatory properties, reducing sepsis mortality rates in some studies. Temperature management, particularly maintaining higher body temperature, has also been associated with improved outcomes in small scale human trials. In conclusion, emerging non-conventional immunomodulatory approaches, including herbal medicine, immunonutrition, and targeted supportive therapies, hold potential for sepsis treatment, but their possible implementation into everyday clinical practice necessitates further research and stringent clinical validation in different settings.
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Affiliation(s)
- M A Slim
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands; Department of Intensive Care, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands.
| | - O Turgman
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
| | - L A van Vught
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands; Department of Intensive Care, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
| | - T van der Poll
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands; Department of Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - W J Wiersinga
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands; Department of Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, the Netherlands
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27
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Doğan NÖ. Initial Vasopressor Dosing After Return of Spontaneous Circulation: Which Drug, Which Dose? J Emerg Med 2024; 66:e391-e392. [PMID: 38499403 DOI: 10.1016/j.jemermed.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/31/2023] [Accepted: 11/04/2023] [Indexed: 03/20/2024]
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Lawson CK, Faine BA, Rech MA, Childs CA, Brown CS, Slocum GW, Acquisto NM, Ray L. Norepinephrine versus epinephrine for hemodynamic support in post-cardiac arrest shock: A systematic review. Am J Emerg Med 2024; 77:158-163. [PMID: 38150986 DOI: 10.1016/j.ajem.2023.12.031] [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: 11/03/2023] [Accepted: 12/17/2023] [Indexed: 12/29/2023] Open
Abstract
PURPOSE The preferred vasopressor in post-cardiac arrest shock has not been established with robust clinical outcomes data. Our goal was to perform a systematic review and meta-analysis comparing rates of in-hospital mortality, refractory shock, and hemodynamic parameters in post-cardiac arrest patients who received either norepinephrine or epinephrine as primary vasopressor support. METHODS We conducted a search of PubMed, Cochrane Library, and CINAHL from 2000 to 2022. Included studies were prospective, retrospective, or published abstracts comparing norepinephrine and epinephrine in adults with post-cardiac arrest shock or with cardiogenic shock and extractable post-cardiac arrest data. The primary outcome of interest was in-hospital mortality. Other outcomes included incidence of arrhythmias or refractory shock. RESULTS The database search returned 2646 studies. Two studies involving 853 participants were included in the systematic review. The proposed meta-analysis was deferred due to low yield. Crude incidence of in-hospital mortality was numerically higher in the epinephrine group compared with norepinephrine in both studies, but only statistically significant in one. Risk of bias was moderate to severe for in-hospital mortality. Additional outcomes were reported differently between studies, minimizing direct comparison. CONCLUSION The vasopressor with the best mortality and hemodynamic outcomes in post-cardiac arrest shock remains unclear. Randomized studies are crucial to remedy this.
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Affiliation(s)
- Christine K Lawson
- Department of Pharmacy, Rhode Island Hospital, 593 Eddy St, Providence, RI 02903, USA.
| | - Brett A Faine
- Department of Pharmacy and Department of Emergency Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Dr., Iowa City, IA 52242, USA
| | - Megan A Rech
- Department of Veteran Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, 5000 5th Ave., Hines, IL 60141, USA
| | - Christopher A Childs
- Hardin Library for the Health Sciences, University of Iowa, 600 Newton Rd., Iowa City, IA 52242, USA
| | - Caitlin S Brown
- Department of Emergency Medicine and Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Giles W Slocum
- Department of Emergency Medicine and Department of Pharmacy, Rush University Medical Center, 1653 W. Congress Parkway, Chicago, IL 60612, USA
| | - Nicole M Acquisto
- Department of Emergency Medicine and Department of Pharmacy, University of Rochester Medical Center, 601 Elmwood Ave, Box 638, Rochester, NY 14642, USA
| | - Lance Ray
- Department of Pharmacy, Denver Health and Hospital Authority, 790 Delaware St., MC 0056, Denver, CO 80204, USA; Department of Emergency Medicine, University of Colorado, 13001 E 17th Pl., Aurora, CO 80045, USA
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Kurita T, Kawashima S, Khaleelullah MMSI, Nakajima Y. IMPACT OF HIGH-DOSE VASOPRESSOR DURING ENDOTOXIC SHOCK ON THE CEREBRAL, LINGUAL, HEPATIC, AND RENAL MICROCIRCULATION EVALUATED BY NEAR-INFRARED SPECTROSCOPY IN SWINE. Shock 2024; 61:406-413. [PMID: 38010114 DOI: 10.1097/shk.0000000000002282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
ABSTRACT Background: High-dose vasopressors maintain blood pressure during septic shock but may adversely reduce microcirculation in vital organs. We assessed the effect of high-dose norepinephrine and vasopressin on the microcirculation of the brain, tongue, liver, and kidney during endotoxic shock using near-infrared spectroscopy (NIRS). Methods: Thirteen pigs (24.5 ± 1.8 kg) were anesthetized, and an NIRS probe was attached directly to each organ. Approximately 0.2, 0.5, 1, and 2 μg/kg/min of norepinephrine were administered in a stepwise manner, followed by 0.5, 1, 2, and 5 μg/kg/min of sodium nitroprusside in normal condition. Moreover, 1 μg/kg/h of lipopolysaccharide was administered continuously after 100 μg bolus to create endotoxic shock and after 1,000 mL of crystalloid infusion and high-dose norepinephrine (2, 5, 10, and 20 μg/kg/min) and vasopressin (0.6, 1.5, 3, and 6 U/min) were administered in a stepwise manner. The relationship between the MAP and each tissue oxygenation index (TOI) during vasopressor infusion was evaluated. Results: Three pigs died after receiving lipopolysaccharides, and 10 were analyzed. An increase of >20% from the baseline MAP induced by high-dose norepinephrine during endotoxic shock reduced the TOI in all organs except the liver. The elevation of MAP to baseline with vasopressin alone increased the kidney and liver TOIs and decreased the tongue TOI. Conclusion: Forced blood pressure elevation with high-dose norepinephrine during endotoxic shock decreased the microcirculation of vital organs, especially the kidney. Cerebral TOI may be useful for identifying the upper limit of blood pressure, at which norepinephrine impairs microcirculation.
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Affiliation(s)
- Tadayoshi Kurita
- Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, Hamamatsu, Japan
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30
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Yang J, Zou X, Wang R, Kang Y, Ou X, Wang B. MEAN ARTERIAL PRESSURE/NOREPINEPHRINE EQUIVALENT DOSE INDEX AS AN EARLY MEASURE FOR MORTALITY RISK IN PATIENTS WITH SHOCK ON VASOPRESSORS. Shock 2024; 61:253-259. [PMID: 38157472 DOI: 10.1097/shk.0000000000002298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
ABSTRACT Purpose: We aimed to investigate the association between the early mean arterial pressure (MAP)/norepinephrine equivalent dose (NEQ) index and mortality risk in patients with shock on vasopressors and further identify the breakpoint value of the MAP/NEQ index for high mortality risk. Methods: Based on the Medical Information Mart for Intensive Care IV database, we conducted a retrospective cohort study involving 19,539 eligible intensive care unit records assigned to three groups (first tertile, second tertile, and third tertile) by different MAP/NEQ indexes within 24 h of intensive care unit admission. The study outcomes were 7-, 14-, 21-, and 28-day mortality. A Cox model was used to examine the risk of mortality following different MAP/NEQ indexes. The receiving operating characteristic curve was used to evaluate the predictive ability of the MAP/NEQ index. The restricted cubic spline was applied to fit the flexible correlation between the MAP/NEQ index and risk of mortality, and segmented regression was further used to identify the breakpoint value of the MAP/NEQ index for high mortality risk. Results: Multivariate Cox analysis showed that a high MAP/NEQ index was independently associated with decreased mortality risks. The areas under the receiving operating characteristic curve of the MAP/NEQ index for different mortality outcomes were nearly 0.7. The MAP/NEQ index showed an L-shaped association with mortality outcomes or mortality risks. Exploration of the breakpoint value of the MAP/NEQ index suggested that a MAP/NEQ index less than 183 might be associated with a significantly increased mortality risk. Conclusions: An early low MAP/NEQ index was indicative of poor prognosis in patients with shock on vasopressors.
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Affiliation(s)
- Jie Yang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xia Zou
- Clinical Research Management Department, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Ruoran Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xiaofeng Ou
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Bo Wang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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Fu F, Yang MJ, Xu LL, Chen XZ. A comparison of the effect of phenylephrine and norepinephrine on uteroplacental vascular resistance during the treatment of postspinal hypotension in preeclamptic patients: A randomised controlled study. Eur J Anaesthesiol 2024; 41:150-152. [PMID: 38164096 PMCID: PMC10763705 DOI: 10.1097/eja.0000000000001924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Affiliation(s)
- Feng Fu
- From the Department of Anaesthesia, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China (FF, MJY, LLX, XZC)
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Gales K, Hunt M, Marler J. The Association of Elevated Lactate With Multiple Vasopressor Administration in Patients With Septic Shock: A Retrospective Cohort Study. J Pharm Pract 2024; 37:110-117. [PMID: 36124978 DOI: 10.1177/08971900221128640] [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: 11/15/2022]
Abstract
Purpose: In patients with septic shock and elevated lactate, there is limited evidence evaluating supplementary vasopressor use beyond vasopressin (AVP) and norepinephrine (NE). The purpose of this study is to describe vasopressor utilization and clinical outcomes based on lactate level. Methods: We conducted a retrospective study of patients with septic shock requiring NE. Patients were divided into 2 groups: baseline lactate level of ≥4 mmol/L (lactate group) or <4 mmol/L (control group). The primary outcome was supplementary utilization of AVP, phenylephrine (PE), epinephrine, and dopamine, in addition to background NE therapy between the 2 patient groups. Results: A total of 100 patients in each group were included. Mean baseline lactate was 7.6 mmol/L and 2.3 mmol/L in the study and control groups, respectively (P < .01). Combination therapy with NE plus AVP (55% vs 26%; P < .01), NE plus PE (26% vs 3%; P < .01), and NE, AVP, plus PE (17% vs 0%; P < .01) was more common in the lactate group. On regression analysis, lactate group was a predictor of using AVP (OR 3.0; 95% CI 1.6-5.9), PE (OR 7.5; 95% CI 2.1-26.7), and AVP plus PE (OR 11.1; 95% CI 2.5-49.7). Conclusions: In this small retrospective study, multiple vasopressor use was high in patients with severely elevated lactate. The optimal vasopressor regimen in this patient population needs further investigation.
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Affiliation(s)
- Kee Gales
- Department of Pharmacy, Veterans Affairs Hospital, Memphis, TN, USA
| | - Molly Hunt
- Department of Pharmacy, Veterans Affairs Hospital, Memphis, TN, USA
| | - Jacob Marler
- Department of Pharmacy, Veterans Affairs Hospital, Memphis, TN, USA
- Department of Clinical Pharmacy, University of Tennessee Health Sciences Center (UTHSC), Memphis, TN, USA
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Joosten A, Rinehart J, Cannesson M, Coeckelenbergh S, Pochard J, Vicaut E, Duranteau J. Control of mean arterial pressure using a closed-loop system for norepinephrine infusion in severe brain injury patients: the COMAT randomized controlled trial. J Clin Monit Comput 2024; 38:25-30. [PMID: 38310591 DOI: 10.1007/s10877-023-01119-w] [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: 09/25/2023] [Accepted: 12/15/2023] [Indexed: 02/06/2024]
Abstract
Brain injury patients require precise blood pressure (BP) management to maintain cerebral perfusion pressure (CPP) and avoid intracranial hypertension. Nurses have many tasks and norepinephrine titration has been shown to be suboptimal. This can lead to limited BP control in patients that are in critical need of cerebral perfusion optimization. We have designed a closed-loop vasopressor (CLV) system capable of maintaining mean arterial pressure (MAP) in a narrow range and we aimed to assess its performance when treating severe brain injury patients. Within the first 48 h of intensive care unit (ICU) admission, 18 patients with a severe brain injury underwent either CLV or manual norepinephrine titration. In both groups, the objective was to maintain MAP in target (within ± 5 mmHg of a predefined target MAP) to achieve optimal CPP. Fluid administration was standardized in the two groups. The primary objective was the percentage of time patients were in target. Secondary outcomes included time spent over and under target. Over the four-hour study period, the mean percentage of time with MAP in target was greater in the CLV group than in the control group (95.8 ± 2.2% vs. 42.5 ± 27.0%, p < 0.001). Severe undershooting, defined as MAP < 10 mmHg of target value was lower in the CLV group (0.2 ± 0.3% vs. 7.4 ± 14.2%, p < 0.001) as was severe overshooting defined as MAP > 10 mmHg of target (0.0 ± 0.0% vs. 22.0 ± 29.0%, p < 0.001). The CLV system can maintain MAP in target better than nurses caring for severe brain injury patients.
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Affiliation(s)
- Alexandre Joosten
- Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, Ronald Reagan Medical Center, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA, 90095, USA.
| | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California Irvine, California, CA, 92868, USA
| | - Maxime Cannesson
- Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, Ronald Reagan Medical Center, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA, 90095, USA
| | - Sean Coeckelenbergh
- Department of Anesthesiology, Université Paris-Saclay, Hôpital Paul-Brousse, Assistance Publique Hôpitaux de Paris, Villejuif, France
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Jonas Pochard
- Department of Intensive Care, Université Paris-Saclay, Hôpital Bicetre, Assistance Publique Hôpitaux de Paris, Le Kremlin Bicetre, France
| | - Eric Vicaut
- Unité de Recherche Clinique, Lariboisière University Hospital, Paris 7 Diderot University, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Jacques Duranteau
- Department of Intensive Care, Université Paris-Saclay, Hôpital Bicetre, Assistance Publique Hôpitaux de Paris, Le Kremlin Bicetre, France
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See EJ, Chaba A, Spano S, Maeda A, Clapham C, Liu J, Khasin M, Liskaser G, Eastwood G, Bellomo R. Exploring the norepinephrine to angiotensin II conversion ratio in patients with vasodilatory hypotension: A post-hoc analysis of the ARAMIS trial. J Crit Care 2024; 79:154453. [PMID: 37890357 DOI: 10.1016/j.jcrc.2023.154453] [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: 09/24/2023] [Revised: 10/18/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023]
Abstract
PURPOSE Angiotensin II is approved for catecholamine-refractory vasodilatory shock but the conversion dose ratio from norepinephrine to angiotensin II remains unclear. METHODS We conducted a post-hoc analysis of the Acute Renal effects of Angiotensin II Management in Shock (ARAMIS) trial involving patients with vasodilatory hypotension. We determined the norepinephrine equivalent dose immediately prior to angiotensin II initiation and calculated the conversion dose ratio between norepinephrine and angiotensin II. We performed subgroup analyses based on recent exposure to angiotensin receptor blockers (ARBs) and renin levels at baseline. RESULTS In 37 patients, the median conversion dose ratio between norepinephrine equivalent and angiotensin II was to 10:1 for norepinephrine bitartrate (5:1 for norepinephrine base). The conversion ratio was not affected by the baseline renin, with a median ratio of 10 (7-21) in the high renin group versus 12 (5-22) in the low renin group. Finally, exposure to ARBs prior admission appeared to diminish the conversion ratio with a median ratio of 7 (4-13) in ARB patients vs. 12 (7-22) in non-ARB patients. CONCLUSIONS The norepinephrine to angiotensin II conversion dose ratio is 10:1 in a vasodilatory hypotension population. These findings can guide clinicians and researchers in the use, dosing, and study of angiotensin II in critical care.
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Affiliation(s)
- Emily J See
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Nephrology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Anis Chaba
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Sofia Spano
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Akinori Maeda
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Caroline Clapham
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Jasmine Liu
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Monique Khasin
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Grace Liskaser
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Australia.
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Coeckelenbergh S, Vincent JL, Duranteau J, Joosten A, Rinehart J. Perioperative Fluid and Vasopressor Therapy in 2050: From Experimental Medicine to Personalization Through Automation. Anesth Analg 2024; 138:284-294. [PMID: 38215708 DOI: 10.1213/ane.0000000000006672] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Abstract
Intravenous (IV) fluids and vasopressor agents are key components of hemodynamic management. Since their introduction, their use in the perioperative setting has continued to evolve, and we are now on the brink of automated administration. IV fluid therapy was first described in Scotland during the 1832 cholera epidemic, when pioneers in medicine saved critically ill patients dying from hypovolemic shock. However, widespread use of IV fluids only began in the 20th century. Epinephrine was discovered and purified in the United States at the end of the 19th century, but its short half-life limited its implementation into patient care. Advances in venous access, including the introduction of the central venous catheter, and the ability to administer continuous infusions of fluids and vasopressors rather than just boluses, facilitated the use of fluids and adrenergic agents. With the advent of advanced hemodynamic monitoring, most notably the pulmonary artery catheter, the role of fluids and vasopressors in the maintenance of tissue oxygenation through adequate cardiac output and perfusion pressure became more clearly established, and hemodynamic goals could be established to better titrate fluid and vasopressor therapy. Less invasive hemodynamic monitoring techniques, using echography, pulse contour analysis, and heart-lung interactions, have facilitated hemodynamic monitoring at the bedside. Most recently, advances have been made in closed-loop fluid and vasopressor therapy, which apply computer assistance to interpret hemodynamic variables and therapy. Development and increased use of artificial intelligence will likely represent a major step toward fully automated hemodynamic management in the perioperative environment in the near future. In this narrative review, we discuss the key events in experimental medicine that have led to the current status of fluid and vasopressor therapies and describe the potential benefits that future automation has to offer.
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Affiliation(s)
- Sean Coeckelenbergh
- From the Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Saclay, Université Paris-Saclay, Hôpital Paul-Brousse, Paris, France
- Outcomes Research Consortium, Cleveland, Ohio
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Duranteau
- From the Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Saclay, Université Paris-Saclay, Hôpital Paul-Brousse, Paris, France
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Saclay, Université Paris-Saclay, Hôpital De Bicêtre, Paris, France
| | - Alexandre Joosten
- From the Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Saclay, Université Paris-Saclay, Hôpital Paul-Brousse, Paris, France
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Saclay, Université Paris-Saclay, Hôpital De Bicêtre, Paris, France
| | - Joseph Rinehart
- Outcomes Research Consortium, Cleveland, Ohio
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, California
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Coeckelenbergh S, Soucy-Proulx M, Van der Linden P, Clanet M, Rinehart J, Cannesson M, Duranteau J, Joosten A. Tight control of mean arterial pressure using a closed loop system for norepinephrine infusion after high-risk abdominal surgery: a randomized controlled trial. J Clin Monit Comput 2024; 38:19-24. [PMID: 38108944 DOI: 10.1007/s10877-023-01104-3] [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: 09/18/2023] [Accepted: 11/06/2023] [Indexed: 12/19/2023]
Abstract
Intensive care unit (ICU) nurses frequently manually titrate norepinephrine to maintain a predefined mean arterial pressure (MAP) target after high-risk surgery. However, achieving this task is often suboptimal. We have developed a closed-loop vasopressor (CLV) controller to better maintain MAP within a narrow range. After ethical committee approval, fifty-three patients admitted to the ICU following high-risk abdominal surgery were randomized to CLV or manual norepinephrine titration. In both groups, the aim was to maintain MAP in the predefined target of 80-90 mmHg. Fluid administration was standardized in the two groups using an advanced hemodynamic monitoring device. The primary outcome of our study was the percentage of time patients were in the MAP target. Over the 2-hour study period, the percentage of time with MAP in target was greater in the CLV group than in the control group (median: IQR25-75: 80 [68-88]% vs. 42 [22-65]%), difference 37.2, 95% CI (23.0-49.2); p < 0.001). Percentage time with MAP under 80 mmHg (1 [0-5]% vs. 26 [16-75]%, p < 0.001) and MAP under 65 mmHg (0 [0-0]% vs. 0 [0-4]%, p = 0.017) were both lower in the CLV group than in the control group. The percentage of time with a MAP > 90 mmHg was not statistically different between groups. In patients admitted to the ICU after high-risk abdominal surgery, closed-loop control of norepinephrine infusion better maintained a MAP target of 80 to 90 mmHg and significantly decreased postoperative hypotensive when compared to manual norepinephrine titration.
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Affiliation(s)
- Sean Coeckelenbergh
- Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris, Paris-Saclay University, Villejuif, France.
- Outcomes Research Consortium, Cleveland, OH, USA.
| | - Maxim Soucy-Proulx
- Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris, Paris-Saclay University, Villejuif, France
| | | | - Matthieu Clanet
- Department of Anesthesiology, CHIREC Delta Hospital, Brussels, Belgium
| | - Joseph Rinehart
- Outcomes Research Consortium, Cleveland, OH, USA
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Los Angeles, CA, USA
| | - Maxime Cannesson
- Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris, Paris-Saclay University, Villejuif, France
| | - Alexandre Joosten
- Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris, Paris-Saclay University, Villejuif, France
- Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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37
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Javed U, Bhatia K. Total intravenous anaesthesia for caesarean delivery: incidence, maternal and neonatal outcomes from a tertiary unit. Int J Obstet Anesth 2024; 57:103933. [PMID: 37866971 DOI: 10.1016/j.ijoa.2023.103933] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/01/2023] [Accepted: 09/23/2023] [Indexed: 10/24/2023]
Affiliation(s)
- U Javed
- Department of Anaesthesia, Health Education England North-West, Manchester, UK
| | - K Bhatia
- Department of Anaesthesia, Saint Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester, UK.
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38
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Munroe ES. A Case for the Evidence-Based Use of Peripheral Vasopressors. Chest 2024; 165:236-238. [PMID: 38336432 DOI: 10.1016/j.chest.2023.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/15/2023] [Indexed: 02/12/2024] Open
Affiliation(s)
- Elizabeth S Munroe
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI.
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39
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La Via L, Contino M, Chiesa Estomba C, Lombardo G, Maniaci A. Impact of perioperative use of vasopressors in free flap surgery: A trial sequential analysis. Head Neck 2024; 46:452-455. [PMID: 38169068 DOI: 10.1002/hed.27623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 12/17/2023] [Indexed: 01/05/2024] Open
Affiliation(s)
- Luigi La Via
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Policlinico "G.Rodolico-San Marco", Catania, Italy
| | - Matteo Contino
- School of Anesthesia and Intensive Care, University "Magna Graecia", Catanzaro, Italy
| | - Carlos Chiesa Estomba
- Department of Otorhinolaryngology-Head & Neck Surgery, Hospital Universitario Donostia, San Sebastian, Spain
| | - Giuseppe Lombardo
- Faculty of Medicine and Surgery, University of Enna Kore, Enna, Italy
| | - Antonino Maniaci
- Faculty of Medicine and Surgery, University of Enna Kore, Enna, Italy
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40
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Ramsie M, Cheung PY, O'Reilly M, Roberts CT, Polglase GR, Schmölzer GM. Cardiac Agents during Neonatal Cardiopulmonary Resuscitation. Neonatology 2024; 121:157-166. [PMID: 38228124 DOI: 10.1159/000535502] [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: 06/20/2023] [Accepted: 11/17/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND Epinephrine (adrenaline) is currently the only cardiac agent recommended during neonatal resuscitation. The inability to predict which newborns are at risk of requiring resuscitative efforts at birth has prevented the collection of large, high-quality human data. SUMMARY Information on the optimal dosage and route of epinephrine administration is extrapolated from neonatal animal studies and human adult and pediatric studies. Adult resuscitation guidelines have previously recommended vasopressin use; however, neonatal studies needed to create guidelines are lacking. A review of the literature demonstrates conflicting results regarding epinephrine efficacy through various routes of access as well as vasopressin during asystolic cardiac arrest in animal models. Vasopressin appears to improve hemodynamic and post-resuscitation outcomes compared to epinephrine in asystolic cardiac arrest animal models. KEY MESSAGES The current neonatal resuscitation guidelines recommend epinephrine be primarily given via the intravenous or intraosseous route, with the endotracheal route as an alternative if these routes are not feasible or unsuccessful. The intravenous or intraosseous dose ranges between 0.01 and 0.03 mg/kg, which should be repeated every 3-5 min during chest compressions. However, the optimal dosing and route of administration of epinephrine remain unknown. There is evidence from adult and pediatric studies that vasopressin might be an alternative to epinephrine; however, the neonatal data are scarce.
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Affiliation(s)
- Marwa Ramsie
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Megan O'Reilly
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Calum T Roberts
- Monash Newborn, Monash Children's Hospital, Clayton, Victoria, Australia
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Graeme R Polglase
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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41
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Wood AJ, Rauniyar R, Jacques A, Palmer RN, Wibrow B, Anstey MH. Response to "What is a case-control study? Comment on 'Oral midodrine does not expedite liberation from protracted vasopressor infusions: A case-control study'". Anaesth Intensive Care 2024; 52:74. [PMID: 37999999 DOI: 10.1177/0310057x231197692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Affiliation(s)
- Alexander Jt Wood
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia
- School of Medicine, University of Western Australia, Perth, Australia
| | - Rashmi Rauniyar
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia
| | - Angela Jacques
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, Australia
- Department of Research, Sir Charles Gairdner Hospital, Perth, Australia
| | - Robert N Palmer
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia
| | - Bradley Wibrow
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia
- School of Medicine, University of Western Australia, Perth, Australia
| | - Matthew H Anstey
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia
- School of Medicine, University of Western Australia, Perth, Australia
- School of Public Health, Curtin University, Perth, Australia
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42
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Meng L, Sun Y, Zhao X, Meng DM, Liu Z, Adams DC, McDonagh DL, Rasmussen M. Effects of phenylephrine on systemic and cerebral circulations in humans: a systematic review with mechanistic explanations. Anaesthesia 2024; 79:71-85. [PMID: 37948131 DOI: 10.1111/anae.16172] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 11/12/2023]
Abstract
We conducted a systematic review of the literature reporting phenylephrine-induced changes in blood pressure, cardiac output, cerebral blood flow and cerebral tissue oxygen saturation as measured by near-infrared spectroscopy in humans. We used the proportion change of the group mean values reported by the original studies in our analysis. Phenylephrine elevates blood pressure whilst concurrently inducing a reduction in cardiac output. Furthermore, despite increasing cerebral blood flow, it decreases cerebral tissue oxygen saturation. The extent of phenylephrine's influence on cardiac output (r = -0.54 and p = 0.09 in awake humans; r = -0.55 and p = 0.007 in anaesthetised humans), cerebral blood flow (r = 0.65 and p = 0.002 in awake humans; r = 0.80 and p = 0.003 in anaesthetised humans) and cerebral tissue oxygen saturation (r = -0.72 and p = 0.03 in awake humans; r = -0.24 and p = 0.48 in anaesthetised humans) appears closely linked to the magnitude of phenylephrine-induced blood pressure changes. When comparing the effects of phenylephrine in awake and anaesthetised humans, we found no evidence of a significant difference in cardiac output, cerebral blood flow or cerebral tissue oxygen saturation. There was also no evidence of a significant difference in effect on systemic and cerebral circulations whether phenylephrine was given by bolus or infusion. We explore the underlying mechanisms driving the phenylephrine-induced cardiac output reduction, cerebral blood flow increase and cerebral tissue oxygen saturation decrease. Individualised treatment approaches, close monitoring and consideration of potential risks and benefits remain vital to the safe and effective use of phenylephrine in acute care.
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Affiliation(s)
- L Meng
- Department of Anesthesia, Indiana University School of Medicine, IA, Indianapolis, USA
| | - Y Sun
- Department of Anesthesiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - X Zhao
- Department of Anesthesiology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - D M Meng
- Choate Rosemary Hall School, CT, Wallingford, USA
| | - Z Liu
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, IA, Indianapolis, USA
| | - D C Adams
- Department of Anesthesia, Indiana University School of Medicine, IA, Indianapolis, USA
| | - D L McDonagh
- Departments of Anesthesiology and Pain Management, Neurological Surgery, Neurology and Neurotherapeutics, UT Southwestern Medical Center, TX, Dallas, USA
| | - M Rasmussen
- Department of Anesthesiology, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
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43
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Song NYE, Kim KH, Hong KJ. Effect of no-flow period on the vasopressor effect of initial epinephrine administration in cardiac arrest. Am J Emerg Med 2024; 75:154-159. [PMID: 37950984 DOI: 10.1016/j.ajem.2023.10.053] [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: 06/21/2023] [Revised: 10/21/2023] [Accepted: 10/28/2023] [Indexed: 11/13/2023] Open
Abstract
OBJECTIVES Whether a longer no-flow (NF) interval affects the magnitude of response to epinephrine in the resuscitation has not been well studied. Therefore, this study aimed to evaluate the effect of NF interval on the vasopressor effect of initial epinephrine administration in a porcine model. METHODS We enrolled 20 pigs from two randomized porcine experimental studies using a ventricular fibrillation (VF) cardiac arrest model. The first experiment subjects were resuscitated after 4 min of NF (Short NF group), followed by three cycles (6 min) of chest compression using a mechanical cardiopulmonary resuscitation device before epinephrine administration. Second experiment subjects received 6 min of NF (Long NF group), two cycles (4 min) of chest compressions, and administration of epinephrine. Defibrillation for VF was delivered 8 and 10 min after VF induction in the Short NF and Long NF groups, respectively. The mean arterial pressure (MAP) and cerebral perfusion pressure (CePP) in the 2-min resuscitation period after epinephrine administration were compared between the study groups using the Wilcoxon rank-sum test. The mean differences in the parameters between phases were also compared. RESULTS Seven pigs in the Short NF group and 13 pigs in the Long NF group were included in the analysis. All 2-min resuscitation phases from 6 to 16 min after VF induction were compared between the study groups. The Short NF group showed higher MAP and CePP in all phases (p < 0.01). Change of mean MAP after the epinephrine administration was significantly different between the study groups: mean difference (95% confidence interval) of 16.6 (15.8-17.4) mmHg in the Short NF group and 4.2 (3.9-4.5) mmHg in the Long NF group. CONCLUSION In the porcine VF cardiac arrest model, 6 min of NF before resuscitation may affect the vasopressor effect of the initial epinephrine administered compared to 4 min of NF. A short NF may play a role in maximizing the effect of epinephrine in advanced cardiovascular life support.
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Affiliation(s)
| | - Ki Hong Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea.
| | - Ki Jeong Hong
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea
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McCloskey MM, Gibson GA, Pope HE, Giacomino BD, Hampton N, Micek ST, Kollef MH, Betthauser KD. Comment: Does Early Vasopressin in Septic Shock Improve Outcomes? An Important Piece to This Emerging Puzzle Has Arrived. Ann Pharmacother 2024; 58:89-90. [PMID: 37056047 DOI: 10.1177/10600280221096886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
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45
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Myles PS. What is a case-control study? Comment on 'Oral midodrine does not expedite liberation from protracted vasopressor infusions: A case-control study'. Anaesth Intensive Care 2024; 52:73. [PMID: 38000004 DOI: 10.1177/0310057x231196914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Affiliation(s)
- Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Australia
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46
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White CM. Does Early Vasopressin in Septic Shock Improve Outcomes? An Important Piece to This Emerging Puzzle Has Arrived. Ann Pharmacother 2024; 58:86-88. [PMID: 37056042 DOI: 10.1177/10600280221096881] [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: 04/15/2023] Open
Abstract
In this month's Annals of Pharmacotherapy, the largest observational study assessing the early versus later use of vasopressin has been published. When this new study is combined with the other available observational studies, there are 2 important outcomes to focus on. When all the observational studies are pooled together, no reduction in new onset arrhythmias is seen (odds ratio [OR] = 0.91, 95% confidence interval [CI] = 0.41-1.95) with early versus late vasopressin use while the reduction in renal replacement therapy just missed statistical significance (OR = 0.56, 95% CI = 0.32-1.00). Early vasopressin likely does not reduce new onset arrhythmias versus later use but might reduce the need for renal replacement therapy.
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Affiliation(s)
- C Michael White
- Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, CT, USA
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47
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Suero OR, Park Y, Wieruszewski PM, Chatterjee S. Management of Vasoplegic Shock in the Cardiovascular Intensive Care Unit after Cardiac Surgery. Crit Care Clin 2024; 40:73-88. [PMID: 37973358 DOI: 10.1016/j.ccc.2023.06.002] [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] [Indexed: 11/19/2023]
Abstract
Vasoplegic shock after cardiac surgery is characterized by hypotension, a high cardiac output, and vasodilation. Much of the understanding of this pathologic state is informed by the understanding of septic shock. Adverse outcomes and mortality are increased with vasoplegic shock. Early recognition and a systematic approach to its management are critical. The need for vasopressors to sustain an adequate blood pressure as well as pharmacologic adjuncts to mitigate the inflammatory inciting process are necessary. The rationale behind vasopressor escalation and consideration of adjuncts are discussed.
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Affiliation(s)
- Orlando R Suero
- Baylor St. Lukes Medical Center, 6720 Bertner Avenue, Room 0-520, Houston, TX 77030, USA
| | - Yangseon Park
- Baylor St. Lukes Medical Center, 6720 Bertner Avenue, Room 0-520, Houston, TX 77030, USA
| | - Patrick M Wieruszewski
- Department of Pharmacy, Mayo Clinic, RO_MB_GR_722PH, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, TX, USA.
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Badura K, Frąk W, Hajdys J, Majchrowicz G, Młynarska E, Rysz J, Franczyk B. Hepatorenal Syndrome-Novel Insights into Diagnostics and Treatment. Int J Mol Sci 2023; 24:17469. [PMID: 38139297 PMCID: PMC10744165 DOI: 10.3390/ijms242417469] [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: 10/30/2023] [Revised: 12/09/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023] Open
Abstract
Hepatorenal syndrome (HRS) is a disorder associated with cirrhosis and renal impairment, with portal hypertension as its major underlying cause. Moreover, HRS is the third most common cause of acute kidney injury, thus creating a major public health concern. This review summarizes the available information on the pathophysiological implications of HRS. We discuss pathogenesis associated with HRS. Mechanisms such as dysfunction of the circulatory system, bacterial infection, inflammation, impaired renal autoregulation, circulatory, and others, which have been identified as critical pathways for development of HRS, have become easier to diagnose in recent years. Additionally, relatively recently, renal dysfunction biomarkers have been found indicating renal injury, which are involved in the pathophysiology of HRS. This review also summarizes the available information on the management of HRS, focusing on vasoconstrictive drugs, renal replacement therapy, and liver transplant together with currently being investigated novel therapies. Analyzing new discoveries for the underlying causes of this condition assists the general research to improve understanding of the mechanism of pathophysiology and thus prevention of HRS.
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Affiliation(s)
- Krzysztof Badura
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Weronika Frąk
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Joanna Hajdys
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Gabriela Majchrowicz
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Ewelina Młynarska
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Beata Franczyk
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
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Abu Sardaneh A, Penm J, Oliver M, Gattas D, McLachlan AJ, James C, Cella C, Aljuhani O, Acquisto NM, Patanwala AE. International pharmacy survey of peripheral vasopressor infusions in critical care (INFUSE). J Crit Care 2023; 78:154376. [PMID: 37536012 DOI: 10.1016/j.jcrc.2023.154376] [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: 01/31/2023] [Revised: 07/08/2023] [Accepted: 07/10/2023] [Indexed: 08/05/2023]
Abstract
PURPOSE The primary objective was to determine the proportion of hospitals that administered norepinephrine peripheral vasopressor infusions (PVIs) in critically ill adult patients. Secondary objectives were to describe how norepinephrine is used such as the maximum duration, infusion rate and concentration, and to determine the most common first-line PVI used by country. MATERIALS AND METHODS An international multi-centre cross-sectional survey study was conducted in adult intensive care units in Australia, US, UK, Canada, and Saudi Arabia. RESULTS Critical care pharmacists from 132 institutions responded to the survey. Norepinephrine PVIs were utilised in 86% of institutions (n = 113/132). The median maximum duration of norepinephrine PVIs was 24 h (IQR 24-24) (n = 57/113). The most common maximum norepinephrine PVI rate was between 11 and 20 μg/min (n = 16/113). The most common maximum norepinephrine PVI concentration was 16 μg/mL (n = 60/113). Half of the institutions had a preference to administer another PVI over norepinephrine as a first-line agent (n = 66/132). The most common alternative PVI used by country was: US (phenylephrine 41%, n = 37/90), Canada (dopamine 31%, n = 5/16), UK (metaraminol 82%, n = 9/11), and Australia (metaraminol 89%, n = 8/9). CONCLUSIONS There is variability in clinical practice regarding PVI administration in critically ill adult patients dependent on drug availability and local institutional recommendations.
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Affiliation(s)
- Arwa Abu Sardaneh
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Pharmacy, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Jonathan Penm
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Pharmacy, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Matthew Oliver
- Department of Emergency Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - David Gattas
- School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Intensive Care Service, Royal Prince Alfred Hospital, Sydney, Australia
| | - Andrew J McLachlan
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Christie James
- Department of Pharmacy, Grange University Hospital, Cwmbran, Wales, United Kingdom
| | - Christina Cella
- Canadian Society of Hospital Pharmacists, Ottawa, Ontario, Canada
| | - Ohoud Aljuhani
- Pharmacy Practice Department, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Pharmacy, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Nicole M Acquisto
- Department of Pharmacy, University of Rochester Medical Center, Rochester, NY, United States; Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Asad E Patanwala
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Pharmacy, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
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Affiliation(s)
- Ajay Kumar Jha
- Cardiothoracic Anaesthesia Division, Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Medical Education and Research, Pondicherry, India
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