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Annals of Cardiac Anaesthesia 2015Despite the growing body of evidence evaluating the efficacy of vasoactive agents in the management of hemodynamic instability and circulatory shock, it appears no agent... (Review)
Review
Despite the growing body of evidence evaluating the efficacy of vasoactive agents in the management of hemodynamic instability and circulatory shock, it appears no agent is superior. This is becoming increasingly accepted as current guidelines are moving away from detailed algorithms for the management of shock, and instead succinctly state that vasoactive agents should be individualized and guided by invasive hemodynamic monitoring. This extends to the perioperative period, where vasoactive agent selection and use may still be left to the discretion of the treating physician with a goal-directed approach, consisting of close hemodynamic monitoring and administration of the lowest effective dose to achieve the hemodynamic goals. Successful therapy depends on the ability to rapidly diagnose the etiology of circulatory shock and thoroughly understand its pathophysiology as well as the pharmacology of vasoactive agents. This review focuses on the physiology and resuscitation goals in perioperative shock, as well as the pharmacology and recent advances in vasoactive agent use in its management.
Topics: Cardiotonic Agents; Hemodynamics; Humans; Intraoperative Complications; Perioperative Care; Postoperative Complications; Shock; Vasoconstrictor Agents
PubMed: 26440241
DOI: 10.4103/0971-9784.166464 -
Journal of Reconstructive Microsurgery Feb 2016The purpose of this study is to identify whether intraoperative use of vasoactive medications increases the risk of free flap failure or complications through a... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The purpose of this study is to identify whether intraoperative use of vasoactive medications increases the risk of free flap failure or complications through a systematic review and meta-analysis.
MATERIALS AND METHODS
PubMed/MEDLINE, EMBASE, and Scopus databases were searched for studies published through January 2015. English publications that met the following criteria were included: (1) adult patients undergoing head and neck free flap reconstruction; (2) comparison of patients with and without intraoperative vasopressor administration; and (3) documentation of flap failure rate and/or flap complications. The primary outcome was the incidence of flap failure. The secondary outcome was the incidence of overall flap complications. Meta-analysis was performed to obtain pooled odds ratios (ORs) of the effect of intraoperative use of vasopressors on flap failure and complication rates.
RESULTS
Four cohort studies met inclusion criteria. All studies were of high methodological quality with an average Methodological Index for Non-Randomized Studies score of 18.75 (range 16-23). A total of 933 patients undergoing head and neck free flap reconstruction were included. Meta-analysis demonstrated no statistically significant difference in the incidence of flap failure (2.9 vs. 3.6%; OR, 0.68; 95% confidence interval [CI], 0.23-1.99; p = 0.48) or incidence of flap complications (16.8 vs. 18.6%; OR, 0.92; 95% CI, 0.60-1.42; p = 0.71).
CONCLUSION
Based on the current evidence, intraoperative use of vasopressors has no impact on the incidence of flap failure or flap complications.
Topics: Free Tissue Flaps; Graft Survival; Head and Neck Neoplasms; Humans; Intraoperative Period; Odds Ratio; Postoperative Complications; Plastic Surgery Procedures; Retrospective Studies; Treatment Outcome; Vasoconstrictor Agents
PubMed: 26340760
DOI: 10.1055/s-0035-1563381 -
Alimentary Pharmacology & Therapeutics Mar 2017Hepatorenal syndrome type 1 (HRS1) is a functional, rapidly progressive, potentially reversible form of acute kidney injury occurring in patients with cirrhosis.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Hepatorenal syndrome type 1 (HRS1) is a functional, rapidly progressive, potentially reversible form of acute kidney injury occurring in patients with cirrhosis. Characterised by intense renal arterial vasoconstriction, it carries a very poor prognosis. There is a significant unmet need for a widely approved, safe and effective pharmacological treatment.
AIM
To re-evaluate efficacy and safety of pharmacological treatments for HRS1, in the light of recently published randomised controlled trials (RCTs).
METHODS
MEDLINE (OvidSP), EMBASE, PubMed and Cochrane registers were searched for RCTs reporting efficacy and adverse events related to pharmacological treatment of HRS1. Search terms included: 'hepatorenal syndrome', 'terlipressin', 'noradrenaline', 'octreotide', 'midodrine', 'vasopressin', 'dopamine', 'albumin' and synonyms. Comparison of vasoactive drugs vs. placebo/no treatment, and two active drugs were included. Meta-analysis was performed for HRS1 reversal, creatinine improvement, mortality and adverse events.
RESULTS
Twelve RCTs enrolling 700 HRS1 patients were included. Treatment with terlipressin and albumin led to HRS1 reversal more frequently than albumin alone or placebo (RR: 2.54, 95% CI: 1.51-4.26). Noradrenaline was effective in reversing HRS1, but trials were small and nonblinded. Overall, there was mortality benefit with terlipressin (RR: 0.79, 95% CI: 0.63-1.01), but sensitivity analysis including only trials with low risk of selection bias weakened this relationship (RR: 0.87, 95% CI: 0.71-1.06). Notably, there was a significant risk of adverse events with terlipressin therapy (RR: 4.32, 95% CI: 0.75-24.86).
CONCLUSIONS
Terlipressin treatment is superior to placebo for achieving HRS1 reversal, but mortality benefit is less clear. Terlipressin is associated with significant adverse events, but infusion regimens may be better tolerated. There is continued need for safe and effective treatment options for hepatorenal syndrome.
Topics: Albumins; Creatinine; Hepatorenal Syndrome; Humans; Liver Cirrhosis; Lypressin; Prognosis; Randomized Controlled Trials as Topic; Terlipressin; Treatment Outcome; Vasoconstrictor Agents
PubMed: 28052382
DOI: 10.1111/apt.13912 -
The Lancet. Gastroenterology &... Feb 2017Several drugs have been studied to improve outcomes for patients with hepatorenal syndrome, but trials have reported variable efficacy. We aimed to compare the efficacy... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Several drugs have been studied to improve outcomes for patients with hepatorenal syndrome, but trials have reported variable efficacy. We aimed to compare the efficacy of different management strategies for type 1 hepatorenal syndrome.
METHODS
For this systematic review and network meta-analysis, we searched Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Scopus, and Web of Science for papers published up to June 9, 2016. We selected randomised controlled trials of adults (>18 years) with decompensated cirrhosis and type 1 hepatorenal syndrome that compared the efficacy of active vasoactive drugs (terlipressin, midodrine, octreotide, noradrenaline, and dopamine; alone or in combination) with placebo or each other. The primary outcome was reduction in short-term mortality. Secondary outcomes were reversal of hepatorenal syndrome, relapse of hepatorenal syndrome after initial reversal, and adverse events. We did pairwise and network meta-analyses to produce odds ratios (ORs) and 95% CIs. We used the GRADE criteria to appraise quality of evidence.
FINDINGS
We identified 13 randomised controlled trials done in 739 adults with type 1 hepatorenal syndrome. All participants received supportive therapy with albumin. Moderate-quality evidence might support the use of terlipressin over placebo for reduction of short-term mortality (OR 0·65, 95% CI 0·41-1·05), whereas only low-quality evidence supported the use of noradrenaline, midodrine plus octreotide, and dopamine plus furosemide over placebo to reduce mortality, and no ORs for any of the comparisons versus placebo were significant. Moderate-quality evidence supported the use of terlipressin over midodrine plus octreotide (OR 26·25, 95% CI 3·07-224·21) to reverse hepatorenal syndrome, with low-quality evidence supporting the use of noradrenaline over placebo (4·17, 1·37-12·50) and over midodrine plus octreotide (10·00, 1·49-50·00) for this outcome. A median of 16% (range 5-20) of terlipressin-treated patients, and 33% (range 6-40) noradrenaline-treated patients with reversal of hepatorenal syndrome had recurrence on discontinuation of therapy. A median of 8% (range 4-22) terlipressin-treated patients required discontinuation of therapy due to serious adverse events.
INTERPRETATION
Terlipressin with albumin might reduce short-term mortality compared with placebo in patients with type 1 hepatorenal syndrome. Terlipressin with albumin and noradrenaline with albumin are both superior to midodrine plus octreotide with albumin for reversal of hepatorenal syndrome. Pragmatic clinical trials of terlipressin with albumin are warranted to evaluate real-world effectiveness and safety in patients with type 1 hepatorenal syndrome.
FUNDING
None.
Topics: Dopamine; Drug Therapy, Combination; Gastrointestinal Agents; Hepatorenal Syndrome; Humans; Lypressin; Midodrine; Network Meta-Analysis; Norepinephrine; Octreotide; Terlipressin; Treatment Outcome; Vasoconstrictor Agents
PubMed: 28403995
DOI: 10.1016/S2468-1253(16)30157-1 -
European Journal of Surgical Oncology :... Oct 2023Neuroblastoma is a malignant tumour affecting 10.5/1 million children annually. It arises from sympathetic nervous system precursor cells and is most frequently found in... (Review)
Review
Neuroblastoma is a malignant tumour affecting 10.5/1 million children annually. It arises from sympathetic nervous system precursor cells and is most frequently found in the adrenal gland and abdominal paravertebral ganglia. Diarrhoea as a presenting symptom of neuroblastoma is uncommon and usually linked to vasoactive intestinal peptide (VIP) tumour secretion. Even more rarely, postoperative diarrhoea may follow neuroblastoma tumour resection. Published studies generally associate postoperative diarrhoea with subadventitial tumour resection. These findings are however based on a handful of reports. This systematic review therefore aims to analyse the true incidence of postoperative diarrhoea and its morbid correlation with the extent/type of surgical resection. Pubmed/Embase databases were searched according to PRISMA guidelines. Final analysis consisted of 16 studies: N = 779 patients. Postoperative diarrhoea was significantly more common in all patients who underwent subadventitial resection compared to non subadventitial resection, p < 0.001 (OR 25.9, 95% CI 9.3-72.4). 5-year survival rates were equivalent in both groups. Preoperative diarrhoea was rarely reported in studies and always strongly linked to elevated VIP secretion. In the majority of neuroblastoma patients, preoperative diarrhoea ameliorated after gross tumour resection with elevated VIP normalized. The operative technique of subadventitial neuroblastoma resection portends significant risk(s) of post operative diarrhoea not seen in those patients undergoing other classical methods of tumour resection with 5-year survival rates strikingly similar. These findings affirm that subadventitial tumour resection should be avoided when undertaking surgery for neuroblastoma to minimize the risk(s) of persistent postoperative diarrhoea.
PubMed: 37183049
DOI: 10.1016/j.ejso.2023.04.020 -
BMJ Open Respiratory Research Mar 2024Vasoactive drugs have exhibited clinical efficacy in addressing pulmonary arterial hypertension, manifesting a significant reduction in morbidity and mortality....
OBJECTIVES
Vasoactive drugs have exhibited clinical efficacy in addressing pulmonary arterial hypertension, manifesting a significant reduction in morbidity and mortality. Pulmonary hypertension may complicate advanced interstitial lung disease (PH-ILD) and is associated with high rates of disability, hospitalisation due to cardiac and respiratory illnesses, and mortality. Prior management hinged on treating the underlying lung disease and comorbidities. However, the INCREASE trial of inhaled treprostinil in PH-ILD has demonstrated that PH-ILD can be effectively treated with vasoactive drugs.
METHODS
This comprehensive systematic review examines the evidence for vasoactive drugs in the management of PH-ILD.
RESULTS
A total of 1442 pubblications were screened, 11 RCTs were considered for quantitative synthesis. Unfortunately, the salient studies are limited by population heterogeneity, short-term follow-up and the selection of outcomes with uncertain clinical significance.
CONCLUSIONS
This systematic review underscores the necessity of establishing a precision medicine-oriented strategy, directed at uncovering and addressing the intricate cellular and molecular mechanisms that underlie the pathophysiology of PH-ILD.
PROSPERO REGISTRATION NUMBER
CRD42023457482.
Topics: Humans; Hypertension, Pulmonary; Lung Diseases, Interstitial; Comorbidity
PubMed: 38479818
DOI: 10.1136/bmjresp-2023-002161 -
The Turkish Journal of Pediatrics 2023To describe the existing pharmacological managements for Multisystem Inflammatory Syndrome in Children (MIS-C) in a systematic way, to identify the available... (Review)
Review
BACKGROUND
To describe the existing pharmacological managements for Multisystem Inflammatory Syndrome in Children (MIS-C) in a systematic way, to identify the available pharmacological managements in MIS-C, evaluate its safety and efficacy and identify the best treatment procedures for practice recommendation.
METHODS
A systematic search using six databases was conducted on August 18, 2021, updated in January 26th 2023. Terminologies that were used in this search are children, MIS-C/PIMS and SARS-CoV-2. A PRISMA flow diagram was used to report the study selection process. Quality analysis was done based on NOS and GRADE tools. Data synthesis was conducted by extracting the information on drugs used, efficacy and side effects.
RESULTS
From the 32 articles included, a total of 2331 children with MIS-C were studied. The main pharmacological approaches were immunomodulatory therapy, i.e., intravenous immunoglobulin (IVIG) (77.3%), steroids (60.5%), and a combination of IVIG and steroids (41.3%). IVIG and steroids were found to be potentially effective and safe treatments for MIS-C. Combination of IVIG and steroids was found favorable in severe cases with higher recovery rate. Refractory treatments include second dose of initial treatment and biological response modifier drugs like anakinra, tocilizumab, infliximab. A small number of studies investigating supportive treatment consisted of vasoactive, inotropic and anticoagulation. The mortality rate was 1.28% and only three studies reported side effects from the treatment. Evidence of outcome from GRADE were mostly at moderate, low and very low levels.
CONCLUSIONS
This review provides preliminary evidence to support the current standard treatment practices in managing MIS-C pharmacologically. However, comprehensive investigation is required using clinical trials to provide stronger outcome evidence.
Topics: Child; Humans; COVID-19; SARS-CoV-2; Immunoglobulins, Intravenous; Drug-Related Side Effects and Adverse Reactions; Steroids
PubMed: 37853964
DOI: 10.24953/turkjped.2022.765 -
Frontiers in Cardiovascular Medicine 2021Vitamin D (VitD) is an important pleiotropic hormone for organ systems. Studies have focused on the level of VitD, especially that of 25-hydroxyvitamin D...
Vitamin D (VitD) is an important pleiotropic hormone for organ systems. Studies have focused on the level of VitD, especially that of 25-hydroxyvitamin D (25-(OH)-VitD), in patients after cardiac surgery and the relationship between VitD deficiency and adverse outcomes, but the results have been inconsistent. We carried out a meta-analysis to evaluate differences in the 25-(OH)-VitD level before and after cardiac surgery, and evaluated the predictive value of 25-(OH)-VitD level in the clinical outcomes of patients undergoing cardiac surgery. Studies related to VitD level and cardiac surgery were searched from PubMed, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials databases from inception to October 2020. We applied the Newcastle-Ottawa Scale to assess the risk of a bias in individual studies. We examined the heterogeneity and publication bias and performed subgroup analyses and sensitivity analyses. Fifteen studies were included in our analysis. The 25-(OH)-VitD level was significantly lower immediately after surgery [stand mean difference (SMD), 0.69; 95%CI (0.1, 1.28), = 0.023] and 24-h after surgery [0.84; (0.47, 1.21), 0.000] compared with that before surgery. A higher prevalence of 25-(OH)-VitD deficiency was recorded 24 h after surgery [RR, 0.59; 95%CI (0.47, 0.73), = 0.00]. Pooled results demonstrated a significant relationship between the preoperative 25-(OH)-VitD level and vasoactive-inotropic score (VIS) [SMD, -3.71; 95%CI (-6.32, -1.10); = 0.005], and patients with 25-(OH)-VitD deficiency revealed a comparatively poor prognosis and severe condition after cardiac surgery [-0.80; (-1.41, -0.19), 0.01]. However, 25-(OH)-VitD deficiency was not associated with the duration of stay in the intensive care unit. Cardiac surgery would leads to deficiency of 25-(OH)-VitD. And the preoperative and postoperative levels of 25-(OH)-VitD are associated with adverse events, which is eligible to work as an indicator to demonstrate clinical outcomes.
PubMed: 34869636
DOI: 10.3389/fcvm.2021.734504 -
Journal of Clinical Anesthesia Jun 2024The determination of optimal positive end-expiratory pressure (PEEP) values in patients undergoing general anesthesia remains controversial. Electrical impedance... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The determination of optimal positive end-expiratory pressure (PEEP) values in patients undergoing general anesthesia remains controversial. Electrical impedance tomography (EIT) directed individualized PEEP has emerged as a novel approach to PEEP setting and has garnered increasing attention. This meta-analysis aims to systematically assess the effect of EIT-guided PEEP setting compared to traditional fixed PEEP values or other PEEP titration strategies in patients undergoing general anesthesia.
METHODS
A comprehensive search of electronic databases, including PubMed, Web of Science, EMBASE, and the Cochrane Library, was conducted from inception to January 2023, with no language restrictions. The search terms used were "EIT"and "PEEP" with their corresponding free words. Two researchers independently conducted literature screening, data extraction, and quality evaluation. The primary outcomes of interest were oxygenation index (OI), lung compliance, and number of postoperative pulmonary complications (PPCs). The secondary outcomes included mean arterial blood pressure (MAP) and number of vasoactive drug injections. RevMan 5.3 software was used to analyze the data and draw the forest plot, and Stata 14.2 software was used to conduct sensitivity analysis to assess the stability of the results.
RESULTS
5 studies involving 272 participants were included in this meta-analysis. Our findings suggest that EIT-guided individualized PEEP setting is superior to traditional fixed PEEP values and other individualized PEEP titration methods in terms of intraoperative OI(OR = 95.73, 95%CI: (49.10, 142.37); P < 0.0001) and lung compliance(OR = 7.69, 95%CI: (5.55, 9.83); P < 0.00001), without affecting intraoperative hemodynamic parameters such as MAP(OR = 2.07, 95%CI: (-1.00, 5.13); P = 0.19) and the number of intravenous vasoactive drugs(OR = 1.22, 95%CI: (0.68, 2.21); P = 0.51) or increasing the incidence of postoperative PPCs(OR = 0.87, 95%CI: (0.41, 1.82); P = 0.71).
CONCLUSIONS
Our meta-analysis suggests potential benefits of EIT-guided individualized PEEP setting in improving intraoperative oxygenation and lung compliance in patients undergoing general anesthesia. However, further research is needed to establish conclusive evidence, and caution should be exercised in interpreting these findings as the current literature remains inconclusive regarding the impact on intraoperative hemodynamics and postoperative complications.
Topics: Humans; Anesthesia, General; Electric Impedance; Lung; Positive-Pressure Respiration; Postoperative Complications; Tomography
PubMed: 38278058
DOI: 10.1016/j.jclinane.2024.111397 -
Headache Jun 2020The aim of this systematic review and meta-analysis (SR-MA) was to identify signaling molecule profiles and blood-derived biomarkers in migraine and cluster headache... (Meta-Analysis)
Meta-Analysis
Serotonin and Neuropeptides in Blood From Episodic and Chronic Migraine and Cluster Headache Patients in Case-Control and Case-Crossover Settings: A Systematic Review and Meta-Analysis.
OBJECTIVE
The aim of this systematic review and meta-analysis (SR-MA) was to identify signaling molecule profiles and blood-derived biomarkers in migraine and cluster headache (CH) patients.
BACKGROUND
Currently no migraine and CH valid biomarkers are available. Blood tests based on biomarker profiles have been used to gather information about the nervous system. Such tests have not yet been established within the primary headache field.
METHODS
Case-control and case-crossover studies investigating whole blood, plasma, and serum were identified worldwide. The qualitative synthesis focused on 9 signaling molecules (serotonin [5-HT], calcitonin gene-related peptide [CGRP], endothelin-1 [ET-1], neurokinin A, neurokinin B, neuropeptide Y, pituitary adenylate cyclase-activating peptide 38 [PACAP-38], substance P (SP), and vasoactive intestinal peptide) and the quantitative synthesis on 5-HT and CGRP (≥5 comparisons available). The meta-analysis was conducted using standard and 3-level random effect models.
RESULTS
Fifty-four eligible studies were identified (87.0% migraine, 9.3% CH, 3.7% migraine, and CH), and 2768 headache patients and 1165 controls included. Comparable fluctuations of 5-HT, CGRP, ET-1, PACAP-38, and SP in blood were generally observed between migraine and CH. Significant findings were observed for some subgroups and strata, for example, higher interictal and ictal 5-HT venous blood levels (ratio of means = 1.32, 95% CI: 1.08; 1.61; ratio of means = 1.23, 95% CI: 1.01; 1.49) in episodic migraine with aura with a female-dominated case group, higher interictal CGRP blood levels in episodic migraine (ratio of means = 1.63, 95% CI: 1.18; 2.26), and chronic migraine (ratio of means = 1.89, 95% CI: 1.33; 2.68), and higher ictal CGRP blood levels (ratio of means = 1.35, 95% CI: 1.09; 1.68) in episodic migraine were observed. In most subgroups, the quantitative synthesis revealed a high degree of heterogeneity between studies in part explained by the blood sampling site, specimen source, blood specimen, and sex distribution. Other potential confounders were age, aura, study quality, menstrual cycle, and methodology (eg, storage temperature).
CONCLUSIONS
Potential migraine and CH signaling molecule profiles and biomarkers were revealed. Nevertheless, the high degree of heterogeneity between studies impedes identification of valid biomarkers but allowed us to assess the presence of confounders. Consideration of the potential confounders identified in this SR-MA might be of importance in the experimental planning of future studies. This consideration could be incorporated through establishment of specific guidelines.
Topics: Biomarkers; Cluster Headache; Humans; Migraine Disorders; Neuropeptides; Serotonin
PubMed: 32293721
DOI: 10.1111/head.13802