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Critical Care (London, England) Aug 2023During septic shock, vasopressor infusion is usually started only after having corrected the hypovolaemic component of circulatory failure, even in the most severe...
During septic shock, vasopressor infusion is usually started only after having corrected the hypovolaemic component of circulatory failure, even in the most severe patients. However, earlier administration of norepinephrine, simultaneously with fluid resuscitation, should be considered in some cases. Duration and depth of hypotension strongly worsen outcomes in septic shock patients. However, the response of arterial pressure to volume expansion is inconstant, delayed, and transitory. In the case of profound, life-threatening hypotension, relying only on fluids to restore blood pressure may unduly prolong hypotension and organ hypoperfusion. Conversely, norepinephrine rapidly increases and better stabilizes arterial pressure. By binding venous adrenergic receptors, it transforms part of the unstressed blood volume into stressed blood volume. It increases the mean systemic filling pressure and increases the fluid-induced increase in mean systemic filling pressure, as observed in septic shock patients. This may improve end-organ perfusion, as shown by some animal studies. Two observational studies comparing early vs. later administration of norepinephrine in septic shock patients using a propensity score showed that early administration reduced the administered fluid volume and day-28 mortality. Conversely, in another propensity score-based study, norepinephrine administration within the first hour following shock diagnosis increased day-28 mortality. The only randomized controlled study that compared the early administration of norepinephrine alone to a placebo showed that the early continuous administration of norepinephrine at a fixed dose of 0.05 µg/kg/min, with norepinephrine added in open label, showed that shock control was achieved more often than in the placebo group. The choice of starting norepinephrine administration early should be adapted to the patient's condition. Logically, it should first be addressed to patients with profound hypotension, when the arterial tone is very low, as suggested by a low diastolic blood pressure (e.g. ≤ 40 mmHg), or by a high diastolic shock index (heart rate/diastolic blood pressure) (e.g. ≥ 3). Early administration of norepinephrine should also be considered in patients in whom fluid accumulation is likely to occur or in whom fluid accumulation would be particularly deleterious (in case of acute respiratory distress syndrome or intra-abdominal hypertension for example).
Topics: Animals; Blood Pressure; Hypotension; Norepinephrine; Shock, Septic; Vasoconstrictor Agents; Humans
PubMed: 37608327
DOI: 10.1186/s13054-023-04593-5 -
Clinics in Liver Disease May 2022Hepatorenal syndrome (HRS) is defined as a functional renal failure without major histologic changes in individuals with severe liver disease and it is associated with a... (Review)
Review
Hepatorenal syndrome (HRS) is defined as a functional renal failure without major histologic changes in individuals with severe liver disease and it is associated with a high mortality rate. Renal hypoperfusion due to marked vasoconstriction as a result of complex circulatory dysfunction has been suggested to be the cornerstone of HRS. Splanchnic and peripheral arterial vasodilation and cirrhotic cardiomyopathy result in effective arterial hypovolemia and compensatory activation of vasoconstrictor mechanisms. The efficacy of current therapeutic strategies targeting this circulatory dysfunction is limited. Increasing evidence suggests a substantial role of systemic inflammation in HRS via either vascular or direct renal effects. Here we summarize the current understanding of HRS pathophysiology.
Topics: Female; Hepatorenal Syndrome; Humans; Liver Cirrhosis; Male; Vasoconstrictor Agents; Vasodilation
PubMed: 35487603
DOI: 10.1016/j.cld.2022.01.013 -
Journal of Critical Care Jun 2015The aim of this study was to collect and describe all published reports of local tissue injury or extravasation from vasopressor administration via either peripheral... (Review)
Review
PURPOSE
The aim of this study was to collect and describe all published reports of local tissue injury or extravasation from vasopressor administration via either peripheral intravenous (IV) or central venous catheter.
METHODS
A systematic search of Medline, Embase, and Cochrane databases was performed from inception through January 2014 for reports of adults who received vasopressor intravenously via peripheral IV or central venous catheter for a therapeutic purpose. We included primary studies or case reports of vasopressor administration that resulted in local tissue injury or extravasation of vasopressor solution.
RESULTS
Eighty-five articles with 270 patients met all inclusion criteria. A total of 325 separate local tissue injury and extravasation events were identified, with 318 events resulting from peripheral vasopressor administration and 7 events resulting from central administration. There were 204 local tissue injury events from peripheral administration of vasopressors, with an average duration of infusion of 55.9 hours (±68.1), median time of 24 hours, and range of 0.08 to 528 hours. In most of these events (174/204, 85.3%), the infusion site was located distal to the antecubital or popliteal fossae.
CONCLUSIONS
Published data on tissue injury or extravasation from vasopressor administration via peripheral IVs are derived mainly from case reports. Further study is warranted to clarify the safety of vasopressor administration via peripheral IVs.
Topics: Catheterization, Central Venous; Catheterization, Peripheral; Central Venous Catheters; Critical Illness; Extravasation of Diagnostic and Therapeutic Materials; Humans; Infusions, Intravenous; Necrosis; Soft Tissue Injuries; Vascular Access Devices; Vasoconstrictor Agents
PubMed: 25669592
DOI: 10.1016/j.jcrc.2015.01.014 -
Critical Care Medicine Jan 2020
Topics: Critical Care; Critical Illness; Enteral Nutrition; Humans; Practice Guidelines as Topic; Vasoconstrictor Agents
PubMed: 31414992
DOI: 10.1097/CCM.0000000000003965 -
Scientific Reports Apr 2023Patients with sepsis often require emergency intubation. In emergency departments (EDs), rapid-sequence intubation with a single-dose induction agent is standard... (Randomized Controlled Trial)
Randomized Controlled Trial
Patients with sepsis often require emergency intubation. In emergency departments (EDs), rapid-sequence intubation with a single-dose induction agent is standard practice, but the best choice of induction agent in sepsis remains controversial. We conducted a randomized, controlled, single-blind trial in the ED. We included septic patients who were aged at least 18 years and required sedation for emergency intubation. Patients were randomly assigned by a blocked randomization to receive 0.2-0.3 mg/kg of etomidate or 1-2 mg/kg of ketamine for intubation. The objectives were to compare the survival outcomes and adverse events after intubation between etomidate and ketamine. Two hundred and sixty septic patients were enrolled; 130 patients/drug arm whose baseline characteristics were well balanced at baseline. In the etomidate group, 105 patients (80.8%) were alive at 28 days, compared with 95 patients (73.1%) in the ketamine group (risk difference [RD], 7.7%; 95% confidence interval [CI], - 2.5 to 17.9%; P = 0.092). There was no significant difference in the proportion of patients who survived at 24 h (91.5% vs. 96.2%; P = 0.097) and survived at 7 days (87.7% vs. 87.7%; P = 0.574). A significantly higher proportion of the etomidate group needed a vasopressor within 24 h after intubation: 43.9% vs. 17.7%, RD, 26.2% (95% CI, 15.4 to 36.9%; P < 0.001). In conclusion, there were no differences in early and late survival rates between etomidate and ketamine. However, etomidate was associated with higher risks of early vasopressor use after intubation. Trial registration: The trial protocol was registered in the Thai Clinical Trials Registry (identification number: TCTR20210213001). Registered 13 February 2021-Retrospectively registered, https://www.thaiclinicaltrials.org/export/pdf/TCTR20210213001 .
Topics: Humans; Adolescent; Adult; Etomidate; Ketamine; Anesthetics, Intravenous; Single-Blind Method; Intubation, Intratracheal; Sepsis; Emergency Service, Hospital; Vasoconstrictor Agents
PubMed: 37076524
DOI: 10.1038/s41598-023-33679-x -
American Journal of Health-system... Jan 2023
Topics: Humans; Terlipressin; Vasoconstrictor Agents; Acetates
PubMed: 36259893
DOI: 10.1093/ajhp/zxac291 -
Current Opinion in Critical Care Jun 2023The aim of this study was to illustrate the varying roles of echocardiography in all phases of shock ranging from a rapid, diagnostic tool at the bedside, to a tool for... (Review)
Review
PURPOSE OF REVIEW
The aim of this study was to illustrate the varying roles of echocardiography in all phases of shock ranging from a rapid, diagnostic tool at the bedside, to a tool for monitoring the adequacy and effects of shock treatment and finally for identification of patients suitable for de-escalation of therapy.
RECENT FINDINGS
Echocardiography has become an indispensable tool for establishing diagnosis in patients with shock. It is also important for assessing the adequacy of treatment such as fluid resuscitation, vasopressors and inotropes by providing integrated information on cardiac contractility and systemic flow conditions, particularly when used in conjunction with other methods of advanced haemodynamic monitoring. Apart from a traditional, diagnostic role, it may be used as an advanced, albeit intermittent, monitoring tool. Examples include the assessment of heart-lung interactions in mechanically ventilated patients, fluid responsiveness, vasopressor adequacy, preload dependence in ventilator-induced pulmonary oedema and indications for and monitoring during extracorporeal life support. Emerging studies also illustrate the role of echocardiography in de-escalation of shock treatment.
SUMMARY
This study provides the reader with a structured review on the uses of echocardiography in all phases of shock treatment.
Topics: Humans; Echocardiography; Shock; Heart; Fluid Therapy; Vasoconstrictor Agents; Hemodynamics
PubMed: 37078626
DOI: 10.1097/MCC.0000000000001041 -
Current Opinion in Anaesthesiology Apr 2022The purpose of this review is to look at the current evidence on the consequences of intraoperative hypotension and discuss improvements that can be implemented for its... (Review)
Review
PURPOSE OF REVIEW
The purpose of this review is to look at the current evidence on the consequences of intraoperative hypotension and discuss improvements that can be implemented for its prevention.
RECENT FINDINGS
Literature continues to supply convincing evidence that even brief periods of intraoperative hypotension are associated with increased perioperative morbidity and mortality. Recent randomized controlled trial showed intraoperative early use of vasopressor and maintaining blood pressure within tight ranges improves outcomes.
SUMMARY
There should be a shift in paradigm in focusing on the prevention of intraoperative hypotension instead treatment. The suggested goals to help maintaining hemodynamic stability during anesthesia include ensure adequate blood pressure and flow; hypotension prevention; and ensure adequate anesthetic depth without overdose.
Topics: Anesthesia; Anesthetics; Blood Pressure; Humans; Hypotension; Vasoconstrictor Agents
PubMed: 35125394
DOI: 10.1097/ACO.0000000000001115 -
Current Opinion in Critical Care Aug 2020Cardiogenic shock is a multifactorial and diverse entity in which inotropes are the cornerstone therapy. Although published clinical trials have focused on pharmacologic... (Review)
Review
PURPOSE OF REVIEW
Cardiogenic shock is a multifactorial and diverse entity in which inotropes are the cornerstone therapy. Although published clinical trials have focused on pharmacologic treatment of cardiogenic shock, there is lack of an established and widely accepted decision-making algorithm on the use of inotropic agents in cardiogenic shock.
RECENT FINDINGS
The current review incorporates cardiogenic shock pathophysiology, inotropes and vasopressors pharmacodynamics. It emphasizes on each agent's indications, potential adverse effects, highlights special considerations and fsummarizes the recent guidelines.
SUMMARY
Finally, proposes an algorithm of inotropes and vasopressors use and their potential combinations based on the clinical stage of cardiogenic shock. This algorithm can be used as a guide during the initial management of cardiogenic shock while underlying cause investigation is underway.
Topics: Cardiotonic Agents; Humans; Shock, Cardiogenic; Vasoconstrictor Agents
PubMed: 32496275
DOI: 10.1097/MCC.0000000000000744 -
Critical Care Nursing Clinics of North... Sep 2021Shock from all causes carries a high mortality. Rapid and intentional intervention to resuscitate can reduce mortality and organ injury. Approaches to fluid... (Review)
Review
Shock from all causes carries a high mortality. Rapid and intentional intervention to resuscitate can reduce mortality and organ injury. Approaches to fluid resuscitation, vasopressor use as well as commonly assessed laboratory values are reviewed in this paper.
Topics: Fluid Therapy; Humans; Resuscitation; Shock, Septic; Vasoconstrictor Agents
PubMed: 34340787
DOI: 10.1016/j.cnc.2021.05.001