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Journal of the Irish Dental Association Dec 2015
Topics: Astringents; Gingiva; Gingival Retraction Techniques; Hemostatics; Humans; Time Factors; Tooth Preparation; Vasoconstrictor Agents
PubMed: 26902073
DOI: No ID Found -
Current Opinion in Critical Care Aug 2017Norepinephrine is the first-line agent recommended during resuscitation of septic shock to correct hypotension due to depressed vascular tone. Important clinical issues... (Review)
Review
PURPOSE OF REVIEW
Norepinephrine is the first-line agent recommended during resuscitation of septic shock to correct hypotension due to depressed vascular tone. Important clinical issues are the best timing to start norepinephrine, the optimal blood pressure target, and the best therapeutic options to face refractory hypotension when high doses of norepinephrine are required to reach the target.
RECENT FINDINGS
Recent literature has reported benefits of early administration of norepinephrine because of the following reasons: profound and durable hypotension is an independent factor of increased mortality, early administration of norepinephrine increases cardiac output, improves microcirculation and avoids fluid overload. Recent data are in favor of targeting a mean arterial pressure of at least 65 mmHg and higher values in case of chronic hypertension. When hypotension is refractory to norepinephrine, it is recommended adding vasopressin, which is relatively deficient during sepsis and acts on other vascular receptors than α1-adernergic receptors. However, increasing the dose of norepinephrine further cannot be discouraged.
SUMMARY
Early administration of norepinephrine is beneficial for septic shock patients to restore organ perfusion. The mean arterial pressure target should be individualized. Adding vasopressin is recommended in case of shock refractory to norepinephrine.
Topics: Blood Pressure; Humans; Norepinephrine; Shock, Septic; Vasoconstrictor Agents
PubMed: 28509668
DOI: 10.1097/MCC.0000000000000418 -
The Cochrane Database of Systematic... Feb 2016Initial goal-directed resuscitation for hypotensive shock usually includes administration of intravenous fluids, followed by initiation of vasopressors. Despite obvious... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Initial goal-directed resuscitation for hypotensive shock usually includes administration of intravenous fluids, followed by initiation of vasopressors. Despite obvious immediate effects of vasopressors on haemodynamics, their effect on patient-relevant outcomes remains controversial. This review was published originally in 2004 and was updated in 2011 and again in 2016.
OBJECTIVES
Our objective was to compare the effect of one vasopressor regimen (vasopressor alone, or in combination) versus another vasopressor regimen on mortality in critically ill participants with shock. We further aimed to investigate effects on other patient-relevant outcomes and to assess the influence of bias on the robustness of our effect estimates.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015 Issue 6), MEDLINE, EMBASE, PASCAL BioMed, CINAHL, BIOSIS and PsycINFO (from inception to June 2015). We performed the original search in November 2003. We also asked experts in the field and searched meta-registries to identify ongoing trials.
SELECTION CRITERIA
Randomized controlled trials (RCTs) comparing various vasopressor regimens for hypotensive shock.
DATA COLLECTION AND ANALYSIS
Two review authors abstracted data independently. They discussed disagreements between them and resolved differences by consulting with a third review author. We used a random-effects model to combine quantitative data.
MAIN RESULTS
We identified 28 RCTs (3497 participants) with 1773 mortality outcomes. Six different vasopressors, given alone or in combination, were studied in 12 different comparisons.All 28 studies reported mortality outcomes; 12 studies reported length of stay. Investigators reported other morbidity outcomes in a variable and heterogeneous way. No data were available on quality of life nor on anxiety and depression outcomes. We classified 11 studies as having low risk of bias for the primary outcome of mortality; only four studies fulfilled all trial quality criteria.In summary, researchers reported no differences in total mortality in any comparisons of different vasopressors or combinations in any of the pre-defined analyses (evidence quality ranging from high to very low). More arrhythmias were observed in participants treated with dopamine than in those treated with norepinephrine (high-quality evidence). These findings were consistent among the few large studies and among studies with different levels of within-study bias risk.
AUTHORS' CONCLUSIONS
We found no evidence of substantial differences in total mortality between several vasopressors. Dopamine increases the risk of arrhythmia compared with norepinephrine and might increase mortality. Otherwise, evidence of any other differences between any of the six vasopressors examined is insufficient. We identified low risk of bias and high-quality evidence for the comparison of norepinephrine versus dopamine and moderate to very low-quality evidence for all other comparisons, mainly because single comparisons occasionally were based on only a few participants. Increasing evidence indicates that the treatment goals most often employed are of limited clinical value. Our findings suggest that major changes in clinical practice are not needed, but that selection of vasopressors could be better individualised and could be based on clinical variables reflecting hypoperfusion.
Topics: Drug Therapy, Combination; Humans; Hypotension; Randomized Controlled Trials as Topic; Shock; Shock, Septic; Vasoconstrictor Agents
PubMed: 26878401
DOI: 10.1002/14651858.CD003709.pub4 -
Expert Opinion on Drug Safety 2016The management of sepsis essentially relies on effective resuscitation with fluids and vasopressors, appropriate and adequate antimicrobial therapy, and organ support.... (Review)
Review
INTRODUCTION
The management of sepsis essentially relies on effective resuscitation with fluids and vasopressors, appropriate and adequate antimicrobial therapy, and organ support. Any of these interventions can have beneficial but also harmful effects.
AREAS COVERED
We focus on the key hemodynamic signs of sepsis and discuss the potential safety risks associated with the management of each of them, including optimizing arterial pressure, cardiac output and oxygen delivery. We also underline the importance of the timing of interventions.
EXPERT OPINION
Patients with septic shock are heterogeneous, making it particularly difficult to provide therapeutic recommendations that are safe and effective for all. A personalized medicine approach should be used with treatment decisions carefully considered and the risks and benefits of each intervention balanced in each individual patient.
Topics: Anti-Infective Agents; Arterial Pressure; Cardiac Output; Fluid Therapy; Humans; Oxygen; Precision Medicine; Sepsis; Shock, Septic; Vasoconstrictor Agents
PubMed: 26634948
DOI: 10.1517/14740338.2016.1128411 -
Archivos de Cardiologia de Mexico 2018The cardiovascular system is a dynamic system, which is required to ensure adequate delivery of oxygen, nutrients, and hormones to the tissues that are necessary for... (Review)
Review
The cardiovascular system is a dynamic system, which is required to ensure adequate delivery of oxygen, nutrients, and hormones to the tissues that are necessary for cell metabolism. It also synthesises and modifies the vasoactive components that regulate vascular tone and myocardial function. These vasoactive components have demonstrated their beneficial effects in the management of paediatric patients in a critical condition with heart failure and shock. However, their use and abuse brings harmful effects, increases mortality, and is associated with arrhythmias. An increase in myocardial oxygen consumption favours the presence of ischaemia, therefore it is necessary to know the mechanism of action and indications of these drugs to minimise their harmful effects. The purpose of this review is to describe the pharmacology and clinical applications of inotropic and vasopressor agents in the paediatric patient in acritical condition.
Topics: Cardiotonic Agents; Child; Heart Failure; Humans; Vasoconstrictor Agents
PubMed: 28336302
DOI: 10.1016/j.acmx.2017.02.005 -
Minerva Anestesiologica Nov 2015We present a review of the hemodynamic management of septic shock. Although substantial amount of evidence is present in this area, most key decisions on the management... (Review)
Review
We present a review of the hemodynamic management of septic shock. Although substantial amount of evidence is present in this area, most key decisions on the management of these patients remain dependent on physiological reasoning and on pathophysiological principles rather than randomized controlled trials. During primary (early) resuscitation, restoration of adequate arterial pressure and cardiac output using fluids and vasopressor and/or inotropic drugs is guided by basic hemodynamic monitoring and physical examination in the emergency department. When more advanced level of monitoring is present in these patients, i.e. during secondary resuscitation (later phase in the emergency department and in the ICU), hemodynamic management can be guided by more advanced measurements of the macrocirculation. Our understanding of the microcirculation in septic shock is limited and reliable therapeutic modalities to optimize it do not yet exist. No specific hemodynamic treatment strategy, be it medications including fluids, monitoring devices or treatment algorithms has yet been proved to improve outcome. Moreover, there is virtually no data on the optimal management of the resolution phase of septic shock. Despite these gaps in knowledge, the data from observational studies and trials suggests that mortality in septic shock has been generally decreasing during the last decade.
Topics: Fluid Therapy; Hemodynamics; Humans; Shock, Septic; Vasoconstrictor Agents
PubMed: 25369134
DOI: No ID Found -
Shock (Augusta, Ga.) May 2017Refractory septic shock is defined as persistently low mean arterial blood pressure despite volume resuscitation and titrated vasopressors/inotropes in patients with a... (Review)
Review
Refractory septic shock is defined as persistently low mean arterial blood pressure despite volume resuscitation and titrated vasopressors/inotropes in patients with a proven or suspected infection and concomitant organ dysfunction. Its management typically requires high doses of catecholamines, which can induce significant adverse effects such as ischemia and arrhythmias. Angiotensin II (Ang II), a key product of the renin-angiotensin-aldosterone system, is a vasopressor agent that could be used in conjunction with other vasopressors to stabilize critically ill patients during refractory septic shock, and reduce catecholamine requirements. However, very few clinical data are available to support Ang II administration in this setting. Here, we review the current literature on this topic to better understand the role of Ang II administration during refractory septic shock, differentiating experimental from clinical studies. We also consider the potential role of exogenous Ang II administration in specific organ dysfunction and possible pitfalls with Ang II in sepsis. Various issues remain unresolved and future studies should investigate important topics such as: the optimal dose and timing of Ang II administration, a comparison between Ang II and the other vasopressors (epinephrine; vasopressin), and Ang II effects on microcirculation.
Topics: Angiotensin II; Hemodynamics; Humans; Shock, Septic; Vasoconstrictor Agents
PubMed: 27879559
DOI: 10.1097/SHK.0000000000000807 -
Expert Review of Anti-infective Therapy Jan 2017Distributive shock is associated with decreased systemic vascular resistance and altered oxygen extraction. Septic shock is the most frequent form of distributive shock.... (Review)
Review
Distributive shock is associated with decreased systemic vascular resistance and altered oxygen extraction. Septic shock is the most frequent form of distributive shock. In shock states, duration of hypotension is associated with poor outcomes. The speed at which treatment to restore adequate perfusion pressure is initiated is, therefore, important to improve survival. Areas covered: This review presents an overview of the literature related to the management of vasopressor-dependent distributive shock, and in particular the relationship between arterial pressure and organ perfusion and function. Studies that have tried to determine an optimal blood pressure level are discussed demonstrating that it is difficult to define and will vary according to individual patient factors, including age and a history of chronic hypertension. An initial target mean arterial pressure (MAP) of 65-70 mmHg is probably sufficient in most patients. The influence of increasing MAP on the microcirculation is also covered. Expert commentary: Microcirculatory monitoring may be the best way to individualize management of these patients, but remains experimental at present. In the meantime, repeated blood lactate levels and venous oxygen saturations, combined with hemodynamic variables and the clinical picture, can provide an indication of the response to treatment and adequacy of tissue perfusion.
Topics: Blood Flow Velocity; Blood Pressure; Humans; Microcirculation; Practice Guidelines as Topic; Shock, Septic; Vascular Resistance; Vasoconstrictor Agents
PubMed: 27774825
DOI: 10.1080/14787210.2017.1252673 -
Critical Care Medicine Apr 2022
Topics: Vasoconstrictor Agents
PubMed: 35311781
DOI: 10.1097/CCM.0000000000005344 -
Seminars in Fetal & Neonatal Medicine Jun 2022Managing perfusion in the micropreemie is challenging and should be guided by the patho-physiology, gestational and postnatal age of the baby, perinatal history, and the... (Review)
Review
Managing perfusion in the micropreemie is challenging and should be guided by the patho-physiology, gestational and postnatal age of the baby, perinatal history, and the persistence of fetal shunts. The assessment should incorporate bedside tools such as blood pressure, clinical perfusion markers, and functional echocardiography. The multimodal approach to diagnose and identify the cause of hemodynamic compromise paves the way to a targeted approach to treatment. Characterizing the predominant pathophysiologic cause of low cardiac output and impaired cellular metabolism enables a more accurate use of inotropes, vasopressors, and volume support to suit a particular pathophysiologic situation.
Topics: Blood Pressure; Cardiotonic Agents; Hemodynamics; Humans; Vasoconstrictor Agents
PubMed: 35382998
DOI: 10.1016/j.siny.2022.101329