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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 -
Shock (Augusta, Ga.) Jun 2022Sepsis and septic shock usually show a high mortality rate and frequently need of intensive care unit admissions. After fluid resuscitation, norepinephrine (NE) is the... (Review)
Review
Sepsis and septic shock usually show a high mortality rate and frequently need of intensive care unit admissions. After fluid resuscitation, norepinephrine (NE) is the first-choice vasopressor in septic shock patients. However, high-NE doses are associated with increased rates of adverse effects and mortality. In this perspective, many authors have proposed the administration of non-adrenergic vasopressors (NAV). Selepressin is a selective vasopressin type 1A (V1A) receptor agonist and may be a valid option in this field, because it can decrease NE requirements and also limit the deleterious effects induced by high doses of catecholamines. Only few clinical data actually support selepressin administration in this setting. Here, we review the current literature on this topic analyzing some pathophysiological aspects, the rationale about the use of NAV, the possible use of selepressin differentiating animal, and human studies. Various issues remain unresolved and future trials should be focused on early interventions based on a multimodal activation of the vasopressive pathways using both alpha and V1A receptors pathways.
Topics: Catecholamines; Humans; Norepinephrine; Sepsis; Shock, Septic; Vasoconstrictor Agents
PubMed: 35759300
DOI: 10.1097/SHK.0000000000001932 -
British Journal of Anaesthesia Sep 2022Chiu and colleagues report a retrospective analysis describing the 5-yr trend in both intraoperative fluid and vasopressor administration in 32 250 patients undergoing...
Chiu and colleagues report a retrospective analysis describing the 5-yr trend in both intraoperative fluid and vasopressor administration in 32 250 patients undergoing elective abdominal surgery within the Multicenter Perioperative Outcomes Group (MPOG) database from 2015 to 2019, and exploring the association between these two factors and acute kidney injury. Modelling predicted the lowest risk for acute kidney injury when the administered crystalloid volume was 15-20 ml kg h, and an 80% increase in risk for acute kidney injury as intraoperative vasopressor use increased from 0 to 0.04 μg kg min of norepinephrine equivalents. Although these results are consistent with those of a large, randomised trial (REstrictive Versus LIbEral Fluid Therapy in Major Abdominal Surgery [RELIEF]) published in 2018, the mean intraoperative volume of crystalloid administered in the current study declined monotonically through every year included, from 6.4 ml kg h in 2015 to 5.5 ml kg h in 2019. These new findings support the broad generalisability of the RELIEF trial; highlight the complexity of the relationship between intravenous crystalloid volume infused, arterial pressure, and acute kidney injury; and demonstrate the ongoing challenge of translating high-quality evidence into clinical practice.
Topics: Abdomen; Acute Kidney Injury; Crystalloid Solutions; Fluid Therapy; Humans; Retrospective Studies; Vasoconstrictor Agents
PubMed: 35927095
DOI: 10.1016/j.bja.2022.06.016 -
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 -
Clinical Journal of the American... Jun 2022The definition of sepsis has evolved significantly over the past three decades. Today, sepsis is defined as a dysregulated host immune response to microbial invasion... (Review)
Review
The definition of sepsis has evolved significantly over the past three decades. Today, sepsis is defined as a dysregulated host immune response to microbial invasion leading to end organ dysfunction. Septic shock is characterized by hypotension requiring vasopressors after adequate fluid resuscitation with elevated lactate. Early recognition and intervention remain hallmarks for sepsis management. We addressed the current literature and assimilated thought regarding optimum initial resuscitation of the patient with sepsis. A nuanced understanding of the physiology of lactate is provided in our review. Physiologic and practical knowledge of steroid and vasopressor therapy for sepsis is crucial and addressed. As blood purification may interest the nephrologist treating sepsis, we have also added a brief discussion of its status.
Topics: Fluid Therapy; Humans; Lactic Acid; Nephrologists; Sepsis; Shock, Septic; Vasoconstrictor Agents
PubMed: 35551069
DOI: 10.2215/CJN.14381121 -
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 -
Seminars in Respiratory and Critical... Feb 2021Arterial pressure management is a crucial task in the operating room and intensive care unit. In high-risk surgical and in critically ill patients, sustained hypotension... (Review)
Review
Arterial pressure management is a crucial task in the operating room and intensive care unit. In high-risk surgical and in critically ill patients, sustained hypotension is managed with continuous infusion of vasopressor agents, which most commonly have direct α agonist activity like phenylephrine or norepinephrine. The current standard of care to guide vasopressor infusion is manual titration to an arterial pressure target range. This approach may be improved by using automated systems that titrate vasopressor infusions to maintain a target pressure. In this article, we review the evidence behind blood pressure management in the operating room and intensive care unit and discuss current and potential future applications of automated blood pressure control.
Topics: Blood Pressure; Critical Illness; Humans; Hypotension; Intensive Care Units; Vasoconstrictor Agents
PubMed: 32746471
DOI: 10.1055/s-0040-1713083