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The American Journal of Emergency... Dec 2021Given the dramatic increase in critically ill patients who present to the emergency department for care, along with the persistence of boarding of critically ill... (Review)
Review
Given the dramatic increase in critically ill patients who present to the emergency department for care, along with the persistence of boarding of critically ill patients, it is imperative for the emergency physician to be knowledgeable about recent developments in resuscitation and critical care medicine. This review summarizes important articles published in 2020 that pertain to the resuscitation and care of select critically ill patients. These articles have been selected based on the authors annual review of key critical care, emergency medicine and medicine journals and their opinion of the importance of study findings as it pertains to the care of critically ill ED patients. Several key findings from the studies discussed in this paper include the administration of dexamethasone to patients with COVID-19 infection who require mechanical ventilation or supplemental oxygen, the use of lower levels of positive end-expiratory pressure for patients without acute respiratory distress syndrome, and early initiation of extracorporeal membrane oxygenation for out-of-hospital cardiac arrest patients with refractory ventricular fibrillation if resources are available. Furthermore, the emergency physician should not administer tranexamic acid to patients with acute gastrointestinal bleeding or administer the combination of vitamin C, thiamine, and hydrocortisone for patients with septic shock. Finally, the emergency physician should titrate vasopressor medications to more closely match a patient's chronic perfusion pressure rather than target a mean arterial blood pressure of 65 mmHg for all critically ill patients.
Topics: COVID-19; Critical Care; Humans; Respiration, Artificial; Resuscitation; Vasoconstrictor Agents
PubMed: 34879487
DOI: 10.1016/j.ajem.2021.09.056 -
Current Opinion in Critical Care Dec 2020This review discusses the macrocirculatory and microcirculatory aspects of renal perfusion, as well as novel methods by which to measure renal blood flow. Finally,... (Review)
Review
PURPOSE OF REVIEW
This review discusses the macrocirculatory and microcirculatory aspects of renal perfusion, as well as novel methods by which to measure renal blood flow. Finally, therapeutic options are briefly discussed, including renal-specific microcirculatory effects.
RECENT FINDINGS
The optimal mean arterial pressure (MAP) needed for preservation of renal function has been debated but is most likely a MAP of 60-80 mmHg. In addition, attention should be paid to renal outflow pressure, typically central venous pressure. Heterogeneity in microcirculation can exist and may be mitigated through appropriate use of vasopressors with unique microcirculatory effects. Excessive catecholamines have been shown to be harmful and should be avoided. Both angiotensin II and vasopressin may improve glomerular flow through a number of mechanisms. Macrocirculatory and microcirculatory blood flow can be measured through a number of bedside ultrasound modalities, sublingual microscopy and urinary oxygen measurement, SUMMARY: Acute kidney injury (AKI) is a common manifestation of organ failure in shock, and avoidance of hemodynamic instability can mitigate this risk. Measurement of renal haemodynamics is not routinely performed but may help to guide therapeutic goals. A thorough understanding of pathophysiology, measurement techniques and therapeutic options may allow for a personalized approach to blood pressure management in patients with septic shock and may ultimately mitigate AKI.
Topics: Hemodynamics; Humans; Microcirculation; Renal Circulation; Shock, Septic; Vasoconstrictor Agents
PubMed: 33044238
DOI: 10.1097/MCC.0000000000000774 -
Minerva Anestesiologica Oct 2020
Topics: Humans; Phenylephrine; Vasoconstrictor Agents
PubMed: 32613813
DOI: 10.23736/S0375-9393.20.14716-3 -
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 -
European Journal of Internal Medicine Mar 2024Sepsis remains a critical global health issue, demanding novel therapeutic strategies. Traditional immunomodulation treatments such as corticosteroids, specific... (Review)
Review
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.
Topics: Humans; Sepsis; Vasoconstrictor Agents; Immunity; Immunomodulation; Anti-Inflammatory Agents; Hypnotics and Sedatives
PubMed: 37919123
DOI: 10.1016/j.ejim.2023.10.032 -
Anaesthesia, Critical Care & Pain... Jun 2023
Topics: Humans; Norepinephrine; Cardiac Surgical Procedures; Vasoconstrictor Agents; Cardiopulmonary Bypass
PubMed: 36870666
DOI: 10.1016/j.accpm.2023.101210 -
Neonatology 2024Epinephrine (adrenaline) is currently the only cardiac agent recommended during neonatal resuscitation. The inability to predict which newborns are at risk of requiring... (Review)
Review
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.
Topics: Animals; Infant, Newborn; Child; Humans; Resuscitation; Cardiopulmonary Resuscitation; Epinephrine; Heart Arrest; Vasopressins; Animals, Newborn; Vasoconstrictor Agents
PubMed: 38228124
DOI: 10.1159/000535502 -
Critical Care Medicine Dec 2023To determine if angiotensin II is associated with improved outcomes as measured by 30- and 90-day mortality as well as other secondary outcomes such as organ dysfunction...
OBJECTIVES
To determine if angiotensin II is associated with improved outcomes as measured by 30- and 90-day mortality as well as other secondary outcomes such as organ dysfunction and adverse events.
DESIGN
Retrospective, matched analysis of patients receiving angiotensin II compared with both historical and concurrent controls receiving equivalent doses of nonangiotensin II vasopressors.
SETTING
Multiple ICUs in a large, university-based hospital.
PATIENTS
Eight hundred thirteen adult patients with shock admitted to an ICU and requiring vasopressor support.
INTERVENTIONS
None.
MEASUREMENTS AND MAIN RESULTS
Angiotensin II use had no association with the primary outcome of 30-day mortality (60% vs 56%; p = 0.292). The secondary outcome of 90-day mortality was also similar (65% vs 63%; p = 0.440) as were changes in Sequential Organ Failure Assessment scores over a 5-day monitoring period after enrollment. Angiotensin II was not associated with increased rates of kidney replacement therapy (odds ratio [OR], 1.39; 95% CI, 0.88-2.19; p = 0.158) or receipt of mechanical ventilation (OR, 1.50; 95% CI, 0.41-5.51; p = 0.539) after enrollment, and the rate of thrombotic events was similar between angiotensin II and control patients (OR, 1.02; 95% CI, 0.71-1.48; p = 0.912).
CONCLUSIONS
In patients with severe shock, angiotensin II was not associated with improved mortality or organ dysfunction and was not associated with an increased rate of adverse events.
Topics: Adult; Humans; Angiotensin II; Multiple Organ Failure; Retrospective Studies; Shock; Vasoconstrictor Agents
PubMed: 37378469
DOI: 10.1097/CCM.0000000000005975 -
European Journal of Cell Biology Apr 2022The vascular endothelium is an important regulator of vascular reactivity and preserves the balance between vasoconstrictor and vasodilator tone during normal... (Review)
Review
The vascular endothelium is an important regulator of vascular reactivity and preserves the balance between vasoconstrictor and vasodilator tone during normal physiologic conditions. Example endothelial-derived vasoconstrictors include endothelin-1 and thromboxane A2; example vasodilators include nitric oxide and prostacyclin. A growing body of evidence points to the existence of a non-nitric oxide, non-prostacyclin endothelium-derived vasodilatory factor of currently unclear identity, often referred to as endothelium-derived hyperpolarizing factor (EDHF). Recent research testifies to the significance of EDHF in endothelium-dependent vascular smooth muscle relaxation. Special emphasis has been placed on the role of small conductance calcium-activated potassium channels (SK) in facilitating the endothelial and vascular responses to EDHF across the microcirculation, including coronary, mesenteric, and pulmonary vascular beds. Meanwhile, decreased activity of endothelial SK channel activity has been implicated in the pathology of a variety of disease states that alter the balance between vasodilator and vasoconstrictor tone. Hence the primary goal of this review is to characterize the physiology of endothelial SK channels in the microvasculature under normal and pathological conditions. Themes of regulation and dysregulation of SK channel activity through the action of protein kinases, reactive oxygen species, and byproducts of intermediary metabolism provide unifying principles to tie together vascular pathology in altered metabolic states ranging from hypertension to diabetes, to ischemia-reperfusion. A comprehensive understanding of SK channel pathophysiology may provide a foundation for development of new therapeutics targeting SK channels, particularly SK channel potentiators, that may have widespread application for many chronic disease states.
Topics: Biological Factors; Endothelium, Vascular; Small-Conductance Calcium-Activated Potassium Channels; Vasoconstrictor Agents; Vasodilation; Vasodilator Agents
PubMed: 35151983
DOI: 10.1016/j.ejcb.2022.151208