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Medizinische Klinik, Intensivmedizin... Sep 2021Circulatory shock requires treatment of the underlying pathology in addition to supportive pharmacological therapy that is guided by hemodynamic monitoring. Based on the...
Circulatory shock requires treatment of the underlying pathology in addition to supportive pharmacological therapy that is guided by hemodynamic monitoring. Based on the evaluation of the patient's volume, perfusion and cardiac status, the following therapeutic goals should be achieved: (1) Normalization of the intra- and extravascular fluid volume. (2) Provision of sufficient perfusion pressure and organ perfusion. (3) Optimization of cardiac function including protecting an ischemic and exhausted myocardium from overload. The most important therapeutic substances are balanced electrolyte solutions and the vasopressor noradrenaline. Because there is little scientific evidence for the use of alternative drugs, these should only be given if there is a good pathophysiologic rationale and if their effect is continuously monitored and re-evaluated.
Topics: Fluid Therapy; Hemodynamics; Humans; Monitoring, Physiologic; Norepinephrine; Shock; Vasoconstrictor Agents
PubMed: 34338810
DOI: 10.1007/s00063-021-00838-9 -
American Journal of Respiratory and... Sep 2020
Topics: Humans; Norepinephrine; Sepsis; Shock, Septic; Vasoconstrictor Agents
PubMed: 32813548
DOI: 10.1164/rccm.202006-2301ED -
The American Journal of Emergency... Jul 2023Septic shock is a leading cause of death in intensive care units (ICUs), with short-term mortality rates of 35-40%. Vasopressin (AVP) is a second-line vasoactive agent...
BACKGROUND
Septic shock is a leading cause of death in intensive care units (ICUs), with short-term mortality rates of 35-40%. Vasopressin (AVP) is a second-line vasoactive agent for septic shock, and recent studies suggest that early AVP use can be beneficial. However, differences between early initiation of AVP combined with norepinephrine (NE) and nonearly AVP with NE are unclear. A retrospective cohort research was designed to explore the effects of early AVP initiation versus nonearly AVP initiation.
METHODS
This retrospective single-center cohort study included adult patients with septic shock from the MIMIC (Medical Information Mart for Intensive Care)-IV database. According to whether AVP was used early in the ICU (intensive care unit), patients were assigned to the early- (within 6 h of septic shock onset) and non-early-AVP (at least 6 h after septic shock onset) groups. The primary outcome was 28-day mortality. The secondary outcomes were ICU and hospital mortality, the numbers of vasopressor-free and ventilation-free days at 28 days, ICU length of stay (LOS), hospital LOS, sequential organ failure assessment (SOFA) score on days 2 and 3, and renal replacement therapy (RRT) use on days 2 and 3. Univariate and multivariate cox proportional-hazards regression, propensity-score matching were used to analyze the differences between the groups.
RESULTS
The study included 531 patients with septic shock: 331 (62.5%) in the early-AVP group and 200 (37.5%) in the non-early-AVP group. For 1:1 matching, 158 patients in the early-AVP group were matched with the same number of patients with nonearly AVP. Regarding the primary outcome, there was no significant difference between the early- and non-early-AVP groups in 28-day mortality (hazard ratio [HR] = 0.91, 95% confidence interval [CI] = 0.68-1.24). For the secondary outcomes, there were no differences between the early- and non-early-AVP groups in ICU mortality (HR = 0.95, 95% CI = 0.67-1.35), hospital mortality (HR = 0.95, 95% CI = 0.69-1.31), the numbers of vasopressor-free and ventilation-free days at 28 days, ICU LOS, hospital LOS, SOFA score on days 2 and 3, and RRT use on days 2 and 3.
CONCLUSIONS
There was no difference in short-term mortality between early AVP combined with NE and nonearly AVP with NE in septic shock.
Topics: Adult; Humans; Norepinephrine; Retrospective Studies; Shock, Septic; Cohort Studies; Vasopressins; Vasoconstrictor Agents; Intensive Care Units
PubMed: 37167890
DOI: 10.1016/j.ajem.2023.04.040 -
Pediatric Critical Care Medicine : a... Aug 2022
Topics: Humans; Shock, Septic; Vasoconstrictor Agents
PubMed: 36165943
DOI: 10.1097/PCC.0000000000002999 -
Cardiovascular Drugs and Therapy Aug 2022Vasoplegia is a common complication after cardiac surgery and is related to the use of cardiopulmonary bypass (CPB). Despite its association with increased morbidity and... (Review)
Review
PURPOSE
Vasoplegia is a common complication after cardiac surgery and is related to the use of cardiopulmonary bypass (CPB). Despite its association with increased morbidity and mortality, no consensus exists in terms of its treatment. In December 2017, angiotensin II (AII) was approved by the Food and Drug Administration (FDA) for use in vasodilatory shock; however, except for the ATHOS-3 trial, its use in vasoplegic patients that underwent cardiac surgery on CPB has mainly been reported in case reports. Thus, the aim of this review is to collect all the clinically relevant data and describe the pharmacologic mechanism, efficacy, and safety of this novel pharmacologic agent for the treatment of refractory vasoplegia in this population.
METHODS
Two independent reviewers performed a systematic search in PubMed, Embase, Web of Science, and Cochrane Library using relevant MeSH terms (Angiotensin II, Vasoplegia, Cardiopulmonary Bypass, Cardiac Surgical Procedures).
RESULTS
The literature search yielded 820 unique articles. In total, 9 studies were included. Of those, 2 were randomized clinical trials (RCTs) and 6 were case reports and 1 was a retrospective cohort study.
CONCLUSIONS
AII appears to be a promising means of treatment for patients with post-operative vasoplegia. It is demonstrated to be effective in raising blood pressure, while no major adverse events have been reported. It remains uncertain whether this agent will be broadly available and whether it will be more advantageous in the clinical management of vasoplegia compared to other available vasopressors. For that reason, we should contain our eagerness and enthusiasm regarding its use until supplementary knowledge becomes available.
Topics: Angiotensin II; Cardiac Surgical Procedures; Cardiopulmonary Bypass; Humans; Randomized Controlled Trials as Topic; United States; Vasoconstrictor Agents; Vasoplegia
PubMed: 33085026
DOI: 10.1007/s10557-020-07098-3 -
Reproduction (Cambridge, England) Oct 2022There is a pregnancy-induced vasodilation of blood vessels, which is known to have a protective effect on cardiovascular function and can be maintained postpartum. This... (Review)
Review
IN BRIEF
There is a pregnancy-induced vasodilation of blood vessels, which is known to have a protective effect on cardiovascular function and can be maintained postpartum. This review outlines the cardiovascular changes that occur in a healthy human and rodent pregnancy, as well as different pathways that are activated by angiotensin II and relaxin that result in blood vessel dilation.
ABSTRACT
During pregnancy, systemic and uteroplacental blood flow increase to ensure an adequate blood supply that carries oxygen and nutrients from the mother to the fetus. This results in changes to the function of the maternal cardiovascular system. There is also a pregnancy-induced vasodilation of blood vessels, which is known to have a protective effect on cardiovascular health/function. Additionally, there is evidence that the effects of maternal vascular vasodilation are maintained post-partum, which may reduce the risk of developing high blood pressure in the next pregnancy and reduce cardiovascular risk later in life. At both non-pregnant and pregnant stages, vascular endothelial cells produce a number of vasodilators and vasoconstrictors, which transduce signals to the contractile vascular smooth muscle cells to control the dilation and constriction of blood vessels. These vascular cells are also targets of other vasoactive factors, including angiotensin II (Ang II) and relaxin. The binding of Ang II to its receptors activates different pathways to regulate the blood vessel vasoconstriction/vasodilation, and relaxin can interact with some of these pathways to induce vasodilation. Based on the available literature, this review outlines the cardiovascular changes that occur in a healthy human pregnancy, supplemented by studies in rodents. A specific focus is placed on vasodilation of blood vessels during pregnancy; the role of endothelial cells and endothelium-derived vasodilators will also be discussed. Additionally, different pathways that are activated by Ang II and relaxin that result in blood vessel dilation will also be reviewed.
Topics: Angiotensin II; Endothelial Cells; Endothelium, Vascular; Female; Humans; Oxygen; Pregnancy; Relaxin; Vasoconstrictor Agents; Vasodilator Agents
PubMed: 36018774
DOI: 10.1530/REP-21-0428 -
Journal of Burn Care & Research :... Mar 2023Acute burn surgery has long been associated with significant intra-operative bleeding. Several techniques were introduced to limit hemorrhage, including tourniquets,...
Acute burn surgery has long been associated with significant intra-operative bleeding. Several techniques were introduced to limit hemorrhage, including tourniquets, tumescent infiltration, and topical agents. To date, no study has comprehensively investigated the available data regarding topical hemostatic agents in burn surgery. A systematic review was performed by two independent reviewers using electronic databases (PubMed, Scopus, Web of Science) from first available to September 10, 2021. Articles were included if they were published in English and described or evaluated topical hemostatic agents used in burn excision and/or grafting. Data were extracted on the agent(s) used, their dosage, mode of delivery, hemostasis outcomes, and complications. The search identified 1982 nonduplicate citations, of which 134 underwent full-text review, and 49 met inclusion criteria. In total, 32 studies incorporated a vasoconstrictor agent, and 28 studies incorporated a procoagulant agent. Four studies incorporated other agents (hydrogen peroxide, tranexamic acid, collagen sheets, and TT-173). The most common vasoconstrictor used was epinephrine, with doses ranging from 1:1000 to 1:1,000,000. The most common procoagulant used was thrombin, with doses ranging from 10 to 1000 IU/ml. Among the comparative studies, outcomes of blood loss were not reported in a consistent manner, therefore meta-analysis could not be performed. The majority of studies (94%) were level of evidence III-V. Determining the optimal topical hemostatic agent is limited by low-quality data and challenges with consistent reporting of intra-operative blood loss. Given the routine use of topical hemostatic agents in burn surgery, high-quality research is essential to determine the optimal agent, dosage, and mode of delivery.
Topics: Humans; Burns; Administration, Topical; Vasoconstrictor Agents; Blood Loss, Surgical; Hemostatics; Antifibrinolytic Agents
PubMed: 36516423
DOI: 10.1093/jbcr/irac185 -
Seminars in Respiratory and Critical... Oct 2021Sepsis can influence blood volume, its distribution, vascular tone, and cardiac function. Persistent hypotension or the need for vasopressors after volume resuscitation... (Review)
Review
Sepsis can influence blood volume, its distribution, vascular tone, and cardiac function. Persistent hypotension or the need for vasopressors after volume resuscitation is part of the definition of septic shock. Since increased positive fluid balance has been associated with increased morbidity and mortality in sepsis, timing of vasopressors in the treatment of septic shock seems crucial. However, conclusive evidence on timing and sequence of interventions with the goal to restore tissue perfusion is lacking. The aim of this narrative review is to depict the pathophysiology of hypotension in sepsis, evaluate how common interventions to treat hypotension interfere with physiology, and to give a resume of the results from clinical studies focusing on targets and timing of vasopressor in sepsis. The majority of studies comparing early versus late administration of vasopressors in septic shock are rather small, single-center, and retrospective. The range of "early" is between 1 and 12 hours. The available studies suggest a mean arterial pressure of 60 to 65 mm Hg as a threshold for increased risk of morbidity and mortality, whereas higher blood pressure targets do not seem to add further benefits. The data, albeit mostly from observational studies, speak for combining vasopressors with fluids rather "early" in the treatment of septic shock (within a 0-3-hour window). Nevertheless, the optimal resuscitation strategy should take into account the source of infection, the pathophysiology, the time and clinical course preceding the diagnosis of sepsis, and also comorbidities and sepsis-induced organ dysfunction.
Topics: Fluid Therapy; Humans; Hypotension; Retrospective Studies; Sepsis; Shock, Septic; Vasoconstrictor Agents
PubMed: 34544185
DOI: 10.1055/s-0041-1733897 -
AORN Journal Mar 2022
Topics: Humans; Hypotension; Norepinephrine; Vasoconstrictor Agents
PubMed: 35213045
DOI: 10.1002/aorn.13627 -
Journal of Critical Care Dec 2023To determine whether intravenous vitamin C compared with placebo, reduces vasopressor requirements in patients with vasoplegic shock. (Randomized Controlled Trial)
Randomized Controlled Trial
PURPOSE
To determine whether intravenous vitamin C compared with placebo, reduces vasopressor requirements in patients with vasoplegic shock.
METHODS
Double-blinded, randomised clinical trial (RCT) conducted in two intensive care units in Perth, Australia. Vasopressor requirements at enrolment needed to be >10 μg/min noradrenaline after hypovolaemia was clinically excluded. Patients received either intravenous 1.5 g sodium ascorbate in 100 ml normal saline every 6 h for 5 days, or placebo (100 ml normal saline). The primary outcome was duration of vasopressor usage in hours. Secondary outcomes were ICU and hospital length of stay, and 28-day, ICU and hospital mortality.
RESULTS
Of the 71 patients randomised (35 vitamin C, 36 placebo group), the median vasopressor duration was 44 h [95% CI, 37-54 h] and 55 h [95% CI, 33-66 h]) in the vitamin C and placebo groups (p = 0.057). ICU and hospital length of stay, mortality outcomes were similar between groups.
CONCLUSIONS
In this RCT of patients with vasoplegic shock of at least moderate severity, the use of IV vitamin C compared with placebo did not significantly reduce the duration of vasopressors.
TRIAL REGISTRATION
Prospective registration - trial number ACTRN12617001392358.
Topics: Humans; Ascorbic Acid; Vasoplegia; Saline Solution; Vitamins; Administration, Intravenous; Vasoconstrictor Agents; Double-Blind Method
PubMed: 37478532
DOI: 10.1016/j.jcrc.2023.154369