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European Journal of Anaesthesiology Mar 2020
Topics: Goals; Hemodynamics; Liver; Vasoconstrictor Agents
PubMed: 32028287
DOI: 10.1097/EJA.0000000000001118 -
Future Cardiology Nov 2020Shock is an acute condition of circulatory failure resulting in life-threatening organ dysfunction, high morbidity and high mortality. Current management includes fluid... (Review)
Review
Shock is an acute condition of circulatory failure resulting in life-threatening organ dysfunction, high morbidity and high mortality. Current management includes fluid and catecholamine therapy to maintain adequate mean arterial pressure and organ perfusion. Norepinephrine is recommended as first-line vasopressor, but other agents are available. Angiotensin II is an alternative potent vasoconstrictor without chronotropic or inotropic properties. Several studies, including a large randomized controlled trial have demonstrated its ability to increase blood pressure with catecholamine-sparing effects. Angiotensin II was consequently approved by the US FDA in 2017 and the EU in 2019 as an add-on vasopressor in vasodilatory shock. This review aims to discuss its basic pharmacology, clinical efficacy, safety and future perspectives.
Topics: Angiotensin II; Blood Pressure; Humans; Randomized Controlled Trials as Topic; Shock; Vasoconstrictor Agents; Vasodilation
PubMed: 32462921
DOI: 10.2217/fca-2020-0019 -
International Journal of Molecular... Jul 2019Brain natriuretic peptide (BNP) is an important biomarker for patients with heart failure, hypertension and cardiac hypertrophy. Although it is known that BNP levels are... (Review)
Review
Brain natriuretic peptide (BNP) is an important biomarker for patients with heart failure, hypertension and cardiac hypertrophy. Although it is known that BNP levels are relatively higher in patients with chronic kidney disease and no heart disease, the mechanism remains unknown. Here, we review the functions and the roles of BNP in the heart-kidney interaction. In addition, we discuss the relevant molecular mechanisms that suggest BNP is protective against chronic kidney diseases and heart failure, especially in terms of the counterparts of the renin-angiotensin-aldosterone system (RAAS). The renal medulla has been reported to express depressor substances. The extract of the papillary tips from kidneys may induce the expression and secretion of BNP from cardiomyocytes. A better understanding of these processes will help accelerate pharmacological treatments for heart-kidney disease.
Topics: Angiotensin Receptor Antagonists; Animals; Disease Susceptibility; Gene Expression Regulation; Heart; Humans; Kidney; Myocytes, Cardiac; Natriuretic Peptide, Brain; Neprilysin; Renin-Angiotensin System; Signal Transduction; Vasoconstrictor Agents
PubMed: 31336656
DOI: 10.3390/ijms20143581 -
Journal of Cardiothoracic and Vascular... Dec 2022The renin-angiotensin-aldosterone system (RAAS), whose major vasopressor effector is angiotensin II (ATII), has multiple activities and regulates sodium-water... (Review)
Review
The renin-angiotensin-aldosterone system (RAAS), whose major vasopressor effector is angiotensin II (ATII), has multiple activities and regulates sodium-water homeostasis and fluid and blood pressure homeostasis. RAAS plays a crucial role in cardiocirculatory shock because it counteracts hypotension and hypovolemia by activating different physiologic responses. Based on the encouraging results of the ATHOS-3 trial, the US Food and Drug Administration and the European Medicines Agency approved the use of ATII for catecholamine-resistant vasodilatory shock. More recently, ATII was used for the compassionate treatment of critically ill patients with COVID-19. Beyond its vasopressor properties, ATII was hypothesized to have antiviral activity because it induces internalization and degradation of angiotensin-converting enzyme 2 receptors used by SARS-Cov-2 to infect cells. Overall, the use of ATII in patients with COVID-19 showed promising results because its administration was associated with the achievement and maintenance of target mean arterial pressure, increased PO/FO ratio, and decreased FO. The aim of this narrative review is to summarize the available knowledge on the use of ATII in patients with COVID-19.
Topics: Humans; SARS-CoV-2; Angiotensin II; COVID-19; Renin-Angiotensin System; Vasoconstrictor Agents; Sepsis
PubMed: 35995637
DOI: 10.1053/j.jvca.2022.07.022 -
Journal of Cerebral Blood Flow and... Apr 2021Adrenoceptor and calcium channel modulating medications are widely used in clinical practice for acute neurological and systemic conditions. It is generally assumed that... (Review)
Review
Adrenoceptor and calcium channel modulating medications are widely used in clinical practice for acute neurological and systemic conditions. It is generally assumed that the cerebrovascular effects of these drugs mirror that of their systemic effects - and this is reflected in how these medications are currently used in clinical practice. However, recent research suggests that there are distinct cerebrovascular-specific effects of these medications that are related to the unique characteristics of the cerebrovascular anatomy including the regional heterogeneity in density and distribution of adrenoceptor subtypes and calcium channels along the cerebrovasculature. In this review, we critically evaluate existing basic science and clinical research to discuss known and putative interactions between adrenoceptor and calcium channel modulating pharmacotherapies, the neurovascular unit, and cerebrovascular anatomy. In doing so, we provide a rationale for selecting vasoactive medications based on lesion location and lay a foundation for future investigations that will define neuroprotective paradigms of adrenoceptor and calcium channel modulating therapies to improve neurological outcomes in acute neurological and systemic disorders.
Topics: Adrenergic Agents; Animals; Calcium Channel Blockers; Calcium Channels; Cerebrovascular Disorders; Humans; Nervous System Diseases; Receptors, Adrenergic; Vasoconstrictor Agents
PubMed: 33210576
DOI: 10.1177/0271678X20972869 -
Intensive Care Medicine Dec 2022
Topics: Humans; Shock, Septic; Sepsis; Vasoconstrictor Agents
PubMed: 36102944
DOI: 10.1007/s00134-022-06852-5 -
NeoReviews Mar 2020Failure of the normal transition from in utero to ex utero physiology leads to "" pulmonary hypertension of the newborn (PPHN). PPHN is frequently associated with low... (Review)
Review
Failure of the normal transition from in utero to ex utero physiology leads to "" pulmonary hypertension of the newborn (PPHN). PPHN is frequently associated with low systemic blood pressure and low cardiac output because of increased right ventricular afterload and myocardial dysfunction. The general management of newborns with PPHN is geared toward maintenance of normothermia, normal serum electrolytes, normal intravascular volume, correction of acidosis, adequate sedation/analgesia, adequate ventilation and oxygenation with optimal lung recruitment, and avoidance of hyperoxia. Inotropic and vasoactive agents are commonly initiated early to increase cardiac output, maintain adequate systemic blood pressure, and enhance oxygen delivery to the tissue. Unfortunately, there is not much evidence on the choice, timing of initiation, dosing, monitoring, and titrating of vasoactive agents in this patient population. In this review, we will discuss the pathophysiology of PPHN and review the use of inotropic, lusitropic, and vasoactive agents in the management of PPHN, with particular attention to milrinone.
Topics: Cardiotonic Agents; Humans; Infant, Newborn; Milrinone; Persistent Fetal Circulation Syndrome; Vasoconstrictor Agents
PubMed: 32123121
DOI: 10.1542/neo.21-3-e165 -
British Journal of Anaesthesia May 2023Off-label use of medications in paediatric anaesthesia is common practice, owing to the relative paucity of evidence-based dosing regimens in children. Well-performed...
Off-label use of medications in paediatric anaesthesia is common practice, owing to the relative paucity of evidence-based dosing regimens in children. Well-performed dose-finding studies, especially in infants, are rare and urgently needed. Unanticipated effects can result when paediatric dosing is based on adult parameters or local traditions. A recent dose-finding study on ephedrine highlights the uniqueness of paediatric dosing in comparison with adult dosing. We discuss the problems of off-label medication use and the lack of evidence for various definitions of hypotension and associated treatment strategies in paediatric anaesthesia. What is the aim of treating hypotension associated with anaesthesia induction: restoring the MAP to awake baseline values or elevating it above a provisional hypotension threshold?
Topics: Adult; Infant; Humans; Child; Ephedrine; Vasoconstrictor Agents; Anesthesia, Spinal; Hypotension; Anesthesia, Obstetrical
PubMed: 36906461
DOI: 10.1016/j.bja.2023.02.007 -
Journal of Medical Toxicology :... Apr 2022Shock in drug poisoning is a life-threatening condition and current management involves fluid resuscitation and vasopressor therapy. Management is limited by the... (Review)
Review
BACKGROUND
Shock in drug poisoning is a life-threatening condition and current management involves fluid resuscitation and vasopressor therapy. Management is limited by the toxicity of high-dose vasopressors such as catecholamines. Clinical trials have shown the efficacy of angiotensin II as an adjunct vasopressor in septic shock. The aim of this review is to assess the use of angiotensin II in patients with shock secondary to drug overdose.
METHODS
Medline (from 1946), Embase (from 1947) and PubMed (from 1946) databases were searched until July 2021 via OVID. Included studies were those with shock due to drug poisoning and received angiotensin II as part of their treatment regimen. Of the 481 articles identified, 13 studies (case reports and scientific abstracts) were included in the final analysis with a total of 14 patients. Extracted data included demographics, overdose drug and dosage, angiotensin II dosage, time of angiotensin II administration, haemodynamic changes, length of hospital stay, mortality, complications, cardiac function and other treatment agents used.
RESULTS
Thirteen studies were included consisting of 6 case reports, 6 scientific abstracts and 1 case series. Overdose drugs included antihypertensives (n = 8), psychotropics (n = 4), isopropanol (n = 1) and tamsulosin (n = 1). Out of a total of 14 patients, 3 patients died. Ten patients had their haemodynamic changes reported. In terms of MAP or SBP changes, three patients (30%) had an immediate response to angiotensin II, four patients (40%) had responses within 30 min, one patient (10%) within two hours and two patients (20%) did not have their time reported. Two patients were shown to have direct chronotropic effects within 30 min of angiotensin II administration. The median hospital stay for patients was 5 days (IQR = 4). The time from overdose until angiotensin II administration ranged from 5 to 56 h. Other vasopressors used included phenylephrine, noradrenaline, adrenaline, vasopressin, dobutamine, dopamine, methylene blue and ephedrine. A median of 3 vasopressors were used before initiation of angiotensin II. Twelve patients received angiotensin II as their final treatment.
CONCLUSIONS
Angiotensin II may be useful as an adjunct vasopressor in treating shock secondary to drug poisoning. However, the current literature consisted of only very low-quality studies. To truly assess the utility of angiotensin II use in drug-induced poisoned patients, further well-designed prospective studies are required.
Topics: Angiotensin II; Drug Overdose; Epinephrine; Humans; Norepinephrine; Shock; Vasoconstrictor Agents
PubMed: 35258848
DOI: 10.1007/s13181-022-00885-4 -
Burns : Journal of the International... Feb 2021Vasopressors may be required during acute burn resuscitation to support mean arterial blood pressure, but their use is not well-described in the burn literature. The... (Review)
Review
BACKGROUND
Vasopressors may be required during acute burn resuscitation to support mean arterial blood pressure, but their use is not well-described in the burn literature. The purpose of this study was to examine vasopressor use during acute fluid resuscitation.
METHODS
Retrospective review of adults with burns ≥ 20% TBSA admitted to an ABA-verified regional burn center. Patients administered an infusion of a vasopressor for at least 30 min during the 1 st 48 h post-burn formed the PRESSOR group while patients who did not receive vasopressors formed the NoPRESSOR group.
RESULTS
We studied 52 burned adults, 85% of which had flame burns. Vasopressors were administered during resuscitation to 31% of patients. Vasopressor infusions began at 20.9 ± 10.9 h post burn and were continued for 16.8 ± 10.8 h. PRESSOR patients (N = 16) had significantly greater total (p = 0.001) and full thickness burn size (p < 0.001), and need for mechanical ventilation (p = 0.005) than NoPRESSOR patients (N = 36). PRESSOR and NoPRESSOR patients did not differ significantly in per cent predicted fluid volume received in the first 24 h (143 ± 58 Vs. 125 ± 46 respectively). PRESSOR patients compared to NoPRESSOR patients tended to have been administered 5% albumin (Alb) less often (38% Vs 47%) and high dose vitamin C (HDVC) more often during resuscitation (69% vs 17%). Multivariate regression analysis found that patient age (OR 1.189, 95% CI: 1.047, 1.351) and HDVC (OR 24.701, 95% CI: 1.558, 391.551) were independently associated with greater use of vasopressors. An inverse probability weighted propensity analysis also identified a significant association between HDVC and increased use of vasopressors (OR 6.902, 95 % CI: 2.503, 19.026), and significantly decreased vasopressor administration following Alb administration (OR 0.310, 95% CI: 0.130, 0.739).
CONCLUSION
Advanced age appears to be the most important determinant of vasopressor use during resuscitation. While vasopressor requirements appear to have been increased by HDVC and decreased by Alb, this needs to be formally evaluated in a large randomized study.
Topics: Adult; Aged; Burns; Chi-Square Distribution; Female; Fluid Therapy; Humans; Male; Middle Aged; Resuscitation; Retrospective Studies; Vasoconstrictor Agents
PubMed: 33293152
DOI: 10.1016/j.burns.2020.09.005