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Journal of Special Operations Medicine... May 2022Shock is a life-threatening condition carrying a high mortality rate when untreated. The consequences of shock are cellular and metabolic derangements, which are...
Shock is a life-threatening condition carrying a high mortality rate when untreated. The consequences of shock are cellular and metabolic derangements, which are initially reversible. The authors present the case of a Servicemember who sustained mortar shrapnel wounds that resulted in shock.
Topics: Humans; Shock; Vasoconstrictor Agents
PubMed: 35639896
DOI: 10.55460/24JR-XNAS -
Surgical Infections 2018Sepsis accounts for 10% of intensive care unit admissions and significant healthcare costs. Although the mortality rate from sepsis has been decreasing with better... (Review)
Review
BACKGROUND
Sepsis accounts for 10% of intensive care unit admissions and significant healthcare costs. Although the mortality rate from sepsis has been decreasing with better critical care, early identification of septic patients, and prompt interventions, the mortality rate remains 20%-30%.
METHOD
Review of the English-language literature.
RESULTS
Norepinephrine is the first-line vasopressor in shock and is associated with a lower mortality rate as well as fewer adverse effects. Dopamine has similar actions but is associated with significantly more tachydysrhythmias and should be reserved for patients with bradycardia. Epinephrine and vasopressin are appropriate second-line vasopressors and may enable use of lower doses of norepinephrine while improving hemodynamics. Inotropes may be added in patients with cardiac dysfunction.
CONCLUSION
Appropriate treatment of sepsis includes prompt identification, early antimicrobial drug therapy, appropriate fluid resuscitation, and initiation of vasopressors in the presence of continued septic shock. Further research needs to be done to better understand the ideal timing of the addition of a second agent and the optimal combinations of vasopressors for individual patients.
Topics: Dopamine; Epinephrine; Humans; Norepinephrine; Sepsis; Shock; Vasoconstrictor Agents
PubMed: 29336676
DOI: 10.1089/sur.2017.255 -
Pharmacotherapy Mar 2019Septic shock is a life-threatening disorder associated with high mortality rates requiring rapid identification and intervention. Vasoactive agents are often required to... (Review)
Review
Septic shock is a life-threatening disorder associated with high mortality rates requiring rapid identification and intervention. Vasoactive agents are often required to maintain goal hemodynamics and preserve tissue perfusion. However, guidance regarding the proper administration of adjunct agents for the management of septic shock is limited in patients who are refractory to norepinephrine. This review summarizes vasopressor agents and describes the nuanced application of these agents in patients with septic shock, specifically focusing on clinical scenarios with limited guidance including patients who are nonresponsive to first-line agents and individuals with mixed shock states, tachyarrhythmias, obesity, valvular abnormalities, or other comorbid conditions.
Topics: Hemodynamics; Humans; Norepinephrine; Shock, Septic; Vasoconstrictor Agents
PubMed: 30644586
DOI: 10.1002/phar.2220 -
Critical Care (London, England) Apr 2021It is unclear whether vasopressors can be safely administered through a peripheral intravenous (PIV). Systematic review and meta-analysis methodology was used to examine... (Meta-Analysis)
Meta-Analysis
BACKGROUND
It is unclear whether vasopressors can be safely administered through a peripheral intravenous (PIV). Systematic review and meta-analysis methodology was used to examine the incidence of local anatomic adverse events associated with PIV vasopressor administration in patients of any age cared for in any acute care environment.
METHODS
MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of controlled trials, and the Database of Abstracts of Reviews of Effects were searched without restriction from inception to October 2019. References of included studies and related reviews, as well as relevant conference proceedings were also searched. Studies were included if they were: (1) cohort, quasi-experimental, or randomized controlled trial study design; (2) conducted in humans of any age or clinical setting; and (3) reported on local anatomic adverse events associated with PIV vasopressor administration. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials or the Joanna Briggs Institute checklist for prevalence studies where appropriate. Incidence estimates were pooled using random effects meta-analysis. Subgroup analyses were used to explore sources of heterogeneity.
RESULTS
Twenty-three studies were included in the systematic review, of which 16 and 7 described adults and children, respectively. Meta-analysis from 11 adult studies including 16,055 patients demonstrated a pooled incidence proportion of adverse events associated with PIV vasopressor administration as 1.8% (95% CI 0.1-4.8%, I = 93.7%). In children, meta-analysis from four studies and 388 patients demonstrated a pooled incidence proportion of adverse events as 3.3% (95% CI 0.0-10.1%, I = 82.4%). Subgroup analyses did not detect any statistically significant effects associated with stratification based on differences in clinical location, risk of bias or design between studies, PIV location and size, or vasopressor type or duration. Most studies had high or some concern for risk of bias.
CONCLUSION
The incidence of adverse events associated with PIV vasopressor administration is low. Additional research is required to examine the effects of PIV location and size, vasopressor type and dose, and patient characteristics on the safety of PIV vasopressor administration.
Topics: Catheterization, Peripheral; Drug-Related Side Effects and Adverse Reactions; Humans; Vasoconstrictor Agents
PubMed: 33863361
DOI: 10.1186/s13054-021-03553-1 -
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 -
Critical Care Medicine Apr 2022
Topics: Vasoconstrictor Agents
PubMed: 35311781
DOI: 10.1097/CCM.0000000000005344 -
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 -
The American Journal of Emergency... Jun 2019Septic shock is a life threatening condition and a medical emergency. It is associated with organ dysfunction and hypotension despite optimal volume resuscitation.... (Review)
Review
Septic shock is a life threatening condition and a medical emergency. It is associated with organ dysfunction and hypotension despite optimal volume resuscitation. Refractory septic shock carries a very high rate of mortality and is associated with ischemic and arrhythmogenic complications from high dose vasopressors. Angiotensin II (AT-II) is a product of the renin-angiotensin-aldosterone system. It is a vasopressor agent that has been recently approved by FDA to be used in conjunction with other vasopressors (catecholamines) in refractory shock and to reduce catecholamine requirements. We have reviewed the physiology and current literature on AT-II in refractory septic/vasodilatory shock. Larger trials with longer duration of follow-up are warranted to address the questions which are unanswered by the ATHOS-3 trial, especially pertaining to its effects on lungs, brain, microcirculation, inflammation, and venous thromboembolism risk.
Topics: Angiotensin II; Catecholamines; Humans; Randomized Controlled Trials as Topic; Shock, Septic; Vasoconstrictor Agents
PubMed: 30935784
DOI: 10.1016/j.ajem.2019.03.026 -
Current Opinion in Critical Care Aug 2020Data and interventional trials on vasopressor use during cardiogenic shock are scarce. Their use is limited by their side-effects and the lack of solid evidence... (Review)
Review
PURPOSE OF REVIEW
Data and interventional trials on vasopressor use during cardiogenic shock are scarce. Their use is limited by their side-effects and the lack of solid evidence regarding their effectiveness in improving outcomes. In the present article, we review the current use of vasopressor therapy during cardiogenic shock.
RECENT FINDINGS
Two recent Cochrane analyses concluded that there was insufficient evidence to prove that any one vasopressor was superior to others in terms of mortality. A recent RCT and a meta-analysis on individual data suggested that norepinephrine may be preferred over epinephrine in patients with cardiogenic shock, in particular, after myocardial infarction. In patients with right ventricular failure and pulmonary hypertension, the use of vasopressin may be advocated under advanced monitoring.
SUMMARY
When blood pressure needs to be restored, norepinephrine is a reasonable first-line agent. Information regarding comparative effective outcomes is sparse and their use should be limited to a temporary measure as a bridge to recovery, mechanical circulatory support or heart transplantation.
Topics: Epinephrine; Heart Failure; Humans; Norepinephrine; Shock, Cardiogenic; Vasoconstrictor Agents
PubMed: 32487842
DOI: 10.1097/MCC.0000000000000743 -
Medical Science Monitor : International... Mar 2014The use of vasoconstrictor agents has many advantages, but its use has been limited due to a fear of systemic absorption and the induction of adverse effects in cardiac... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The use of vasoconstrictor agents has many advantages, but its use has been limited due to a fear of systemic absorption and the induction of adverse effects in cardiac compromised patients. The aim of this study was to review the literature to assess any scientific basis for the limited use of dental anaesthesia with a vasoconstrictor agent in cardiovascular compromised patients.
MATERIAL/METHODS
A comprehensive database search was executed with the use of Medline (PubMed), ISI Web of Science, and Cochrane. The inclusion criteria were: a clearly defined dose of vasoconstrictor agent and the testing of at least 1 parameter (pressure, heart rate, or saturation) or occurrence of at least 1 cardiac incident (complication).
RESULTS
Among all complications, only 10 could be directly related to the use of local anaesthesia. It is noteworthy that 40% appeared after the administration of anaesthesia without vasoconstrictor agents. No severe adverse clinical effects were noted in the analysed studies.
CONCLUSIONS
The most frequent complications in cardiovascular compromised patients after dental local anaesthesia with a vasoconstrictor agent were disclosed in ECG arrhythmias. Most of these disclosed arrhythmias were clinically insignificant. The use of ≤ 4 ampules of lignocaine with epinephrine 1:100000 as a dental anaesthetic seems to be relatively safe for cardiovascular compromised patients.
Topics: Adult; Aged; Anesthesia, Local; Cardiovascular Diseases; Demography; Female; Humans; Male; Middle Aged; Publication Bias; Vasoconstrictor Agents
PubMed: 24608362
DOI: 10.12659/MSM.889984