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Minerva Anestesiologica Jun 2024the epidemiology of cardiogenic shock has evolved over the years: in the last decades an increasing prevalence of cardiogenic shock related to acute decompensated heart...
BACKGROUND
the epidemiology of cardiogenic shock has evolved over the years: in the last decades an increasing prevalence of cardiogenic shock related to acute decompensated heart failure was observed. Therefore, treatment bundles should be updated according to the underlying pathophysiology. No data exist regarding the diagnostic/therapeutic strategies in general intensive care units.
METHODS
A 27-questions survey was spread through the GiViTi (Italian Group for the Evaluation of Interventions in Intensive Care Medicine). The results were then divided according to level of hospitals (1-2 versus 3).
RESULTS
Sixty-nine general intensive care units replied to the survey. The shock team is present in 13% of institutions; Society for Cardiovascular Angiography and Interventions shock classification is applied only in 18.8%. Among the ICUs, 94.2% routinely use a cardiac output monitoring device (pulmonary artery catheter more frequently in 3 level centers). The first-line adrenergic drug are vasopressors in 27.5%, inotrope in 21.7% or their combination in 50.7%; 79.7% applies fluid challenge. The first vasopressor of choice is norepinephrine (95.7%) (maximum dosage tolerated higher than 0.5 mcg/kg/min in 29%); the first line inotrope is dobutamine (52.2%), followed by epinephrine in 36.2%. The most frequently used mechanical circulatory supports are intra-aortic balloon pump (71%), Impella (34.8%) and VA-ECMO (33.3%); VA-ECMO is the first line strategy in refractory cardiogenic shock (60.8%).
CONCLUSIONS
According to this survey, there is no standardized approach to cardiogenic shock amongst Italian general intensive care units. The application of shock severity stratification and the treatment bundles may play a key role in improving the outcome.
Topics: Shock, Cardiogenic; Humans; Critical Care; Italy; Intensive Care Units; Surveys and Questionnaires; Health Care Surveys
PubMed: 38551614
DOI: 10.23736/S0375-9393.24.17908-4 -
Cureus Feb 2024Systolic anterior motion of the mitral valve and left ventricular outflow tract obstruction are complications following transcatheter aortic valve implantation and can...
Systolic anterior motion of the mitral valve and left ventricular outflow tract obstruction are complications following transcatheter aortic valve implantation and can lead to hemodynamic collapse. Medical management for those complications is usually centered on a reduction in left ventricular contractility with negative inotropes. An 88-year-old woman underwent transcatheter aortic valve implantation for severe aortic stenosis. Hemodynamic collapse and exacerbation of mitral regurgitation occurred immediately after valve implantation. For suspected left ventricular outflow tract obstruction, medical management centered on negative inotropes was performed. Hemodynamics and left ventricular outflow tract obstruction improved over time; however, the oxygen supply-demand imbalance progressed. On postoperative day 5, the patient suddenly went into pulseless electrical activity. Cardiopulmonary resuscitation was performed for three minutes, resulting in the return of spontaneous circulation. Subsequent refractory hypotension and oxygen supply-demand imbalance improved with continuous infusion of adrenaline, dobutamine, and phenylephrine. Her hemodynamics remained stable after she was weaned off the pressor infusions, and negative inotropes were not required again. In summary, the cause of cardiac arrest was possibly due to excessive negative inotropic effects even though the effects contributed to improvement of left ventricular outflow tract obstruction. Anesthesiologists and intensivists should recognize the risk of cardiac arrest induced by negative inotropic effects and use negative inotropes with rigorous hemodynamic monitoring, even when left ventricular outflow tract obstruction is treated effectively.
PubMed: 38550487
DOI: 10.7759/cureus.55026 -
JACC. Case Reports Mar 2024Dobutamine is a positive inotropic agent often used in treatment of cardiogenic shock. Although there are well-documented adverse effects, dobutamine-induced myoclonus...
Dobutamine is a positive inotropic agent often used in treatment of cardiogenic shock. Although there are well-documented adverse effects, dobutamine-induced myoclonus is a rarely reported phenomenon. Our case offers a direct and temporally related description of myoclonus, with onset observed within hours of dobutamine initiation and complete resolution within minutes of discontinuation.
PubMed: 38549854
DOI: 10.1016/j.jaccas.2024.102255 -
Journal of Cardiovascular Pharmacology Mar 2024To synthesize the available evidence regarding differences in the long-term safety and efficacy of intermittent, repeated, or continuous palliative inotropic therapy...
Comparative effectiveness and safety of intermittent, repeated or continuous use of levosimendan, milrinone, or dobutamine in patients with advanced heart failure: a network and single-arm meta-analysis.
To synthesize the available evidence regarding differences in the long-term safety and efficacy of intermittent, repeated, or continuous palliative inotropic therapy among patients with advanced heart failure (HF). We systematically searched the PubMed, Embase, and Cochrane Library electronic databases, with a cutoff date of November 23, 2023, for studies reporting outcomes in adult patients with advanced HF treated with intermittent, repeated, or continuous levosimendan, milrinone, or dobutamine. Forty-one studies (18 randomized controlled trials and 23 cohort studies) comprising 5137 patients met the inclusion criteria. The results of the network meta-analysis of randomized controlled trials showed that levosimendan had significant advantages over milrinone or dobutamine in reducing mortality and improving LVEF. A single-arm meta-analysis also indicated that levosimendan had the lowest mortality and significantly improved BNP and LVEF. Regarding safety, hypotension events were observed more frequently in the levosimendan group and milrinone groups. However, the current evidence is limited by the heterogeneity and relatively small sample size of the studies.
PubMed: 38547524
DOI: 10.1097/FJC.0000000000001561 -
Cureus Feb 2024The aim of this systematic review and meta-analysis was to compare the outcomes between milrinone and dobutamine in patients with cardiogenic shock. The search strategy... (Review)
Review
The aim of this systematic review and meta-analysis was to compare the outcomes between milrinone and dobutamine in patients with cardiogenic shock. The search strategy involved a comprehensive exploration of electronic databases, including PubMed, EMBASE, Cochrane Library, and Scopus from the the inception of each database up to the 31st of January 2024. A combination of keywords and Medical Subject Headings (MeSH) terms was employed to identify relevant studies. The outcomes assessed in this meta-analysis included all-cause in-hospital mortality, length of intensive care unit (ICU stay), and length of hospital stay. A total of seven studies were included in this meta-analysis enrolling 3,841 patients (2,331 in the dobutamine group and 1,510 in the milrinone group). Pooled analysis showed that the risk of all-cause mortality was significantly higher in patients receiving dobutamine compared to patients receiving milrinone (relative risk (RR): 1.43, 95% confidence interval (CI): 1.02 to 2.01, p-value: 0.04). However, the length of hospital stay and length of ICU stay were not significantly different between the two groups. Limited data are available to favor the use of one inotropic agent over another. Dobutamine might lead to a shorter hospital length of stay, but there is also a risk of increased all-cause mortality. Larger randomized studies with adequate power are needed to validate these observations.
PubMed: 38544600
DOI: 10.7759/cureus.54948 -
Health Science Reports Mar 2024Free flap reconstruction for head and neck cancer is associated with a high risk of perioperative complications. One of the modifiable risk factors associated with...
BACKGROUND
Free flap reconstruction for head and neck cancer is associated with a high risk of perioperative complications. One of the modifiable risk factors associated with perioperative morbidity is intraoperative hypotension (IOH). The main aim of this pilot study is to determine if the intraoperative use of goal-directed hemodynamic therapy (GDHT) is associated with a reduction in the number of IOH events in this population.
METHODS
A before-and-after study design. The patients who had intraoperative GDHT were compared to patients from a previous period before the implementation of GDHT. The primary outcome was the number of IOH episodes defined as five or more successive minutes with a mean arterial pressure <65 mmHg. The secondary outcomes included major postoperative morbidity and 30-day mortality.
RESULTS
A total of 414 patients were included. These were divided into two groups. The control group ( = 346; January 1, 2018, to December 31, 2019), and the monitored group ( = 68; January 1, 2020, to May 1, 2021). The median intraoperative administered fluid volume was similar between the control and monitored groups (2250 interquartile range [IQR] [1607-3050] vs. 2210 IQR [1700-2807] mL). The monitored group was found to have an increased use of norepinephrine and dobutamine (respectively, 1.2% vs. 5.9% and 2.4% vs. 30.9%; < 0.05). When adjusting for confounders (comorbidities, estimated blood loss, and duration of anesthesia) the incidence rate ratio (95% confidence interval) of number of IOH events was 0.94 (0.86-1.03), = 0.24. The rate of postoperative flap and medical complications did not differ between the two groups.
CONCLUSIONS
Even though the use of vasopressors/inotropes was higher in the monitored group, the number of IOH episodes and postoperative morbidity and mortality were similar between the two groups. Further change in hemodynamic management will require the use of specific blood pressure targets in the GDHT fluid algorithm.
PubMed: 38524770
DOI: 10.1002/hsr2.1943 -
Frontiers in Pharmacology 2024We conducted a systematic review to assess the advantages and disadvantages of levosimendan in patients with sepsis compared with placebo, milrinone, and dobutamine and...
We conducted a systematic review to assess the advantages and disadvantages of levosimendan in patients with sepsis compared with placebo, milrinone, and dobutamine and to explore the clinical efficacy of different concentrations of levosimendan. PubMed, Web of Science, Cochrane Library, Embase, CNKI, Wanfang data, VIP, and CBM databases were searched using such keywords as simendan, levosimendan, and sepsis. The search time was from the establishment of the database to July 2023. Two researchers were responsible for literature screening and data collection respectively. After the risk of bias in the included studies was evaluated, network meta-analysis was performed using R software gemtc and rjags package. Thirty-two randomized controlled trials (RCTs) were included in the network meta-analysis. Meta-analysis results showed that while levosimendan significantly improved CI levels at either 0.1 µg/kg/min (mean difference [MD] [95%CrI] = 0.41 [-0.43, 1.4]) or 0.2 µg/kg/min (MD [95%CrI] =0.54 [0.12, 0.99]). Levosimendan, at either 0.075 µg/kg/min (MD [95% CrI] =0.033 [-0.75, 0.82]) or 0.2 µg/kg/min (MD [95% CrI] = -0.014 [-0.26, 0.23]), had no significant advantage in improving Lac levels. Levosimendan, at either 0.1 µg/kg/min (RR [95% CrI] = 0.99 [0.73, 1.3]) or 0.2 µg/kg/min (RR [95% CrI] = 1.0 [0.88, 1.2]), did not have a significant advantage in reducing mortality. The existing evidence suggests that levosimendan can significantly improve CI and lactate levels in patients with sepsis, and levosimendan at 0.1 µg/kg/min might be the optimal dose. Unfortunately, all interventions in this study failed to reduce the 28-day mortality. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023441220.
PubMed: 38523635
DOI: 10.3389/fphar.2024.1358735 -
European Review For Medical and... Mar 2024OBJECTIVE: The primary aim of the present study was to determine the success of single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) in...
UNLABELLED
OBJECTIVE: The primary aim of the present study was to determine the success of single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) in detecting critical coronary artery disease (CAD) as identified by invasive coronary angiography (ICA), as well as to compare the positive predictive values (PPV) of different stress methods. Our secondary aim was to investigate demographic, laboratory, electrocardiographic, and echocardiographic variables that could predict true positive results. PATIENTS AND METHODS: The study was conducted with 317 consecutive patients. Exercise, dipyridamole, adenosine, or dobutamine were used as stress methods. According to the results of ICA, patients with and without critical CAD were divided into two groups and compared statistically. The independent predictors of true positive results of positive SPECT-MPI were determined using univariate and multivariate logistic regression analysis (MLRA). RESULTS: Among the patients, 129 (40.7%) were found to have critical CAD (+) and 188 (50.3%) critical CAD (-). The PPVs of different stress methods were similar. Age, diabetes, and monocyte to HDL ratio (MHR) were found to be independent predictors of critical CAD in MLRA (p<0.005, p=0.002, and p<0.005, respectively). ROC curve analysis revealed 81.4% sensitivity and 47.3% specificity (AUC: 0.683) at a cut-off of 57 for age and 72.1% sensitivity and 54.3% specificity (AUC: 0.649) for MHR at a cut-off of 9.7. CONCLUSIONS: The true positivity rate of SPECT-MPI is low. Moreover, this rate is much lower for women. The PPVs of different stress methods are similar. Age, presence of diabetes, and MHR ratio are independent predictors for true positive results of SPECT-MPI.
GRAPHICAL ABSTRACT
https://www.europeanreview.org/wp/wp-content/uploads/Graphical-abstract-9.jpg.
Topics: Humans; Female; Aged; Myocardial Perfusion Imaging; Adenosine; Coronary Artery Disease; Dobutamine; Diabetes Mellitus
PubMed: 38497864
DOI: 10.26355/eurrev_202403_35595 -
Physiological Reports Mar 2024Patients undergoing cardiopulmonary bypass procedures require inotropic support to improve hemodynamic function and cardiac output. Current inotropes such as dobutamine,...
Patients undergoing cardiopulmonary bypass procedures require inotropic support to improve hemodynamic function and cardiac output. Current inotropes such as dobutamine, can promote arrhythmias, prompting a demand for improved inotropes with little effect on intracellular Ca flux. Low-dose carbon monoxide (CO) induces inotropic effects in perfused hearts. Using the CO-releasing pro-drug, oCOm-21, we investigated if this inotropic effect results from an increase in myofilament Ca sensitivity. Male Sprague Dawley rat left ventricular cardiomyocytes were permeabilized, and myofilament force was measured as a function of -log [Ca ] (pCa) in the range of 9.0-4.5 under five conditions: vehicle, oCOm-21, the oCOm-21 control BP-21, and levosimendan, (9 cells/group). Ca sensitivity was assessed by the Ca concentration at which 50% of maximal force is produced (pCa ). oCOm-21, but not BP-21 significantly increased pCa compared to vehicle, respectively (pCa 5.52 vs. 5.47 vs. 5.44; p < 0.05). No change in myofilament phosphorylation was seen after oCOm-21 treatment. Pretreatment of cardiomyocytes with the heme scavenger hemopexin, abolished the Ca sensitizing effect of oCOm-21. These results support the hypothesis that oCOm-21-derived CO increases myofilament Ca sensitivity through a heme-dependent mechanism but not by phosphorylation. Further analyses will confirm if this Ca sensitizing effect occurs in an intact heart.
Topics: Rats; Animals; Humans; Male; Myofibrils; Carbon Monoxide; Myocardial Contraction; Rats, Sprague-Dawley; Myocytes, Cardiac; Heme; Calcium
PubMed: 38491822
DOI: 10.14814/phy2.15974 -
American Journal of Physiology. Heart... May 2024Noncritical aortic coarctation (COA) typically presents beyond early childhood with hypertension. Correction of COA does not ensure a return to normal cardiovascular...
Noncritical aortic coarctation (COA) typically presents beyond early childhood with hypertension. Correction of COA does not ensure a return to normal cardiovascular health, but the mechanisms are poorly understood. Therefore, we developed a porcine COA model to study the secondary cardiovascular changes. Eight male neonatal piglets (4 sham, 4 COA) underwent left posterolateral thoracotomy with descending aorta (DAO) mobilization. COA was created via a 1-cm longitudinal DAO incision with suture closure, plication, and placement and an 8-mm external band. All animals had cardiac catheterization at 6 (11-13 kg), 12 (26-31 kg), and 20 (67-70 kg) wk of age. Aortic luminal diameters were similar along the thoracic aorta, except for the COA region [6.4 mm COA vs. 17.3 mm sham at 20 wk ( < 0.001)]. Collateral flow could be seen as early as 6 wk. COA peak systolic pressure gradient was 20 mmHg at 6 wk and persisted through 20 wk increasing to 40 mmHg with dobutamine. Pulse pressures distal to the COA were diminished at 12 and 20 wk. This model addresses many limitations of prior COA models including neonatal creation at an expected anatomic position with intimal injury and vessel sizes similar to humans. A neonatal model of aortic coarctation was developed in a porcine model using a readily reproducible method of aortic plication and external wrap placement. This model addresses the limitations of existing models including neonatal stenosis creation, appropriate anatomic location of the stenosis, and intimal injury creation and mimics human somatic growth. Pigs met American Heart Association (AHA) criteria for consideration of intervention, and the stenoses were graded as moderate to severe.
Topics: Humans; Child, Preschool; Infant, Newborn; Male; Animals; Swine; Aortic Coarctation; Constriction, Pathologic; Aorta, Thoracic; Aorta; Hypertension
PubMed: 38488518
DOI: 10.1152/ajpheart.00087.2024