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Acta Anaesthesiologica Scandinavica Nov 2016Adult critically ill patients often suffer from acute circulatory failure, necessitating use of vasopressor therapy. The aim of the Scandinavian Society of... (Review)
Review
BACKGROUND
Adult critically ill patients often suffer from acute circulatory failure, necessitating use of vasopressor therapy. The aim of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) task force for Acute Circulatory Failure was to present clinically relevant, evidence-based treatment recommendations on this topic.
METHODS
This guideline was developed according to standards for trustworthy guidelines, including a systematic review of the literature and use of the GRADE methodology for assessment of the quality of evidence and for moving from evidence to recommendations. We assessed the following subpopulations of patients with acute circulatory failure: 1) shock in general, 2) septic shock, 3) cardiogenic shock, 4) hypovolemic shock and 5) other types of shock, including vasodilatory shock. We assessed patient-important outcome measures, including mortality, serious adverse reactions and quality-of-life.
RESULTS
For patients with shock in general and those with septic shock, we recommend using norepinephrine rather than dopamine, and we suggest using norepinephrine rather than epinephrine, vasopressin analogues, and phenylephrine. For patients with cardiogenic shock and those with hypovolemic shock, we suggest using norepinephrine rather than dopamine, and we provide no recommendations/suggestions of norepinephrine vs. epinephrine, vasopressin analogues, and phenylephrine. For patients with other types of shock, including vasodilatory shock, we suggest using norepinephrine rather than dopamine, epinephrine, vasopressin analogues, and phenylephrine.
CONCLUSIONS
We recommend using norepinephrine rather than other vasopressors as first-line treatment for the majority of adult critically ill patients with acute circulatory failure.
Topics: Acute Disease; Humans; Norepinephrine; Practice Guidelines as Topic; Shock; Vasoconstrictor Agents
PubMed: 27576362
DOI: 10.1111/aas.12780 -
PloS One 2015International guidelines recommend dopamine or norepinephrine as first-line vasopressor agents in septic shock. Phenylephrine, epinephrine, vasopressin and terlipressin... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
International guidelines recommend dopamine or norepinephrine as first-line vasopressor agents in septic shock. Phenylephrine, epinephrine, vasopressin and terlipressin are considered second-line agents. Our objective was to assess the evidence for the efficiency and safety of all vasopressors in septic shock.
METHODS
Systematic review and meta-analysis. We searched electronic database of MEDLINE, CENTRAL, LILACS and conference proceedings up to June 2014. We included randomized controlled trials comparing different vasopressors for the treatment of adult patients with septic shock. Primary outcome was all-cause mortality. Other clinical and hemodynamic measurements were extracted as secondary outcomes. Risk ratios (RR) and mean differences with 95% confidence intervals (CI) were pooled.
RESULTS
Thirty-two trials (3,544 patients) were included. Compared to dopamine (866 patients, 450 events), norepinephrine (832 patients, 376 events) was associated with decreased all-cause mortality, RR 0.89 (95% CI 0.81-0.98), corresponding to an absolute risk reduction of 11% and number needed to treat of 9. Norepinephrine was associated with lower risk for major adverse events and cardiac arrhythmias compared to dopamine. No other mortality benefit was demonstrated for the comparisons of norepinephrine to epinephrine, phenylephrine and vasopressin / terlipressin. Hemodynamic data were similar between the different vasopressors, with some advantage for norepinephrine in central venous pressure, urinary output and blood lactate levels.
CONCLUSIONS
Evidence suggests a survival benefit, better hemodynamic profile and reduced adverse events rate for norepinephrine over dopamine. Norepinephrine should be regarded as the first line vasopressor in the treatment of septic shock.
Topics: Epinephrine; Hemodynamics; Humans; Lypressin; Norepinephrine; Phenylephrine; Shock, Septic; Terlipressin; Treatment Outcome; Vasoconstrictor Agents; Vasopressins
PubMed: 26237037
DOI: 10.1371/journal.pone.0129305 -
Therapeutics and Clinical Risk... 2015Vasopressor agents are often prescribed in septic shock. However, their effects remain controversial. We conducted a systematic review and Bayesian network meta-analysis...
OBJECTIVE
Vasopressor agents are often prescribed in septic shock. However, their effects remain controversial. We conducted a systematic review and Bayesian network meta-analysis to compare the effects among different types of vasopressor agents.
DATA SOURCES
We searched for relevant studies in PubMed, Embase, and the Cochrane Library databases from database inception until December 2014.
STUDY SELECTION
Randomized controlled trials in adults with septic shock that evaluated different vasopressor agents were selected.
DATA EXTRACTION
Two authors independently selected studies and extracted data on study characteristics, methods, and outcomes.
DATA SYNTHESIS
Twenty-one trials (n=3,819) met inclusion criteria, which compared eleven vasopressor agents or vasopressor combinations (norepinephrine [NE], dopamine [DA], vasopressin [VP], epinephrine [EN], terlipressin [TP], phenylephrine [PE], TP+NE, TP + dobutamine [DB], NE+DB, NE+EN, and NE + dopexamine [DX]). Except for the superiority of NE over DA, the mortality of patients treated with any vasopressor agent or vasopressor combination was not significantly different. Compared to DA, NE was found to be associated with decreased cardiac adverse events, heart rate (standardized mean difference [SMD]: -2.10; 95% confidence interval [CI]: -3.95, -0.25; P=0.03), and cardiac index (SMD: -0.73; 95% CI: -1.14, -0.03; P=0.004) and increased systemic vascular resistance index (SVRI) (SMD: 1.03; 95% CI: 0.61, 1.45; P<0.0001). This Bayesian meta-analysis revealed a possible rank of probability of mortality among the eleven vasopressor agents or vasopressor combinations; from lowest to highest, they are NE+DB, EN, TP, NE+EN, TP+NE, VP, TP+DB, NE, PE, NE+DX, and DA.
CONCLUSION
In terms of survival, NE may be superior to DA. Otherwise, there is insufficient evidence to suggest that any other vasopressor agent or vasopressor combination is superior to another. When compared to DA, NE is associated with decreased heart rate, cardiac index, and cardiovascular adverse events, as well as increased SVRI. The effects of vasopressor agents or vasopressor combinations on mortality in patients with septic shock require further investigation.
PubMed: 26203253
DOI: 10.2147/TCRM.S80060 -
The Cochrane Database of Systematic... Oct 2014It is unclear whether blood pressure should be altered actively during the acute phase of stroke. This is an update of a Cochrane review first published in 1997, and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
It is unclear whether blood pressure should be altered actively during the acute phase of stroke. This is an update of a Cochrane review first published in 1997, and previously updated in 2001 and 2008.
OBJECTIVES
To assess the clinical effectiveness of altering blood pressure in people with acute stroke, and the effect of different vasoactive drugs on blood pressure in acute stroke.
SEARCH METHODS
We searched the Cochrane Stroke Group Trials Register (last searched in February 2014), the Cochrane Database of Systematic reviews (CDSR) and the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 2), MEDLINE (Ovid) (1966 to May 2014), EMBASE (Ovid) (1974 to May 2014), Science Citation Index (ISI, Web of Science, 1981 to May 2014) and the Stroke Trials Registry (searched May 2014).
SELECTION CRITERIA
Randomised controlled trials of interventions that aimed to alter blood pressure compared with control in participants within one week of acute ischaemic or haemorrhagic stroke.
DATA COLLECTION AND ANALYSIS
Two review authors independently applied the inclusion criteria, assessed trial quality and extracted data. The review authors cross-checked data and resolved discrepancies by discussion to reach consensus. We obtained published and unpublished data where available.
MAIN RESULTS
We included 26 trials involving 17,011 participants (8497 participants were assigned active therapy and 8514 participants received placebo/control). Not all trials contributed to each outcome. Most data came from trials that had a wide time window for recruitment; four trials gave treatment within six hours and one trial within eight hours. The trials tested alpha-2 adrenergic agonists (A2AA), angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor antagonists (ARA), calcium channel blockers (CCBs), nitric oxide (NO) donors, thiazide-like diuretics, and target-driven blood pressure lowering. One trial tested phenylephrine.At 24 hours after randomisation oral ACEIs reduced systolic blood pressure (SBP, mean difference (MD) -8 mmHg, 95% confidence interval (CI) -17 to 1) and diastolic blood pressure (DBP, MD -3 mmHg, 95% CI -9 to 2), sublingual ACEIs reduced SBP (MD -12.00 mm Hg, 95% CI -26 to 2) and DBP (MD -2, 95%CI -10 to 6), oral ARA reduced SBP (MD -1 mm Hg, 95% CI -3 to 2) and DBP (MD -1 mm Hg, 95% CI -3 to 1), oral beta blockers reduced SBP (MD -14 mm Hg; 95% CI -27 to -1) and DBP (MD -1 mm Hg, 95% CI -9 to 7), intravenous (iv) beta blockers reduced SBP (MD -5 mm Hg, 95% CI -18 to 8) and DBP (-5 mm Hg, 95% CI -13 to 3), oral CCBs reduced SBP (MD -13 mmHg, 95% CI -43 to 17) and DBP (MD -6 mmHg, 95% CI -14 to 2), iv CCBs reduced SBP (MD -32 mmHg, 95% CI -65 to 1) and DBP (MD -13, 95% CI -31 to 6), NO donors reduced SBP (MD -12 mmHg, 95% CI -19 to -5) and DBP (MD -3, 95% CI -4 to -2) while phenylephrine, non-significantly increased SBP (MD 21 mmHg, 95% CI -13 to 55) and DBP (MD 1 mmHg, 95% CI -15 to 16).Blood pressure lowering did not reduce death or dependency either by drug class (OR 0.98, 95% CI 0.92 to 1.05), stroke type (OR 0.98, 95% CI 0.92 to 1.05) or time to treatment (OR 0.98, 95% CI 0.92 to 1.05). Treatment within six hours of stroke appeared effective in reducing death or dependency (OR 0.86, 95% CI 0.76 to 0.99) but not death (OR 0.70, 95% CI 0.38 to 1.26) at the end of the trial. Although death or dependency did not differ between people who continued pre-stroke antihypertensive treatment versus those who stopped it temporarily (worse outcome with continuing treatment, OR 1.06, 95% CI 0.91 to 1.24), disability scores at the end of the trial were worse in participants randomised to continue treatment (Barthel Index, MD -3.2, 95% CI -5.8, -0.6).
AUTHORS' CONCLUSIONS
There is insufficient evidence that lowering blood pressure during the acute phase of stroke improves functional outcome. It is reasonable to withhold blood pressure-lowering drugs until patients are medically and neurologically stable, and have suitable oral or enteral access, after which drugs can than be reintroduced. In people with acute stroke, CCBs, ACEI, ARA, beta blockers and NO donors each lower blood pressure while phenylephrine probably increases blood pressure. Further trials are needed to identify which people are most likely to benefit from early treatment, in particular whether treatment started very early is beneficial.
Topics: Acute Disease; Blood Pressure; Calcium Channel Blockers; Humans; Hypertension; Randomized Controlled Trials as Topic; Risk; Stroke; Time-to-Treatment; Vasodilator Agents
PubMed: 25353321
DOI: 10.1002/14651858.CD000039.pub3 -
Anaesthesia Feb 2014We conducted a systematic review to determine the harm and benefit associated with prophylactic phenylephrine for caesarean section under spinal anaesthesia. We included... (Meta-Analysis)
Meta-Analysis Review
We conducted a systematic review to determine the harm and benefit associated with prophylactic phenylephrine for caesarean section under spinal anaesthesia. We included 21 randomised controlled trials with 1504 women. The relative risk (95% CI) of hypotension with phenylephrine infusion – as defined by authors – before delivery was 0.36 (0.18–0.73) vs placebo, p = 0.004; 0.58 (0.39–0.88) vs an ephedrine infusion, p = 0.009; and 0.73 (0.55–0.96) when added to an ephedrine infusion, p = 0.02. After delivery, the relative risks of hypotension and nausea and vomiting with phenylephrine compared with placebo were 0.37 (0.19–0.71), p = 0.003, and 0.39 (0.17–0.91), p = 0.03, respectively. There was no evidence that hypertension, bradycardia or neonatal endpoints were affected. Phenylephrine reduced the risk for hypotension and nausea and vomiting after spinal doses of bupivacaine generally exceeding 8 mg, but there was no evidence that it reduced other maternal or neonatal morbidities.
Topics: Anesthesia, Obstetrical; Anesthesia, Spinal; Cardiotonic Agents; Cesarean Section; Female; Humans; Hypotension; Phenylephrine; Postoperative Nausea and Vomiting; Pregnancy; Randomized Controlled Trials as Topic
PubMed: 24588024
DOI: 10.1111/anae.12445 -
CNS Neuroscience & Therapeutics Jul 2012A systematic literature review comparing the efficacy of ephedrine and phenylephrine for the management of spinal anesthesia-induced hypotension during Cesarean sections... (Comparative Study)
Comparative Study Meta-Analysis
AIMS
A systematic literature review comparing the efficacy of ephedrine and phenylephrine for the management of spinal anesthesia-induced hypotension during Cesarean sections (C-sections) was published in 2002. A number of well-designed trials with controversial results have been published afterward. Therefore, an updated meta-analysis was necessary.
METHODS
The MEDLINE, EMBASE, and the Cochrane Library databases were searched (last search performed on September 26, 2011). Pooled risk ratio (RR) or standard mean difference (SMD) and their 95% confidence intervals (95% CI) were calculated for the incidence of intra-operative hypotension or umbilical blood pH values.
RESULTS
A total number of 15 trials and 742 parturients under elective C-sections were analyzed. When used to prevent hypotension, patients receiving ephedrine and phenylephrine did not differ significantly in the incidence of hypotension (RR = 1.22; 95% CI, 0.83-1.80), umbilical arterial pH values (SMD = -0.38; 95% CI, -1.67 to 0.92) or venous pH values (SMD = -0.18; 95% CI, -0.44 to 0.07). And administration routes did not affect the incidence of hypotension and umbilical blood pH values. When used to treat hypotension, patients given ephedrine and phenylephrine had comparable incidence of intra-operative hypotension (RR = 0.79; 95% CI, 0.40-1.56), while parturients receiving phenylephrine had neonates with higher umbilical arterial pH values (SMD = -1.32; 95% CI, -2.35 to -0.30) and venous pH values (SMD = -0.79; 95% CI, -1.09 to -0.49) than those given ephedrine.
CONCLUSION
Prophylactic use of ephedrine and phenylephrine were both effective in preventing maternal hypotension during C-section under spinal anesthesia; phenylephrine was superior to ephedrine in treating hypotension, evidenced by higher umbilical blood pH values.
Topics: Anesthesia, Spinal; Cesarean Section; Disease Management; Ephedrine; Female; Humans; Hypotension; Phenylephrine; Pregnancy
PubMed: 22759268
DOI: 10.1111/j.1755-5949.2012.00345.x -
BMJ Clinical Evidence Dec 2011Acute sinusitis is defined pathologically, by transient inflammation of the mucosal lining of the paranasal sinuses lasting less than 4 weeks. Clinically, it is... (Review)
Review
INTRODUCTION
Acute sinusitis is defined pathologically, by transient inflammation of the mucosal lining of the paranasal sinuses lasting less than 4 weeks. Clinically, it is characterised by nasal congestion, rhinorrhoea, facial pain, hyposmia, sneezing, and, if more severe, additional malaise and fever. It affects 1% to 5% of the adult population each year in Europe.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments in people with clinically diagnosed acute sinusitis, and in people with radiologically or bacteriologically confirmed acute sinusitis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2011 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 19 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotics (amoxicillin, amoxicillin-clavulanic acid [co-amoxiclav], doxycycline, cephalosporins, macrolides; different doses, long-course regimens), antihistamines, decongestants (xylometazoline, phenylephrine, pseudoephedrine), saline nasal washes, steam inhalation, and topical corticosteroids (intranasal).
Topics: Acute Disease; Administration, Oral; Amoxicillin; Amoxicillin-Potassium Clavulanate Combination; Double-Blind Method; Evidence-Based Medicine; Humans; Macrolides; Sinusitis
PubMed: 22189346
DOI: No ID Found -
The Cochrane Database of Systematic... Oct 2008It is unclear whether blood pressure should be altered actively during the acute phase of stroke. This is an update of a Cochrane review first published in 1997, and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
It is unclear whether blood pressure should be altered actively during the acute phase of stroke. This is an update of a Cochrane review first published in 1997, and previously updated in 2001.
OBJECTIVES
To assess the effect of altering blood pressure in people with acute stroke, and the effect of different vasoactive drugs on blood pressure in acute stroke.
SEARCH STRATEGY
We searched the Cochrane Stroke Group Trials Register (last searched July 2007), the Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2 2008), MEDLINE, EMBASE and other databases, reference lists of relevant publications and contacted researchers in the field.
SELECTION CRITERIA
Randomised controlled trials of interventions that aimed to alter blood pressure in patients within one week of acute ischaemic or haemorrhagic stroke.
DATA COLLECTION AND ANALYSIS
Two review authors independently applied the inclusion criteria, assessed trial quality and extracted data.
MAIN RESULTS
Twelve trials involving 1153 participants were included (603 participants were assigned active therapy and 550 participants received placebo/control). The trials tested angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor antagonists (ARA), calcium channel blockers (CCBs), clonidine, glyceryl trinitrate (GTN), thiazide diuretic and mixed antihypertensive therapy. One trial tested phenylephrine. At 24 hours after randomisation ACEIs reduced systolic blood pressure (SBP, mean difference, MD -6 mmHg, 95% confidence interval, CI -22 to 10) and diastolic blood pressure (DBP, MD -5 mmHg, 95% CI -18 to 7), ARA reduced SBP (MD -3, 95% CI -7 to 2) and DBP (MD -3, 95% CI -6 to 0.4), iv CCBs reduced SBP (MD -32 mmHg, 95% CI -65 to 1) and DBP (MD -13 mmHg, 95% CI -31 to 6), oral CCBs reduced SBP (MD -13 mmHg, 95% , CI -43 to 17) and DBP (MD -6 mmHg, 95% CI -14 to 2), GTN reduced SBP (MD -10 mmHg, 95% CI -18 to -3) and DBP (MD -1 mmHg, 95% CI -5 to 3) while phenylephrine, non-significantly increased SBP (MD 21 mmHg, 95% CI -13 to 55) and DBP (MD 1 mmHg, 95% CI -15 to 16). Functional outcome and death were not altered by any of the drugs.
AUTHORS' CONCLUSIONS
There is insufficient evidence to evaluate the effect of altering blood pressure on outcome during the acute phase of stroke. In patients with acute stroke, CCBs, ACEI, ARA and GTN each lower blood pressure while phenylephrine probably increases blood pressure.
Topics: Acute Disease; Blood Pressure; Calcium Channel Blockers; Humans; Hypertension; Randomized Controlled Trials as Topic; Risk; Stroke; Vasodilator Agents
PubMed: 18843604
DOI: 10.1002/14651858.CD000039.pub2 -
BMJ Clinical Evidence Mar 2008Acute sinusitis is defined pathologically, by transient inflammation of the mucosal lining of the paranasal sinuses lasting less than 4 weeks. Clinically, it is... (Review)
Review
INTRODUCTION
Acute sinusitis is defined pathologically, by transient inflammation of the mucosal lining of the paranasal sinuses lasting less than 4 weeks. Clinically, it is characterised by nasal congestion, rhinorrhoea, facial pain, hyposmia, sneezing, and, if more severe, additional malaise and fever. It affects 1-5% of the adult population each year in Europe.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments in people with clinically diagnosed acute sinusitis, and with radiologically or bacteriologically confirmed acute sinusitis? We searched: Medline, Embase, The Cochrane Library and other important databases up to August 2007 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 19 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotics (amoxicillin, co-amoxiclav, doxycycline, cephalosporins, macrolides, different doses [amoxicillin, co-amoxiclav, doxycycline, cephalosporins, macrolides], long-course regimens), antihistamines, cephalosporins or macrolides, decongestants (xylometazoline, phenylephrine, pseudoephedrine), doxycycline, saline nasal washes, steam inhalation, and topical corticosteroids (intra-nasal).
Topics: Acute Disease; Administration, Oral; Amoxicillin; Amoxicillin-Potassium Clavulanate Combination; Double-Blind Method; Evidence-Based Medicine; Humans; Macrolides; Sinusitis
PubMed: 19450327
DOI: No ID Found