Administration of methylene blue in septic shock: pros and cons.

Septic shock typically requires the administration of vasopressors. Adrenergic agents remain the first choice, namely norepinephrine. However, their use to counteract life-threatening hypotension comes with potential adverse effects, so that non-adrenergic vasopressors may also be considered. The use of agents that act through different mechanisms may also provide an advantage. Nitric oxide (NO) is the main driver of the vasodilation that leads to hypotension in septic shock, so several agents have been tested to counteract its effects. The use of non-selective NO synthase inhibitors has been of questionable benefit. Methylene blue, an inhibitor of soluble guanylate cyclase, an important enzyme involved in the NO signaling pathway in the vascular smooth muscle cell, has also been proposed. However, more than 25 years since the first clinical evaluation of MB administration in septic shock, the safety and benefits of its use are still not fully established, and it should not be used routinely in clinical practice until further evidence of its efficacy is available.

The pulmonary artery catheter.

PURPOSE OF REVIEW: To review recently published data on pulmonary artery catheter (PAC) use in critically ill patients and consider optimal use of the PAC in personalized clinical practice. RECENT FINDINGS: Although PAC use has decreased considerably since the mid-1990s, PAC-derived variables can still have an important role in elucidating hemodynamic status and directing management in complex patients. Recent studies have suggested benefit, notably in patients having cardiac surgery. SUMMARY: Only a small number of acutely ill patients require a PAC and insertion should be individualized based on clinical context, availability of trained staff, and the possibility that measured variables will be able to help guide therapy.

The medical treatment of cardiogenic shock: cardiovascular drugs.

PURPOSE OF REVIEW: To discuss the use of vasopressors and inotropes in cardiogenic shock. RECENT FINDINGS: The classic form or cardiogenic shock requires administration of inotropic and/or vasopressor agents to try to improve the impaired tissue perfusion. Among vasopressors various alpha-adrenergic agents, vasopressin derivatives and angiotensin can be used. The first-line therapy remains norepinephrine as it is associated with minimal adverse effects and appears to be associated by the best outcome in network meta-analyses. On the contrary, epinephrine is associated with an increased incidence of refractory shock and observational studies suggest an increased risk of death. Vasopressin may be an excellent alternative in tachycardiac patients or in the presence of pulmonary hypertension. Concerning inotropic agents, dobutamine is the first-line agent but levosimendan is an excellent alternative or additional agent in cases not responding to dobutamine. The impact on outcome of inotropic agents remains controversial. SUMMARY: Recent studies have refined the position of the various vasopressor and inotropic agents. Norepinephrine is recommended as first-line vasopressor agent by various guidelines. Among inotropic agents, selection between the agents should be individualized and based on the hemodynamic response.

Uso de inmunoglubolina en el manejo del Síndrome de Stevens-Johnson. Reporte de un caso / Use of immunoglubolin in the handling of the Stevens-Johnson Syndrome. Report of a case

El uso de inmunoglobulina humana se ha descrito en el tratamiento de pacientes con síndrome de Stevens-Johnson. La inmunoglobulina bloquea la apoptosis de los keratinocitos inducida por la interacción del complejo Fas-FasL. No hay estudios clínicos controlados que recomienden el uso rutinario, la dosis y la eficacia de este tratamiento para el síndrome de Stevens-Johnson. Se describe el caso de un paciente de 18 años con un Síndrome de Stevens Johnson secundario a tetraciclinas, que se trató exitosamente con inmunoglobulina intravenosa. Descriptores: Inmunoglobulina, Síndrome Stevens-Johnson.