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1.
Cochrane Database Syst Rev ; 9: CD013708, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32870512

RESUMO

BACKGROUND: Supplemental oxygen is frequently administered to patients with acute respiratory distress syndrome (ARDS), including ARDS secondary to viral illness such as coronavirus disease 19 (COVID-19). An up-to-date understanding of how best to target this therapy (e.g. arterial partial pressure of oxygen (PaO2) or peripheral oxygen saturation (SpO2) aim) in these patients is urgently required. OBJECTIVES: To address how oxygen therapy should be targeted in adults with ARDS (particularly ARDS secondary to COVID-19 or other respiratory viruses) and requiring mechanical ventilation in an intensive care unit, and the impact oxygen therapy has on mortality, days ventilated, days of catecholamine use, requirement for renal replacement therapy, and quality of life. SEARCH METHODS: We searched the Cochrane COVID-19 Study Register, CENTRAL, MEDLINE, and Embase from inception to 15 May 2020 for ongoing or completed randomized controlled trials (RCTs). SELECTION CRITERIA: Two review authors independently assessed all records in accordance with standard Cochrane methodology for study selection. We included RCTs comparing supplemental oxygen administration (i.e. different target PaO2 or SpO2 ranges) in adults with ARDS and receiving mechanical ventilation in an intensive care setting. We excluded studies exploring oxygen administration in patients with different underlying diagnoses or those receiving non-invasive ventilation, high-flow nasal oxygen, or oxygen via facemask. DATA COLLECTION AND ANALYSIS: One review author performed data extraction, which a second review author checked. We assessed risk of bias in included studies using the Cochrane 'Risk of bias' tool. We used the GRADE approach to judge the certainty of the evidence for the following outcomes; mortality at longest follow-up, days ventilated, days of catecholamine use, and requirement for renal replacement therapy. MAIN RESULTS: We identified one completed RCT evaluating oxygen targets in patients with ARDS receiving mechanical ventilation in an intensive care setting. The study randomized 205 mechanically ventilated patients with ARDS to either conservative (PaO2 55 to 70 mmHg, or SpO2 88% to 92%) or liberal (PaO2 90 to 105 mmHg, or SpO2 ≥ 96%) oxygen therapy for seven days. Overall risk of bias was high (due to lack of blinding, small numbers of participants, and the trial stopping prematurely), and we assessed the certainty of the evidence as very low. The available data suggested that mortality at 90 days may be higher in those participants receiving a lower oxygen target (odds ratio (OR) 1.83, 95% confidence interval (CI) 1.03 to 3.27). There was no evidence of a difference between the lower and higher target groups in mean number of days ventilated (14.0, 95% CI 10.0 to 18.0 versus 14.5, 95% CI 11.8 to 17.1); number of days of catecholamine use (8.0, 95% CI 5.5 to 10.5 versus 7.2, 95% CI 5.9 to 8.4); or participants receiving renal replacement therapy (13.7%, 95% CI 5.8% to 21.6% versus 12.0%, 95% CI 5.0% to 19.1%). Quality of life was not reported. AUTHORS' CONCLUSIONS: We are very uncertain as to whether a higher or lower oxygen target is more beneficial in patients with ARDS and receiving mechanical ventilation in an intensive care setting. We identified only one RCT with a total of 205 participants exploring this question, and rated the risk of bias as high and the certainty of the findings as very low. Further well-conducted studies are urgently needed to increase the certainty of the findings reported here. This review should be updated when more evidence is available.


Assuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Unidades de Terapia Intensiva , Oxigênio/administração & dosagem , Pneumonia Viral/complicações , Respiração Artificial , Síndrome do Desconforto Respiratório do Adulto/terapia , Viés , Catecolaminas/uso terapêutico , Tratamento Conservador , Humanos , Razão de Chances , Pandemias , Terapia de Substituição Renal/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Síndrome do Desconforto Respiratório do Adulto/mortalidade , Síndrome do Desconforto Respiratório do Adulto/virologia , Autoimagem , Fatores de Tempo
2.
Am Heart J ; 225: 55-59, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32474205

RESUMO

Cardiogenic shock (CS) complicating acute myocardial infarction (MI) is associated with high mortality. In the absence of data to support coronary revascularization beyond the infarct artery and selection of circulatory support devices or medications, clinical practice may vary substantially. METHODS: We distributed a survey to interventional cardiologists and cardiothoracic surgeons through relevant professional societies to determine contemporary coronary revascularization and circulatory support strategies for MI with CS and multi-vessel coronary artery disease (CAD). RESULTS: A total of 143 participants completed the survey between 1/2019 and 8/2019. Overall, 55.2% of participants reported that the standard approach to coronary revascularization was single vessel PCI of the infarct related artery (IRA) with staged PCI of non-culprit lesions. Single vessel PCI of the IRA only (28.0%), emergency multi-vessel PCI (11.9%), and coronary artery bypass grafting (CABG) (4.9%) were standard approaches at some centers. A plurality of survey respondents (46.9%) believed initial PCI with staged CABG for multi-vessel CAD would be associated with the most favorable outcomes. A minority of respondents believed PCI-only strategies (23.1%) and CABG alone (6.3%) provided optimal care, and 23.1% were unsure of the best strategy. After PCI for CS, Impella (76.9%), intra-aortic balloon pump (IABP) (12.8%), and extra-corporeal membrane oxygenation (ECMO) (7.7%) were preferred. After CABG, IABP (34.3%), Impella (32.2%), and ECMO (28%) were preferred. CONCLUSIONS: This survey indicates substantial heterogeneity in clinical care in CS. There is evidence of provider uncertainty and clinical equipoise regarding the optimal management of patients with MI, multi-vessel CAD, and CS. SHORT ABSTRACT: We sought to determine contemporary practice patterns of coronary revascularization and circulatory support in patients with MI, multi-vessel coronary artery disease (CAD), and cardiogenic shock. A survey was distributed to interventional cardiologists and cardiothoracic surgeons through relevant professional societies. Survey respondents identified substantial heterogeneity in clinical care and evidence of provider uncertainty and clinical equipoise regarding the optimal management of patients with MI, multi-vessel CAD, and CS.


Assuntos
Ponte de Artéria Coronária/estatística & dados numéricos , Doença da Artéria Coronariana/terapia , Infarto do Miocárdio/terapia , Revascularização Miocárdica/métodos , Intervenção Coronária Percutânea/estatística & dados numéricos , Padrões de Prática Médica , Choque Cardiogênico/terapia , Cardiotônicos/uso terapêutico , Catecolaminas/uso terapêutico , Terapia Combinada , Doença da Artéria Coronariana/complicações , Pesquisas sobre Serviços de Saúde , Humanos , Internacionalidade , Infarto do Miocárdio/complicações , Revascularização Miocárdica/normas , Padrões de Prática Médica/estatística & dados numéricos , Choque Cardiogênico/etiologia
3.
Crit Care ; 24(1): 95, 2020 03 18.
Artigo em Inglês | MEDLINE | ID: mdl-32188462

RESUMO

BACKGROUND: Concomitant vasoactive drugs are often required to maintain adequate perfusion pressure in patients with acute myocardial infarction (AMI) and cardiogenic shock (CS) receiving hemodynamic support with an axial flow pump (Impella CP). OBJECTIVE: To compare the effect of equipotent dosages of epinephrine, dopamine, norepinephrine, and phenylephrine on cardiac work and end-organ perfusion in a porcine model of profound ischemic CS supported with an Impella CP. METHODS: CS was induced in 10 pigs by stepwise intracoronary injection of polyvinyl microspheres. Hemodynamic support with Impella CP was initiated followed by blinded crossover to vasoactive treatment with norepinephrine (0.10 µg/kg/min), epinephrine (0.10 µg/kg/min), or dopamine (10 µg/kg/min) for 30 min each. At the end of the study, phenylephrine (10 µg/kg/min) was administered for 20 min. The primary outcome was cardiac workload, a product of pressure-volume area (PVA) and heart rate (HR), measured using the conductance catheter technique. End-organ perfusion was assessed by measuring venous oxygen saturation from the pulmonary artery (SvO2), jugular bulb, and renal vein. Treatment effects were evaluated using multilevel mixed-effects linear regression. RESULTS: All catecholamines significantly increased LV stroke work and cardiac work, dopamine to the greatest extend by 341.8 × 103 (mmHg × mL)/min [95% CI (174.1, 509.5), p < 0.0001], and SvO2 significantly improved during all catecholamines. Phenylephrine, a vasoconstrictor, caused a significant increase in cardiac work by 437.8 × 103 (mmHg × mL)/min [95% CI (297.9, 577.6), p < 0.0001] due to increase in potential energy (p = 0.001), but no significant change in LV stroke work. Also, phenylephrine tended to decrease SvO2 (p = 0.063) and increased arterial lactate levels (p = 0.002). CONCLUSION: Catecholamines increased end-organ perfusion at the expense of increased cardiac work, most by dopamine. However, phenylephrine increased cardiac work with no increase in end-organ perfusion.


Assuntos
Débito Cardíaco/efeitos dos fármacos , Coração Auxiliar , Hemodinâmica/efeitos dos fármacos , Choque Cardiogênico/terapia , Animais , Catecolaminas/uso terapêutico , Modelos Animais de Doenças , Dopamina , Humanos , Infarto do Miocárdio/complicações , Infarto do Miocárdio/terapia , Norepinefrina , Fenilefrina , Choque Cardiogênico/fisiopatologia , Suínos
4.
Biomed Res Int ; 2019: 2613137, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31828097

RESUMO

Purpose: There is no consensus for the optimum duration of preoperative administration of phenoxybenzamine (PXB) before adrenalectomy for pheochromocytoma. The aim of this study is to investigate whether perioperative hemodynamics and postoperative outcomes are related to the duration of PXB administration. Methods: In total, 102 patients managed preoperatively with single α-receptor blocker phenoxybenzamine were enrolled from 469 consecutive patients diagnosed histologically with pheochromocytoma. The patients received surgical treatment in the Department of Urology, Peking University First Hospital, between January 2001 and July 2018. All patients were divided into three groups: Group A (<14 d), Group B (14-30 d), and Group C (>30 d). Patient and tumor characteristics, intraoperative hemodynamics, and postoperative outcomes were recorded and compared among the three groups. Results: These patients included 47 men and 55 women, with an average age of 43 years at the time of surgery. Clinical characteristics, except the status of preoperative biochemical tests (24 hr urine fractioned catecholamine or plasma-fractioned catecholamine) (p=0.020), preoperative hemodynamics, and medicine management and surgical approaches, in the three groups were comparable. Multivariate analyses demonstrated that the size of the tumor (p=0.034) was an independent risk factor for intraoperative hemodynamic instability. Among the three groups, we found no significant difference in intraoperative hemodynamics and postoperative outcomes. Conclusion: The data from the current study indicated that the preoperative management of pheochromocytoma with single α-receptor blocker PXB for more than 2 weeks, after the final dose adjustment, could not further reduce the risk of intraoperative hemodynamic instability or postoperative complications. Thus, our study supports that 14 days would be enough for the duration of preoperative management of pheochromocytoma with single α-receptor blocker PXB in final dose.


Assuntos
Neoplasias das Glândulas Suprarrenais/tratamento farmacológico , Antagonistas Adrenérgicos alfa/uso terapêutico , Fenoxibenzamina/uso terapêutico , Feocromocitoma/tratamento farmacológico , Adrenalectomia/métodos , Adulto , Catecolaminas/uso terapêutico , Feminino , Hemodinâmica/efeitos dos fármacos , Humanos , Masculino , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios
5.
Semin Nephrol ; 39(5): 462-472, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31514910

RESUMO

Acute kidney injury (AKI) is common in the setting of shock. Hemodynamic instability is a risk factor for the development of AKI, and pathophysiological mechanisms include loss of renal perfusion pressure and impaired microcirculation. Although restoration of mean arterial pressure (MAP) may mitigate the risk of AKI to some extent, evidence on this is conflicting. Also debatable is the optimal blood pressure needed to minimize the risk of kidney injury. A MAP of 65 mm Hg traditionally has been considered adequate to maintain renal perfusion pressure, and studies have failed to consistently show improved outcomes at higher levels of MAP. Therapeutic options to support renal perfusion consist of catecholamines, vasopressin, and angiotensin II. Although catecholamines are the most studied, they are associated with adverse events at higher doses, including AKI. Vasopressin and angiotensin II are noncatecholamine options to support blood pressure and may improve microcirculatory hemodynamics through unique mechanisms, including differential vasoconstriction of efferent and afferent arterioles within the nephron. Future areas of study include methods by which clinicians can measure renal blood flow in a macrocirculatory and microcirculatory way, a personalized approach to blood pressure management in septic shock using patient-specific measures of perfusion adequacy, and novel agents that may improve the microcirculation within the kidneys without causing adverse microcirculatory effects in other organs.


Assuntos
Lesão Renal Aguda/tratamento farmacológico , Lesão Renal Aguda/fisiopatologia , Pressão Sanguínea/efeitos dos fármacos , Microcirculação/efeitos dos fármacos , Vasoconstritores/farmacologia , Vasoconstritores/uso terapêutico , Angiotensina II/farmacologia , Angiotensina II/uso terapêutico , Pesquisa Biomédica , Catecolaminas/farmacologia , Catecolaminas/uso terapêutico , Humanos , Vasopressinas/farmacologia , Vasopressinas/uso terapêutico
6.
J Cardiothorac Surg ; 14(1): 145, 2019 Jul 25.
Artigo em Inglês | MEDLINE | ID: mdl-31345252

RESUMO

BACKGROUND: Sinus tachycardia coupled with high-dose catecholamine is common after cardiopulmonary bypass (CPB). The present study assessed the hemodynamic efficacy and safety of combination therapy using low-dose ß1-selective adrenergic blocker (landiolol) and inotropes. METHODS: This was a retrospective, single center, self-comparison study at post-anesthesia care unit within a tertiary care center. The study included adults who underwent cardiac surgery with CPB and received landiolol between April 2007 and November 2011. We assessed hemodynamic data prior to and 1 h after initiation of landiolol therapy. RESULTS: We evaluated 11 patients who were administered 2.6 ± 1.3 µg/kg/min (mean ± SD) landiolol with sinus tachycardia and received catecholamine therapy after on-pump cardiovascular surgery. Landiolol administration led to a significant reduction in heart rate (HR; 112.4 ± 5.8 vs 126.0 ± 7.6 beats/min, p < 0.001), and a significant increase in stroke volume index (SVI) assessed by pulmonary artery catheterization (22.4 ± 5.4 vs. 18.9 ± 4.2 mL/m2, p = 0.04). Only one patient showed no HR reduction, whereas seven patients showed decreased HR and increased SVI (64, 95% confidence interval: 30-98%). Moreover, all five patients who received high-dose catecholamine support showed improved hemodynamics. In terms of safety, no patients required cessation of landiolol therapy. CONCLUSIONS: Low-dose landiolol therapy may safely decrease HR and improve hemodynamics among patients with sinus tachycardia receiving catecholamine treatment after cardiovascular surgery. TRIAL REGISTRATION: This study is retrospective. Registration number: 11. Duration of registration: April 2007~November 2011.


Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Procedimentos Cirúrgicos Cardíacos , Catecolaminas/uso terapêutico , Morfolinas/uso terapêutico , Taquicardia Sinusal/tratamento farmacológico , Ureia/análogos & derivados , Antagonistas Adrenérgicos beta/administração & dosagem , Adulto , Idoso , Feminino , Frequência Cardíaca , Hemodinâmica , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Morfolinas/administração & dosagem , Complicações Pós-Operatórias/tratamento farmacológico , Estudos Retrospectivos , Centros de Atenção Terciária , Ureia/administração & dosagem , Ureia/uso terapêutico , Adulto Jovem
7.
Curr Pharm Des ; 25(19): 2133-2139, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31272348

RESUMO

Vasodilatory shock is a life-threatening syndrome in critically ill patients and is characterized by severe hypotension and resultant tissue hypoperfusion. This shock state requires the use of vasopressor agents to restore adequate vascular tone. Norepinephrine is still recommended as first-line vasopressor in the management of critically ill patients suffering from severe vasodilation. In the recent time, catecholaminergic vasopressor drugs have been associated with possible side effects at higher dosages. This so-called catecholamine toxicity has focused on alternative noncatecholaminergic vasopressors or the use of moderate doses of multiple vasopressors with complementary mechanisms of action. Besides vasopressin and terlipressin, angiotensin II may be a promising drug for the management of vasodilatory shock. In addition, adjunctive drugs, such as hydrocortisone, methylene blue or ascorbic acid can be added to conventional vasopressor therapy. The objective of this review is to give an overview of the current available vasopressor agents used in vasodilatory shock. A thorough search of PubMed was conducted in order to identify the majority of studies related to the subject. Data on the outcome of several drugs and future perspective of possible management strategies for the therapy of vasodilatory shock are discussed.


Assuntos
Choque/tratamento farmacológico , Vasoconstritores/uso terapêutico , Angiotensina II/uso terapêutico , Catecolaminas/efeitos adversos , Catecolaminas/uso terapêutico , Humanos , Norepinefrina/uso terapêutico , Terlipressina/uso terapêutico , Vasodilatação , Vasopressinas/uso terapêutico
8.
Crit Care ; 23(Suppl 1): 149, 2019 Jun 14.
Artigo em Inglês | MEDLINE | ID: mdl-31200777

RESUMO

Catecholamines are used to increase cardiac output and blood pressure, aiming ultimately at restoring/improving tissue perfusion. While intuitive in its concept, this approach nevertheless implies to be effective that regional organ perfusion would increase in parallel to cardiac output or perfusion pressure and that the catecholamine does not have negative effects on the microcirculation. Inotropic agents may be considered in some conditions, but it requires prior optimization of cardiac preload. Alternative approaches would be either to minimize exposure to vasopressors, tolerating hypotension and trying to prioritize perfusion but this may be valid as long as perfusion of the organ is preserved, or to combine moderate doses of vasopressors to vasodilatory agents, especially if these are predominantly acting on the microcirculation. In this review, we will discuss the pros and cons of the use of catecholamines and alternative agents for improving tissue perfusion in septic shock.


Assuntos
Catecolaminas/efeitos adversos , Perfusão/normas , Pressão Arterial/fisiologia , Débito Cardíaco/efeitos dos fármacos , Catecolaminas/farmacologia , Catecolaminas/uso terapêutico , Humanos , Microcirculação/efeitos dos fármacos , Perfusão/métodos , Perfusão/tendências , Ressuscitação/métodos , Ressuscitação/tendências
9.
Crit Care ; 23(1): 168, 2019 05 14.
Artigo em Inglês | MEDLINE | ID: mdl-31088524

RESUMO

BACKGROUND: Catecholamines, especially norepinephrine, are the most frequently used vasopressors for treating patients with septic shock. During the recent decades, terlipressin, vasopressin V1A agonist, and even Ca2+ sensitizer were increasingly used by physicians. The aim of this study is to compare the efficacy of such different kinds of vasoactive medications on mortality among patients with septic shock. METHODS: Relevant randomized controlled trials were identified by searching PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials updated to February 22, 2018. A network meta-analysis was performed to evaluate the effect of different types of vasoactive medications. The primary outcome was 28-day mortality. Intensive care unit (ICU) mortality, hospital and ICU length of stay (LOS), and adverse events were also assessed. RESULTS: A total of 43 trials with 5767 patients assessing 17 treatment modalities were included. Treatments ranking based on surface under the cumulative ranking curve values from largest to smallest were NE/DB 85.9%, TP 75.1%, NE/EP 74.6%, PI 74.1%, EP 72.5%, VP 66.1%, NE 59.8%, PE 53.0%, DA 42.1%, DX 38.2%, SP 27.0%, PA 24.3%, EX 22.8%, LE 21.5%, and DB 13.3% for 28-day mortality. Treatments ranking for ICU mortality were TP/NE 86.4%, TP 80.3%, TP/DB/NE 65.7%, VP/NE 62.8%, NE 57.4%, VP 56.5%, PE 48.4%, DA 33.0%, PA 27.5%, LE 22.1%, and DB 9.9%. The incidence of myocardial infarction was reported with NE/EP 3.33% (n = 1 of 30), followed by EP 3.11% (n = 5 of 161), and then VP 3.10% (n = 19 of 613), NE 3.03% (n = 43 of 1417), DA 2.21% (n = 19 of 858), NE/DB 2.01% (n = 4 of 199), LE 1.16% (n = 3 of 258), and PA 0.39% (n = 1 of 257). The incidence of arrhythmia was reported with DA 26.01% (n = 258 of 992), followed by EP 22.98% (n = 37 of 161), and then NE/DB 20.60% (n = 41 of 199), NE/EP 20.0% (n = 6 of 30), NE 8.33% (n = 127 of 1525), LE 5.81% (n = 15 of 258), PA 2.33% (n = 6 of 257), and VP 1.67% (n = 10 of 600). CONCLUSIONS: The use of norepinephrine plus dobutamine was associated with lower 28-day mortality for septic shock, especially among patients with lower cardiac output.


Assuntos
Catecolaminas/normas , Choque Séptico/tratamento farmacológico , Catecolaminas/uso terapêutico , Dopamina/normas , Dopamina/uso terapêutico , Humanos , Mortalidade/tendências , Norepinefrina/normas , Norepinefrina/uso terapêutico , Razão de Chances , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Terlipressina/normas , Terlipressina/uso terapêutico , Vasopressinas/normas , Vasopressinas/uso terapêutico
10.
A A Pract ; 13(4): 133-136, 2019 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-30985320

RESUMO

In addition to cutaneous, gastrointestinal, hemodynamic, and respiratory symptoms, allergic reactions can induce an acute coronary syndrome in normal or atheromatous coronary arteries and can cause coronary stent thrombosis. Here, we report a case of coronary stent thrombosis due to allergic acute coronary syndrome during anaphylaxis induced by sugammadex in a female patient undergoing general anesthesia. She was emergently treated with percutaneous transluminal coronary balloon angioplasty with catecholamine, vasodilator, and intraaortic balloon support. Knowledge of perioperative allergy-triggered acute coronary syndrome is crucial for prompt and appropriate treatment.


Assuntos
Síndrome Coronariana Aguda/terapia , Trombose Coronária/terapia , Sugammadex/efeitos adversos , Síndrome Coronariana Aguda/induzido quimicamente , Idoso , Anestesia Geral/efeitos adversos , Angioplastia Coronária com Balão , Catecolaminas/uso terapêutico , Colectomia , Neoplasias do Colo/cirurgia , Trombose Coronária/induzido quimicamente , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Resultado do Tratamento
11.
Am J Emerg Med ; 37(6): 1169-1174, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30935784

RESUMO

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.


Assuntos
Angiotensina II/uso terapêutico , Choque Séptico/tratamento farmacológico , Vasoconstritores/uso terapêutico , Catecolaminas/uso terapêutico , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto
12.
Crit Care ; 23(1): 124, 2019 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-30992045

RESUMO

The mainstay of hemodynamic treatment of septic shock is fluid resuscitation followed by vasopressors where fluids alone are insufficient to achieve target blood pressure. Norepinephrine, a catecholamine, is the first-line vasopressor used worldwide but given that all routinely used catecholamines target the same adrenergic receptors, many clinicians may add a non-catecholamine vasopressor where refractory hypotension due to septic shock is present. However, the timing of this additional intervention is variable. This decision is based on three key factors: availability, familiarity, and safety profile. In our opinion, further consideration should be potential vasopressor response because following appropriate volume resuscitation, the response to different vasopressor classes is neither uniform nor predictable. Critically ill patients who are non-responders to high-dose catecholamines have a dismal outcome. Similarly, patients have a variable response to non-catecholamine agents including vasopressin and angiotensin II: but where patients exhibit a blood pressure response the outcomes are improved over non-responders. This variable responsiveness to vasopressors is similar to the clinical approach of anti-microbial sensitivity. In this commentary, the authors propose the concept of "broad spectrum vasopressors" wherein patients with septic shock are started on multiple vasopressors with a different mechanism of action simultaneously while the vasopressor sensitivity is assessed. Once the vasopressor sensitivities are assessed, then the vasopressors are 'de-escalated' accordingly. We believe that this concept may offer a new approach to the treatment of septic shock.


Assuntos
Ressuscitação/métodos , Choque Séptico/tratamento farmacológico , Fatores de Tempo , Vasoconstritores/uso terapêutico , Catecolaminas/uso terapêutico , Humanos , Norepinefrina/uso terapêutico , Ressuscitação/tendências
15.
J Intensive Care Med ; 34(1): 17-25, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28030994

RESUMO

PURPOSE:: Myocardial dysfunction is a known complication in patients with pediatric septic shock (PSS); however, its clinical significance remains unclear. The purpose of this study was to characterize left ventricular (LV) and right ventricular (RV) dysfunction and their prevalence in patients with PSS using echocardiography (echo) and to investigate their associations with the severity of illness and clinical outcomes. METHODS:: Retrospective chart review between 2010 and 2015 from 2 tertiary care pediatric intensive care units. Study included 78 patients (mean age 9.3 ± 7 years) from birth up to 21 years who fulfilled criteria for fluid- and catecholamine-refractory septic shock. Echocardiographic parameters of systolic, diastolic, and global function were measured offline. They were correlated with admission Pediatric Risk of Mortality III (PRISM III) and Pediatric Logistic Organ Dysfunction scores, vasoactive-inotrope score (VIS), ß-type natriuretic peptide (BNP), lactate, type of shock, duration of mechanical ventilation (MV), intensive care unit and hospital length of stay, and mortality. RESULTS:: Overall, 28-day mortality was 26%, and 88% patients required MV. Prevalence of LV dysfunction was 72% and RV dysfunction was 63%. LV systolic dysfunction (fractional shortening z score <-2) was significantly associated with PRISM III, VIS, and BNP. RV systolic dysfunction (tricuspid annular plane systolic excursion z score <-2) was significantly associated with cold shock. LV and RV diastolic dysfunction did not have any significant clinical associations. No echocardiographic measures were associated with mortality. CONCLUSION:: Myocardial dysfunction is highly prevalent in PSS but is not associated with mortality. LV systolic dysfunction is associated with a higher severity of illness, use of vasoactives, and BNP, whereas RV systolic dysfunction is associated with cold shock. Further studies are needed to determine the utility of echo in the bedside management of patients with PSS.


Assuntos
Catecolaminas/uso terapêutico , Cuidados Críticos , Choque Séptico/fisiopatologia , Volume Sistólico/fisiologia , Disfunção Ventricular Esquerda/fisiopatologia , Disfunção Ventricular Direita/fisiopatologia , Adolescente , Criança , Pré-Escolar , Ecocardiografia , Feminino , Hidratação , Humanos , Lactente , Recém-Nascido , Masculino , Testes Imediatos , Estudos Retrospectivos , Choque Séptico/tratamento farmacológico , Choque Séptico/mortalidade , Taxa de Sobrevida , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Direita/diagnóstico por imagem , Disfunção Ventricular Direita/mortalidade , Adulto Jovem
18.
Cardiovasc Revasc Med ; 19(6S): 41-46, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30327095

RESUMO

BACKGROUND: Transfemoral TAVR (tf-TAVR) under conscious sedation (CS) has become popular. The need of anesthesiologic support during tf-TAVR has been questioned. Critical events during the procedure might require immediate action. We analyzed the frequency of periprocedural critical adverse events (CAE) during tf-TAVR with CS in our institution. METHODS: Tf-TAVR has been performed at our institution since 2007. We excluded patients from the first four years to minimize the influence of any learning curve. CAE were defined as occurrence of 1.) "CPR", 2.) "defibrillation", 3.) "emergency extracorporeal circulation (ECC)" and 4.) "conversion to general anesthesia (GA) not related to 1.)-3.)". Data was prospectively collected in our AVIATOR TAVR registry. RESULTS: 601 patients were analyzed retrospectively. Overall, CAE were recorded in 54 patients (9%). CPR was necessary in 12 patients (2%) and defibrillation in 10 patients (1.6%). ECC was rarely needed (n = 2, 0.3%). Conversion to GA was necessary in 34 patients (5.65%). Procedure-related conversion was necessary in 10 patients. With 24 patients, sedation-related conversion occurred more frequently. Unrest and pain were the most common reasons for conversion (n = 13, 2%) and respiratory distress in 11 patients (2%). Catecholaminergic support was needed in 269 (45%) patients. Vasopressors were more often applied (n = 249, 41%) than inotropes (n = 59, 10%). CONCLUSION: Even in a high-volume center, CAE may occur in nearly every tenth patient. Conversion to GA was the most common CAE. Catecholaminergic support (primary vasopressor support) was needed in nearly every second patient. These points underline the necessity of a cardiac anaesthesiologist to be in the room during the procedure. SUMMARY: Despite experience, critical adverse events (CAE) still occur in TAVR patients. We analyzed the occurrence of CAE and the need for catecholaminergic support in sedated TAVR patients.


Assuntos
Estenose da Valva Aórtica/cirurgia , Sedação Consciente/efeitos adversos , Complicações Intraoperatórias/terapia , Complicações Pós-Operatórias/terapia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Anestesia Geral/efeitos adversos , Estenose da Valva Aórtica/mortalidade , Valvuloplastia com Balão/efeitos adversos , Reanimação Cardiopulmonar , Cardiotônicos/uso terapêutico , Catecolaminas/uso terapêutico , Sedação Consciente/mortalidade , Circulação Extracorpórea , Feminino , Hospitais com Alto Volume de Atendimentos , Humanos , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/mortalidade , Masculino , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento , Vasoconstritores/uso terapêutico
19.
Pediatr Transplant ; 22(8): e13304, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30315619

RESUMO

pLT is a highly standardized therapy for children with end-stage liver disease and liver-based metabolic diseases. However, NCs after transplantation occur and especially younger children are considered as more vulnerable and susceptible to NCs. Up to now, detailed data particularly for the very young age group do not exist. We therefore retrospectively studied NCs in children after pLT under age of 24 months. Forty children aged between 19 days and 22 months were evaluated according to type of NC and potential risk factors. NCs occurred in 8/40 patients (20%). All experienced new-onset seizures and in 1/6 surviving patients, seizures evolved into epilepsy. Other NCs were intracerebral abscess (1/8 patients) and subdural hemorrhage (1/8 patients). The overall 3-year mortality rate was 10% (4/40 patients). Significant risk factors for NCs and therefore seizures were HAT (P = 0.020), total surgery time (P = 0.009), retransplantation (P < 0.001), period of catecholamine therapy (P = 0.024), period of mechanical ventilation (P = 0.014), and period of sedation (P = 0.010). Our study is the first to provide detailed information on NCs after pLT in children under 24 months of age. The incidence of NCs in this particular group of very young patients was not increased compared to previously published data of children of all ages. Main NC was new-onset seizure. In the surviving infants, prognosis of seizure was excellent and the risk of developing epilepsy was low. Even more, the occurrence of NCs did not significantly affect mortality or survival in this particular age group.


Assuntos
Doença Hepática Terminal/complicações , Doença Hepática Terminal/cirurgia , Transplante de Fígado/efeitos adversos , Doenças do Sistema Nervoso/complicações , Abscesso Encefálico/complicações , Catecolaminas/uso terapêutico , Epilepsia , Feminino , Hematoma Subdural/complicações , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Respiração Artificial , Estudos Retrospectivos , Fatores de Risco , Convulsões/complicações
20.
Transfusion ; 58(9): 2113-2114, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30153332

RESUMO

BACKGROUND: Drug-induced immune hemolytic anemia (DIIHA) is a rare but sometimes severe side effect. CASE REPORT: We describe the case of a 32-year-old patient who presented a cardiovascular collapse and a severe hemolysis secondary to the injection of iomeprol, a contrast medium, after a carcinologic surgery. RESULTS: The evolution was favorable after blood transfusion and short catecholamine support. The biology showed drug-dependent antibodies after incubation with iomeprol. CONCLUSION: This case is the second report of DIIHA with iomeprol.


Assuntos
Anemia Hemolítica/induzido quimicamente , Meios de Contraste/efeitos adversos , Iopamidol/análogos & derivados , Choque/etiologia , Adulto , Anemia Hemolítica/complicações , Anemia Hemolítica/imunologia , Anemia Hemolítica/terapia , Especificidade de Anticorpos , Catecolaminas/uso terapêutico , Terapia Combinada , Transfusão de Eritrócitos , Feminino , Hematúria/diagnóstico por imagem , Humanos , Iopamidol/efeitos adversos , Iopamidol/imunologia , Neoplasias Ovarianas/complicações , Neoplasias Ovarianas/cirurgia , Complicações Pós-Operatórias/diagnóstico por imagem , Tomografia Computadorizada por Raios X
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