Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 2.246
Filtrar
1.
J Vasc Interv Radiol ; 32(2): 204-210, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33358329

RESUMO

PURPOSE: This pilot study aims to evaluate the effect of hepatic intraarterial norepinephrine injection in vasculature modulation for hepatocellular carcinoma (HCC) tumors. MATERIALS AND METHODS: This is a single-center prospective study of patients with HCC with proven single-lobe tumors > 3 cm. Eight patients were included, with a mean age of 63 y ± 8. All patients had Barcelona Clinic Liver Cancer stage B HCC and an Eastern Cooperative Oncology Group performance status of 0. Mean tumor size was 6.1 cm ± 1.8; all tumors were hypervascular. Patients underwent CT hepatic perfusion before and after injection of 24 µg of norepinephrine intraarterially (4 µg/mL; total 6 mL injected at a rate of 1 mL/s). Color-coded perfusion maps were used to assess the effects of local therapy on hepatic perfusion values. Tumor-to-liver ratio (TLR) was calculated from the ratio of tumor perfusion to background liver perfusion value. RESULTS: Seven of 8 patents had significant (P = .04) absolute increase in tumor perfusion vs background liver, varying from incremental (-2 mL/min/100 mL) to 290 mL/min/100 mL. There was a nonsignificant increase in TLR from 2.7 ± 1.3 to 2.9 ± 1.4 after norepinephrine injection (P = .8). Mean peak time to maximal increase in tumor perfusion after injection was 6.1 s (range, 4.5-9.1 s). Norepinephrine injection was well tolerated without major adverse events. CONCLUSIONS: Norepinephrine causes increased blood flow toward HCC tumors, but with a corresponding smaller increase in blood flow to noncancerous liver tissue, with no observed systemic side effects.


Assuntos
Carcinoma Hepatocelular/irrigação sanguínea , Carcinoma Hepatocelular/diagnóstico por imagem , Artéria Hepática/efeitos dos fármacos , Artéria Hepática/diagnóstico por imagem , Neoplasias Hepáticas/irrigação sanguínea , Neoplasias Hepáticas/diagnóstico por imagem , Tomografia Computadorizada Multidetectores , Norepinefrina/administração & dosagem , Imagem de Perfusão , Vasoconstritores/administração & dosagem , Idoso , Carcinoma Hepatocelular/terapia , Feminino , Artéria Hepática/fisiopatologia , Humanos , Injeções Intra-Arteriais , Neoplasias Hepáticas/terapia , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Valor Preditivo dos Testes , Estudos Prospectivos , Fluxo Sanguíneo Regional
2.
Anesth Analg ; 131(4): 1060-1065, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32925324

RESUMO

BACKGROUND: Continuous infusions of norepinephrine to treat perioperative hypotension are typically administered through a central venous line rather than a peripheral venous catheter to avoid the risk of localized tissue necrosis in case of drug extravasation. There is limited literature to estimate the risk of skin necrosis when peripheral norepinephrine is used to counteract anesthesia-associated hypotension in elective surgical cases. This study aimed to estimate the rate of occurrence of drug-related adverse effects, including skin necrosis requiring surgical management when norepinephrine peripheral extravasation occurs. METHODS: This retrospective cohort study used the perioperative databases of the University Hospitals in Amsterdam and Utrecht, the Netherlands, to identify surgical patients who received norepinephrine peripheral intravenous infusions (20 µg/mL) between 2012 and 2016. The risk of drug-related adverse effects, including skin necrosis, was estimated. Particular care was taken to identify patients who needed plastic surgical or medical attention secondary to extravasation of dilute, peripheral norepinephrine. RESULTS: A total of 14,385 patients who received norepinephrine peripheral continuous infusions were identified. Drug extravasation was observed in 5 patients (5/14,385 = 0.035%). The 95% confidence interval (CI) for infusion extravasation was 0.011%-0.081%, indicating an estimated risk of 1-8 events per every 10,000 patients. There were zero related complications requiring surgical or medical intervention, resulting in a 95% CI of 0%-0.021% and indicating a risk of approximately 0-2 events per 10,000 patients. CONCLUSIONS: In the current database analysis, no significant association was found between the use of peripheral intravenous norepinephrine infusions and adverse events.


Assuntos
Complicações Intraoperatórias/epidemiologia , Norepinefrina/efeitos adversos , Período Perioperatório , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Bases de Dados Factuais , Feminino , Humanos , Infusões Intravenosas , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Necrose , Resultados Negativos , Norepinefrina/administração & dosagem , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Medição de Risco , Pele/patologia
3.
Br J Anaesth ; 125(4): 622-628, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32739045

RESUMO

BACKGROUND: Arterial pressure lability is common during the process of replacing syringes used for norepinephrine infusions in critically ill patients. It is unclear if there is an optimal approach to minimise arterial pressure instability during this procedures. We investigated whether 'double pumping' changeover (DPC) or automated changeover (AC) reduced blood pressure lability in critically ill adults compared with quick syringe changeover (QC). METHODS: Patients requiring a norepinephrine infusion syringe change were randomised in a non-blinded trial undertaken in six ICUs. Randomisation was minimised by norepinephrine flow rate at inclusion and centre. The primary outcome was the frequency of increased/decreased mean arterial pressure (defined by 15 mm Hg from baseline measurements) within 15 min of switching the syringe compared with QC. RESULTS: Patients (mean age: 64 (range:18-88)) yr were randomly assigned to QC (n=95), DPC (n=95), or AC (n=96). Increased MAP was the commonest consequence of syringe changeovers. MAP variability was most frequent after DPC (89/224 changeovers; 39.7%) compared with 57/223 (25.6%) changeovers after quick syringe switch and 46/181 (25.4%) in patients randomised to receive automated changeover (P=0.001). Fewer events occurred with QC compared with DPC (P=0.002). Sensitivity analysis based on mixed models showed that performing several changeovers on a single patient had no impact. Both type of changeover and norepinephrine dose before syringe changeover were independently associated with MAP variations >15 mm Hg. CONCLUSIONS: Quick changeover of norepinephrine syringes was associated with less blood pressure lability compared with DPC. The prevalence of MAP variations was the same between AC and QC. CLINICAL TRIAL REGISTRATION: NCT02304939.


Assuntos
Pressão Arterial/efeitos dos fármacos , Cuidados Críticos , Norepinefrina/administração & dosagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Seringas , Adulto Jovem
5.
Arch Gynecol Obstet ; 302(4): 829-836, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32588134

RESUMO

OBJECTIVE: To investigate the efficacy and safety of prophylactic infusion of norepinephrine (NE) versus normal saline in patients undergoing cesarean section. METHODS: Patients (n = 97) were randomized to receive a bolus of NE (6 µg) immediately following spinal anesthesia with maintenance NE (0.05 µg/kg/min IV) or normal saline (n = 98). The primary endpoint was the incidence of postspinal anesthesia hypotension [systolic blood pressure (SBP) < 80% of baseline] at 1-20 min following spinal anesthesia. Secondary outcomes were the overall stability of SBP control versus baseline, inferior vena cava collapsibility index (IVC-CI), other adverse events (bradycardia, nausea, vomiting, and hypertension), and neonatal outcomes (blood gas values and Apgar scores). RESULTS: The rates of postspinal anesthesia hypotension and severe postspinal anesthesia hypotension (SBP < 60% of the baseline) were significantly lower in the NE group (17.5% vs. 62.2%, p < 0.001; 7.2% vs. 17.4%, p = 0.031). In the NE group, SBP remained more stable and closer to baseline (p < 0.001), and IVC-CI values were lower 5 min after spinal anesthesia and 5 min after fetal delivery (p = 0.045; p < 0.001, respectively). Other adverse effects and neonatal outcomes were not different between the two groups. CONCLUSION: Prophylactic NE infusion effectively lowers the incidence of postspinal anesthesia hypotension and does not increase other adverse events in patients or neonates.


Assuntos
Anestesia Obstétrica/efeitos adversos , Raquianestesia/efeitos adversos , Cesárea/efeitos adversos , Hipotensão/prevenção & controle , Infusões Parenterais/efeitos adversos , Norepinefrina/administração & dosagem , Profilaxia Pré-Exposição/métodos , Vasoconstritores/administração & dosagem , Adulto , Anestesia Obstétrica/métodos , Raquianestesia/métodos , Pressão Sanguínea , Bradicardia/induzido quimicamente , Bradicardia/epidemiologia , Cesárea/métodos , China/epidemiologia , Feminino , Humanos , Hipertensão/induzido quimicamente , Hipertensão/complicações , Hipotensão/epidemiologia , Recém-Nascido , Infusões Parenterais/métodos , Pessoa de Meia-Idade , Náusea/induzido quimicamente , Náusea/epidemiologia , Norepinefrina/efeitos adversos , Gravidez , Resultado do Tratamento , Vasoconstritores/efeitos adversos , Vômito/induzido quimicamente , Vômito/epidemiologia , Adulto Jovem
6.
PLoS One ; 15(5): e0232830, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32407353

RESUMO

During general anesthesia (GA), direct analysis of arterial pressure or aortic flow waveforms may be inconclusive in complex situations. Patient-specific biomechanical models, based on data obtained during GA and capable to perform fast simulations of cardiac cycles, have the potential to augment hemodynamic monitoring. Such models allow to simulate Pressure-Volume (PV) loops and estimate functional indicators of cardiovascular (CV) system, e.g. ventricular-arterial coupling (Vva), cardiac efficiency (CE) or myocardial contractility, evolving throughout GA. In this prospective observational study, we created patient-specific biomechanical models of heart and vasculature of a reduced geometric complexity for n = 45 patients undergoing GA, while using transthoracic echocardiography and aortic pressure and flow signals acquired in the beginning of GA (baseline condition). If intraoperative hypotension (IOH) appeared, diluted norepinephrine (NOR) was administered and the model readjusted according to the measured aortic pressure and flow signals. Such patients were a posteriori assigned into a so-called hypotensive group. The accuracy of simulated mean aortic pressure (MAP) and stroke volume (SV) at baseline were in accordance with the guidelines for the validation of new devices or reference measurement methods in all patients. After NOR administration in the hypotensive group, the percentage of concordance with 10% exclusion zone between measurement and simulation was >95% for both MAP and SV. The modeling results showed a decreased Vva (0.64±0.37 vs 0.88±0.43; p = 0.039) and an increased CE (0.8±0.1 vs 0.73±0.11; p = 0.042) in hypotensive vs normotensive patients. Furthermore, Vva increased by 92±101%, CE decreased by 13±11% (p < 0.001 for both) and contractility increased by 14±11% (p = 0.002) in the hypotensive group post-NOR administration. In this work we demonstrated the application of fast-running patient-specific biophysical models to estimate PV loops and functional indicators of CV system using clinical data available during GA. The work paves the way for model-augmented hemodynamic monitoring at operating theatres or intensive care units to enhance the information on patient-specific physiology.


Assuntos
Anestesia Geral/métodos , Pressão Arterial/fisiologia , Débito Cardíaco/fisiologia , Monitorização Hemodinâmica/métodos , Hipotensão/fisiopatologia , Modelos Cardiovasculares , Volume Sistólico/fisiologia , Algoritmos , Fenômenos Biomecânicos , Pressão Sanguínea , Feminino , Humanos , Hipotensão/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Norepinefrina/administração & dosagem , Estudo de Prova de Conceito , Estudos Prospectivos , Vasoconstritores/administração & dosagem
7.
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue ; 32(2): 243-244, 2020 Feb.
Artigo em Chinês | MEDLINE | ID: mdl-32275016

RESUMO

Norepinephrine (NE) can raise blood pressure and speed up heart rate. However, because its effect of raising heart rate is less than that of reflex reduction of heart rate caused by the increase of blood pressure, NE causes more heart rate decrease in patients. A case of tachyarrhythmia caused by low dose NE was admitted to department of intensive care unit (ICU) of Shijiazhuang Third Hospital. The heart rate of the patient increased with the elevation of NE application dose. A variety of antiarrhythmic drugs was invalid. The related examination was prescribed to eliminate the cause of arrhythmia caused by the disorder of electrolysis and thyroid function, and found that heart rate decreased as the dose of NE tapered. After NE was stopped, the patient recovered sinus rhythm. During one month of follow-up, the patient's heart rhythm was normal. Therefore, the occurrence of tachyarrhythmia is related to NE.


Assuntos
Norepinefrina/efeitos adversos , Taquicardia/induzido quimicamente , Pressão Sanguínea , Frequência Cardíaca , Humanos , Norepinefrina/administração & dosagem , Taquicardia/diagnóstico
8.
Rev. Hosp. Ital. B. Aires (2004) ; 40(1): 25-28, mar. 2020. ilus
Artigo em Espanhol | LILACS | ID: biblio-1102210

RESUMO

Introducción: la zigomicosis es una infección fúngica poco frecuente, con alta tasa de mortalidad y de mal pronóstico. Afecta principalmente a pacientes inmunocomprometidos. La asociación con el síndrome hemofagocítico es extremadamente inusual, más aún en pacientes inmunocompetentes, con pocos ejemplos registrados en la literatura. Caso clínico: se presenta el caso de un paciente masculino inmunocompetente de 40 años con diagnóstico de mucormicosis y síndrome hemofagocítico que evoluciona desfavorablemente, con fallo multiorgánico, a pesar de los esfuerzos médicos. Conclusión: la asociación de mucormicosis con síndrome hemofagocítico en un paciente inmunocompetente es extremadamente rara; existen pocos casos informados en Latinoamérica. Debemos tener presente esta asociación, ya que requiere un tratamiento agresivo y soporte vital avanzado. (AU)


Introduction: zygomycosis is a rare fungal infection that carries with high mortality rates. This poor prognosis, rapidly progressive infection mainly affects immunocompromised patients. The association with hemophagocytic lymphohistiocytosis is extremely unusual, even more in immunocompetent patients, with few cases reported. Case: we present the case of an immunocompetent male patient who was diagnosed with zygomycosis and hemophagocytic lymphohistiocytosis. Despite medical efforts he developed multiorganic failure. Conclusion: the association of mucormycosis with hemophagocytic lymphohistiocytosis in an immunocompetent patient is exceptional with few cases reported in Latin America. We must always suspect this association considering they require aggressive treatment and advanced life support. (AU)


Assuntos
Humanos , Masculino , Adulto , Zigomicose/diagnóstico , Linfo-Histiocitose Hemofagocítica/diagnóstico , Pancitopenia/sangue , Agitação Psicomotora , Vancomicina/uso terapêutico , Norepinefrina/administração & dosagem , Norepinefrina/uso terapêutico , Anfotericina B/uso terapêutico , Exoftalmia/diagnóstico por imagem , Hospedeiro Imunocomprometido/imunologia , Colistina/uso terapêutico , Combinação Amoxicilina e Clavulanato de Potássio/administração & dosagem , Combinação Amoxicilina e Clavulanato de Potássio/uso terapêutico , Zigomicose/etiologia , Zigomicose/mortalidade , Zigomicose/epidemiologia , Delírio , Linfo-Histiocitose Hemofagocítica/etiologia , Linfo-Histiocitose Hemofagocítica/mortalidade , Febre , Meropeném/uso terapêutico , Imunocompetência/imunologia , Icterícia , Mucormicose/complicações , Insuficiência de Múltiplos Órgãos/diagnóstico
9.
Int J Clin Pharmacol Ther ; 58(4): 223-229, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32000886

RESUMO

OBJECTIVE: Low-molecular-weight heparins are frequently used to prevent venous thromboembolism. Vasopressor therapy may be associated with inadequate anti-factor Xa activity, thereby increasing the risk of venous thromboembolism. We aimed to assess the association between anti-factor Xa activity and norepinephrine dose in intensive care unit (ICU) patients treated with subcutaneous dalteparin for venous thromboembolism prophylaxis. MATERIALS AND METHODS: This was a prospective observational pilot study in adult ICU patients treated with dalteparin 5,000 IU subcutaneously once daily and norepinephrine > 0.25 µg/kg/min. Peak anti-factor Xa activity was monitored and dalteparin doses were adjusted following a predefined dose algorithm. RESULTS: From November 2016 to April 2018, 32 patients were included. No correlation was found between norepinephrine dose and anti-factor Xa activity (r = -0.01, 95% confidence interval = -0.47 - 0.27, p = 0.57). Furthermore, following dalteparin 5,000 IU once daily, 28% of the patients showed anti-factor Xa activity < 0.10 IU/mL. Higher body mass index (BMI) (p < 0.001) but not patients' norepinephrine dose, age, or serum creatinine were risk factors for anti-factor Xa activity < 0.10 IU/mL. Dose increments to 7,500 IU once daily resulted in anti-factor Xa activity ≥ 0.10 IU/mL in all 5 patients (p = 0.043). CONCLUSION: In this cohort of ICU patients, no association was found between norepinephrine dose and anti-factor Xa activity following subcutaneous dalteparin 5,000-IU administration once daily. Furthermore, nearly one-third of the patients showed anti-factor Xa activity below the target concentration for venous thromboembolism prophylaxis. Higher BMI was an independent risk factor for reduced anti-Xa activity.


Assuntos
Estado Terminal , Dalteparina/farmacocinética , Inibidores do Fator Xa/farmacocinética , Norepinefrina/administração & dosagem , Tromboembolia Venosa/prevenção & controle , Adulto , Anticoagulantes , Dalteparina/administração & dosagem , Inibidores do Fator Xa/administração & dosagem , Humanos , Unidades de Terapia Intensiva , Projetos Piloto , Estudos Prospectivos
10.
Crit Care ; 24(1): 52, 2020 02 14.
Artigo em Inglês | MEDLINE | ID: mdl-32059682

RESUMO

BACKGROUND: Optimal timing for the start of vasopressors (VP) in septic shock has not been widely studied since it is assumed that fluids must be administered in advance. We sought to evaluate whether a very early start of VP, even without completing the initial fluid loading, might impact clinical outcomes in septic shock. METHODS: A total of 337 patients with sepsis requiring VP support for at least 6 h were initially selected from a prospectively collected database in a 90-bed mixed-ICU during a 24-month period. They were classified into very-early (VE-VPs) or delayed vasopressor start (D-VPs) categories according to whether norepinephrine was initiated or not within/before the next hour of the first resuscitative fluid load. Then, VE-VPs (n = 93) patients were 1:1 propensity matched to D-VPs (n = 93) based on age; source of admission (emergency room, general wards, intensive care unit); chronic and acute comorbidities; and lactate, heart rate, systolic, and diastolic pressure at vasopressor start. A risk-adjusted Cox proportional hazard model was fitted to assess the association between VE-VPs and day 28 mortality. Finally, a sensitivity analysis was performed also including those patients requiring VP support for less than 6 h. RESULTS: Patients subjected to VE-VPs received significantly less resuscitation fluids at vasopressor starting (0[0-510] vs. 1500[650-2300] mL, p < 0.001) and during the first 8 h of resuscitation (1100[500-1900] vs. 2600[1600-3800] mL, p < 0.001), with no significant increase in acute renal failure and/or renal replacement therapy requirements. VE-VPs was related with significant lower net fluid balances 8 and 24 h after VPs. VE-VPs was also associated with a significant reduction in the risk of death compared to D-VPs (HR 0.31, CI95% 0.17-0.57, p < 0.001) at day 28. Such association was maintained after including patients receiving vasopressors for < 6 h. CONCLUSION: A very early start of vasopressor support seems to be safe, might limit the amount of fluids to resuscitate septic shock, and could lead to better clinical outcomes.


Assuntos
Hidratação , Norepinefrina , Choque Séptico , Vasoconstritores , Lesão Renal Aguda/complicações , Idoso , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Norepinefrina/administração & dosagem , Terapia de Substituição Renal , Choque Séptico/tratamento farmacológico , Fatores de Tempo , Vasoconstritores/administração & dosagem
11.
Ann Pharmacother ; 54(8): 742-749, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-31928081

RESUMO

Background: Cortisol thresholds defining adrenal insufficiency (AI) in some cirrhosis-specific studies differ from those recommended by the SCCM/ESICM (Society of Critical Care Medicine/European Society of Intensive Care Medicine) guidelines, which may influence treatment decisions. Objective: To determine if stress-dose hydrocortisone (HC) improves outcomes in vasopressor-dependent patients meeting cirrhosis-specific criteria for AI. Methods: In this retrospective study, AI was defined using criteria from 2 studies in critically ill cirrhosis patients showing mortality reduction with HC (random cortisol <20 µg/dL, or if a standard-dose cosyntropin test was performed, baseline cortisol <15 µg/dL or delta cortisol <9 µg/dL if baseline = 15-34 µg/dL). Use of HC was at the discretion of the intensivist. The primary endpoint was days of vasopressor therapy. Secondary endpoints included hospital mortality and newly acquired infections. Sixty-four patients were evaluated; 40 patients received HC and 24 did not. Results: Mean random cortisol was significantly lower in the HC group (9.8 ± 3.2 vs 12.0 ± 3.7 µg/dL, P = 0.04). Delta cortisol also tended to be lower in the HC group (8.2 ± 4.4 vs 11.3 ± 6.4 µg/dL, P = 0.25). Patients in the HC group exhibited significantly fewer median days of vasopressor therapy (4.0 [2.0-7.0] vs 7.0 [4.2-10.8], P = 0.006), lower mortality (22.5% vs 50%, P = 0.02), and a similar incidence of newly acquired infections. Conclusion and Relevance: The use of HC in patients meeting cirrhosis-specific criteria for AI resulted in significantly shorter duration of vasopressor therapy, lower mortality, and no increased risk of infection. Use of traditional AI definitions may exclude patients with cirrhosis that could benefit from HC therapy.


Assuntos
Insuficiência Adrenal/tratamento farmacológico , Hidrocortisona/sangue , Cirrose Hepática/tratamento farmacológico , Norepinefrina/uso terapêutico , Vasoconstritores/uso terapêutico , Insuficiência Adrenal/sangue , Insuficiência Adrenal/complicações , Insuficiência Adrenal/mortalidade , Adulto , Cuidados Críticos , Estado Terminal , Feminino , Humanos , Hidrocortisona/administração & dosagem , Incidência , Cirrose Hepática/sangue , Cirrose Hepática/complicações , Cirrose Hepática/mortalidade , Masculino , Pessoa de Meia-Idade , Norepinefrina/administração & dosagem , Estudos Retrospectivos , Fatores de Tempo , Vasoconstritores/administração & dosagem
12.
Br J Anaesth ; 124(3): e108-e114, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31959386

RESUMO

BACKGROUND: Norepinephrine infusion has been suggested as an effective method for preventing hypotension during spinal anaesthesia for Caesarean delivery. However, optimal dosing regimens for norepinephrine have not been well established. This study aimed to determine the dose-response characteristics of a weight-adjusted fixed-rate infusion of norepinephrine to prevent hypotension during neuraxial anaesthesia for Caesarean delivery. METHODS: In a double-blind, randomised controlled trial, 80 parturients having elective Caesarean delivery received a prophylactic norepinephrine infusion at 0.025 µg kg-1 min-1 (Group N1), 0.05 µg kg-1 min-1 (Group N2), 0.075 µg kg-1 min-1 (Group N3), or 0.10 µg kg-1 min-1 (Group N4), starting immediately after induction of combined spinal-epidural anaesthesia. The primary outcome was non-occurrence of hypotension, defined as a decrease in systolic arterial pressure ≥20% below baseline value or to ≤90 mm Hg, before delivery. Values for 50% effective dose (ED50) and ED90 were calculated using probit regression. RESULTS: The incidence of hypotension was 11/20 (55%), 6/20 (30%), 2/20 (10%), and 1/20 (5%) in Groups N1, N2, N3, and N4, respectively (P<0.0001). The ED50 and ED90 (95% confidence interval) of norepinephrine infusions for preventing hypotension were 0.029 (-0.002 to 0.043) and 0.080 (0.065-0.116) µg kg-1 min-1, respectively. The incidence of reactive hypertension increased with increasing norepinephrine dose (P=0.002). Other adverse effects were similar among groups. CONCLUSIONS: Under the conditions of this study, an infusion of norepinephrine 0.08 µg kg-1 min-1 was effective for preventing hypotension in 90% of patients. This information should provide a guide for initiating norepinephrine infusions. CLINICAL TRIAL REGISTRATION: ChiCTR1900022322 at the Chinese Clinical Trial Registry (http://www.chictr.org.cn/enindex.aspx).


Assuntos
Anestesia Epidural/efeitos adversos , Anestesia Obstétrica/efeitos adversos , Raquianestesia/efeitos adversos , Hipotensão/prevenção & controle , Norepinefrina/administração & dosagem , Adulto , Pressão Sanguínea/efeitos dos fármacos , Cesárea , Relação Dose-Resposta a Droga , Método Duplo-Cego , Feminino , Humanos , Hipotensão/epidemiologia , Gravidez
13.
Int Heart J ; 61(1): 60-66, 2020 Jan 31.
Artigo em Inglês | MEDLINE | ID: mdl-31956143

RESUMO

Transcatheter aortic valve implantation (TAVI) using a transfemoral approach under local anesthesia with conscious sedation (LACS) is becoming an increasingly common TAVI strategy. However, patients who are awake during the TAVI procedure can experience stress, anxiety, and pain, even when LACS is used. Clinical hypnotherapy is an anxiolytic intervention that can be beneficial for patients undergoing invasive surgery. This study aimed to assess the perioperative outcomes of adjunctive hypnotherapy undergoing transfemoral TAVI with LACS.Consecutive patients (n = 143) with symptomatic severe aortic stenosis who underwent transfemoral TAVI with LACS only (n = 107) or with LACS and hypnotherapy (n = 36) between January 2015 and April 2016 were retrospectively included in the study. The clinical outcomes were compared between the two groups. The LACS with hypnotherapy group had a significantly shorter length of stay in the intensive care unit (ICU; LACS only versus LACS with hypnotherapy: 4.0 (4.0-5.5) days versus 3.0 (3.0-5.0) days, P < 0.01). Moreover, the use of anesthetics (propofol and remifentanil) and norepinephrine was significantly lower in the LACS with hypnotherapy group (e.g., for propofol, LACS only versus LACS with hypnotherapy: 96.4 ± 104.7 mg versus 15.0 ± 31.8 mg, P < 0.001). The multiple regression analysis showed that being male, hypnotherapy, and the composite complication score were independently associated with the length of stay in the ICU.The adjunctive hypnotherapy on LACS among transfemoral TAVI patients may facilitate perioperative management. However, a prospective randomized study is necessary to confirm the efficacy of hypnotherapy among TAVI patients.


Assuntos
Estenose da Valva Aórtica/cirurgia , Sedação Consciente/métodos , Hipnose/métodos , Substituição da Valva Aórtica Transcateter/métodos , Idoso , Idoso de 80 Anos ou mais , Anestesia Local , Feminino , Humanos , Masculino , Norepinefrina/administração & dosagem , Período Perioperatório , Complicações Pós-Operatórias , Propofol/administração & dosagem , Estudos Prospectivos , Análise de Regressão , Remifentanil/administração & dosagem , Estudos Retrospectivos , Resultado do Tratamento
14.
Ann Pharmacother ; 54(7): 706-714, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31958982

RESUMO

Objective: To summarize literature evaluating vasopressin use, focusing on clinical controversies regarding initiation, dosing, and discontinuation and interaction of vasopressin with other therapies in septic shock patients. Data Sources: A PubMed English-language literature search (January 2008 to December 2019) was performed using these terms: arginine vasopressin, septic, shock, and sepsis. Citations, including controlled trials, observational studies, review articles, guidelines, and consensus statements, were reviewed. Study Selection and Data Extraction: Relevant clinical data focusing on specific controversial questions regarding the utility of vasopressin in patients with septic shock were narratively summarized. Data Synthesis: Current literature does not strongly support the use of vasopressin as a first-line initial therapy for septic shock. Additionally, there are conflicting data for weight-based dosing of vasopressin in overweight patients. Evidence for vasopressin renal protection and interaction with corticosteroids is minimal. However, vasopressin has the ability to reduce catecholamine requirements in septic shock patients and may provide a mortality benefit in specific subgroups. Discontinuation of vasopressin last, not second to last, in resolving septic shock may reduce hypotension development. Relevance to Patient Care and Clinical Practice: This review addresses specific clinical controversies that drive vasopressin use in septic shock patients in real-world practice. Conclusion: Vasopressin should remain second-line adjunct to norepinephrine to augment mean arterial pressures. Dosing should be initiated at 0.03 U/min, and higher doses offer minimal benefit. There are conflicting data on the impact of weight on vasopressin response. Studies have failed to show renal benefit with vasopressin use or an interaction with corticosteroid therapy.


Assuntos
Arginina Vasopressina/uso terapêutico , Hipotensão/tratamento farmacológico , Norepinefrina/uso terapêutico , Choque Séptico/tratamento farmacológico , Vasoconstritores/uso terapêutico , Arginina Vasopressina/administração & dosagem , Arginina Vasopressina/efeitos adversos , Pressão Arterial/efeitos dos fármacos , Peso Corporal , Humanos , Norepinefrina/administração & dosagem , Norepinefrina/efeitos adversos , Guias de Prática Clínica como Assunto , Vasoconstritores/administração & dosagem , Vasoconstritores/efeitos adversos
15.
Sci Rep ; 10(1): 822, 2020 01 21.
Artigo em Inglês | MEDLINE | ID: mdl-31964979

RESUMO

Increased concentrations of the vasodilator histamine have been observed in patients undergoing abdominal surgery. The role of histamine during orthotopic liver transplantation (OLT) has only been studied in animals. The aim of this study was to measure plasma concentrations of histamine and its degrading enzyme diamine oxidase (DAO) in patients undergoing orthotopic liver transplantation, and assess whether histamine or DAO correlate with intraoperative noradrenaline requirements. Histamine and DAO concentrations were measured in 22 adults undergoing liver transplantation and 22 healthy adults. Furthermore, norepinephrine requirements during liver transplantation were recorded. Baseline concentrations of histamine and DAO were greater in patients, who underwent liver transplantation, than in healthy individuals (Histamine: 6.4 nM, IQR[2.9-11.7] versus 4.3 nM, IQR[3.7-7.1], p = 0.029; DAO: 2.0 ng/mL, IQR[1.5-4.1] versus <0,5 ng/mL, IQR[<0.5-1.1], p < 0.001). During liver transplantation, histamine concentrations decreased to 1.8 nM, IQR[0.5-4.9] in the anhepatic phase (p < 0.0001 versus baseline), and to 1.5 nM, IQR[0.5-2.9] after reperfusion (p < 0.0001 versus baseline). In contrast, DAO concentrations increased to 35.5 ng/ml, IQR[20-50] in the anhepatic phase (p = 0.001 versus baseline) and to 39.5 ng/ml, IQR[23-64] after reperfusion (p = 0.001 versus baseline), correlating inversely with histamine. Norepinephrine requirements during human liver transplantation correlated significantly with DAO concentrations in the anhepatic phase (r = 0.58, p = 0.011) and after reperfusion (r = 0.56; p = 0.022). In patients undergoing orthotopic liver transplantation, histamine concentrations decrease whereas DAO concentrations increase manifold. Diamine oxidase correlates with intraoperative norepinephrine requirements in patients undergoing OLT.


Assuntos
Amina Oxidase (contendo Cobre)/sangue , Doença Hepática Terminal/cirurgia , Histamina/sangue , Hipotensão/diagnóstico , Complicações Intraoperatórias/diagnóstico , Transplante de Fígado/efeitos adversos , Transplante de Fígado/métodos , Idoso , Biomarcadores/sangue , Doença Hepática Terminal/sangue , Doença Hepática Terminal/fisiopatologia , Feminino , Hemodinâmica , Humanos , Hipotensão/diagnóstico por imagem , Hipotensão/etiologia , Cuidados Intraoperatórios , Complicações Intraoperatórias/tratamento farmacológico , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Norepinefrina/administração & dosagem
16.
J Pharm Biomed Anal ; 177: 112859, 2020 Jan 05.
Artigo em Inglês | MEDLINE | ID: mdl-31522098

RESUMO

Epinephrine and norepinephrine are a class of chiral endogenous catecholamines, which are known as major neurotransmitters. This work described a new LC-MS/MS method coupled with pre-column derivatization, enabling the simultaneous enantiomeric separation of epinephrine and norepinephrine in rat plasma. After protein precipitation procedure, the samples were derivatized with (S)-N-(4-nitrophenoxycarbonyl) phenylalanine methoxyethyl ester, [(S)-NIFE]. The derivatives resolved with good baseline separation on an ACQUITY UPLC BEH C18 column (100 mm × 2.1 mm, 1.7 µm) with mobile phase composed of methanol with 0.2% formic acid in water at a flow rate of 0.2 mL/min. Analysis was performed by multiple reaction monitoring in positive ionization mode. The linear ranges were 1.0-500 ng/mL for epinephrine enantiomers and 1.5-750 ng/mL for norepinephrine enantiomers. The lower limits of quantification for epinephrine and norepinephrine enantiomers were 1.0 and 1.5 ng/mL, respectively. The intra-day and inter-day precision were all less than 10.7% and accuracy ranged from 96.0 to 101.5%. Recoveries for all the analytes were more than 80.3%. The proposed method was successfully applied to simultaneously determine endogenous epinephrine and norepinephrine enantiomers in rat plasma. l-epinephrine and l-norepinephrine were sensitively and accurately quantified while both the d-enantiomers were not detected. Additionally, epinephrine enantiomers were analyzed for stereoselective pharmacokinetics in rats after intravenous administration of racemic epinephrine for the first time. The pharmacokinetic results indicated that the disposition of epinephrine enantiomers was stereoselective and chiral inversion did not occur in rats.


Assuntos
Epinefrina/farmacocinética , Norepinefrina/farmacocinética , Simpatomiméticos/farmacocinética , Animais , Cromatografia Líquida de Alta Pressão/métodos , Epinefrina/administração & dosagem , Epinefrina/sangue , Epinefrina/química , Masculino , Modelos Animais , Estrutura Molecular , Norepinefrina/administração & dosagem , Norepinefrina/sangue , Norepinefrina/química , Ratos , Ratos Wistar , Organismos Livres de Patógenos Específicos , Estereoisomerismo , Relação Estrutura-Atividade , Simpatomiméticos/administração & dosagem , Simpatomiméticos/sangue , Simpatomiméticos/química , Espectrometria de Massas em Tandem/métodos
17.
Ann Pharmacother ; 54(3): 213-218, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31625395

RESUMO

Background: Norepinephrine remains the first-line option to manage patients with circulatory shock. Limited evidence exists evaluating noncatecholamine compounds as first-line monotherapy for managing noncardiogenic shock. Objective: To compare vasopressin monotherapy with norepinephrine monotherapy for reversal of distributive and hemorrhagic shock. Methods: This was a retrospective cohort study including adult patients who were diagnosed with hypovolemic or septic shock, received fluids, and received norepinephrine or vasopressin monotherapy for at least 1 hour. Patients excluded lacked a clear diagnosis, were initiated on 2 or more vasopressors at once, or underwent cardiac surgery. The primary outcome was time to shock reversal. Secondary outcomes included mortality, lengths of stay, and safety end points. A multivariable Cox proportional hazards model was performed incorporating baseline and treatment variables. Results: A total of 85 and 160 patients were treated with vasopressin and norepinephrine, respectively. A decrease in time to shock reversal was observed in the vasopressin group (58.32 hours [95% CI, 50.88-66.00] vs 74.64 hours [95% CI, 60.96-88.32], P = 0.004). Mortality was lower in the vasopressin group (25% vs 41%, P = 0.01), and intensive care unit length of stay was longer (13 days [interquartile range, IQR = 7-19] vs 7 days [IQR = 5-9], P = 0.006). Remaining secondary outcomes were similar. The multivariable analysis revealed no difference in time to shock reversal. Conclusion and Relevance: First-line vasopressin exhibited faster time to distributive shock reversal in the unadjusted analysis but failed to maintain this difference in the multivariable analysis. These findings support safe use of vasopressin as first-line therapy or as an alternative to norepinephrine in distributive shock.


Assuntos
Norepinefrina/uso terapêutico , Choque Hemorrágico/tratamento farmacológico , Choque Séptico/tratamento farmacológico , Vasoconstritores/uso terapêutico , Vasopressinas/uso terapêutico , Adulto , Pressão Sanguínea/efeitos dos fármacos , Estudos de Coortes , Creatinina/sangue , Feminino , Frequência Cardíaca/efeitos dos fármacos , Humanos , Unidades de Terapia Intensiva , Ácido Láctico/sangue , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Norepinefrina/administração & dosagem , Norepinefrina/efeitos adversos , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Choque Hemorrágico/mortalidade , Choque Séptico/mortalidade , Resultado do Tratamento , Vasoconstritores/administração & dosagem , Vasoconstritores/efeitos adversos , Vasopressinas/administração & dosagem , Vasopressinas/efeitos adversos
18.
A A Pract ; 14(1): 12-14, 2020 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-31703007

RESUMO

A 72-year-old man with end-stage renal disease (ESRD) undergoing transurethral resection of a bladder tumor experienced severe and prolonged hypotension after receiving oral 5-aminolevulinic acid (5-ALA). Continuous infusions of norepinephrine and vasopressin ultimately resolved the hypotension over the course of 26 hours. It is uncertain whether 5-ALA is causative or is a contributing factor that influences other factors, such as hypovolemia after hemodialysis and autonomic nerve dysfunction associated with ESRD. Our findings suggest that anesthesiologists should be aware of the possible occurrence of hypotension after administration of 5-ALA, and urologists should consider intravesical 5-ALA administration in patients with ESRD.


Assuntos
Ácido Aminolevulínico/efeitos adversos , Hipotensão/induzido quimicamente , Falência Renal Crônica/fisiopatologia , Neoplasias da Bexiga Urinária/cirurgia , Administração Oral , Idoso , Ácido Aminolevulínico/administração & dosagem , Humanos , Hipotensão/tratamento farmacológico , Norepinefrina/administração & dosagem , Norepinefrina/uso terapêutico , Resultado do Tratamento , Procedimentos Cirúrgicos Urológicos , Vasopressinas/administração & dosagem , Vasopressinas/uso terapêutico
19.
J Cosmet Dermatol ; 19(2): 404-406, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31846189

RESUMO

BACKGROUND: The nipple-areola complex (NAC) is an often overlooked but important erogenous zone in the female sexual response and sexual functional repertoire. Research suggests that nipple stimulation is significant to female sexual satisfaction in as many as 80% of women. Previously, we have reported that stimulation of the arrector pili muscle in the NAC increases nipple sensitivity and has a positive impact on female sexual function. AIMS: To study the effect of RJ-101 on female orgasm. METHODS: A randomized double-blinded placebo-controlled study of RJ101, a novel topical formulation that stimulates the arrector pili muscle of the NAC, in 59 women. Each subject completed a survey composed of Likert scale questions in order to identify changes in orgasm after topical application of RJ101 or placebo. RESULTS: We demonstrated a positive increase in the perceived intensity of orgasm and orgasmic satisfaction/pleasure in women using RJ101 vs those in the placebo group. After 4 weeks of treatment, 76% of the women in the RJ101 arm reported a positive improvement in satisfaction with orgasm versus 47% in the placebo cohort. The mean change in score for overall satisfaction with orgasm in the RJ101 group was statistically significant (P = .007) compared to placebo. CONCLUSION: The application of RJ101 to the NAC 30 minutes prior to sexual activity can improve orgasmic strength, pleasure, and satisfaction.


Assuntos
Agonistas de Receptores Adrenérgicos alfa 1/administração & dosagem , Mamilos/fisiologia , Norepinefrina/administração & dosagem , Orgasmo/efeitos dos fármacos , Administração Tópica , Adulto , Feminino , Humanos , Pessoa de Meia-Idade , Mamilos/efeitos dos fármacos , Mamilos/inervação , Orgasmo/fisiologia , Satisfação Pessoal , Placebos/administração & dosagem
20.
Microb Pathog ; 138: 103799, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31614192

RESUMO

Salmonella spp. are among the leading pathogens responsible for foodborne illnesses worldwide. Bacterial communities use a quorum sensing (QS) system to control biofilm formation. QS is a cell-to-cell signaling mechanism involving compounds called auto-inducers (AI). Norepinephrine utilizes the same bacterial signaling of AI-3 and serves as a signal of QS. Acid stress is a challenge encountered by microorganisms in food processing environments and in the gastrointestinal tracts of hosts. Thus, adaptation to acidic environments may increase the pathogenicity of the strain. The aim of this study was to evaluate the influence of two concentrations of norepinephrine (100 µM and 250 µM) and acidification (pH 3.0) of the medium on the growth and adhesion of Salmonella Heidelberg strains isolated from poultry sources at 12 °C and 25 °C. Furthermore, three genes associated with the biofilm formation process were detected (adrA, csgD, and sidA). Norepinephrine stimulation did not influence the growth or adhesion of Salmonella Heidelberg strains, regardless of the catecholamine concentration and temperature. On the other hand, the use of acidified medium (pH 3.0) resulted in a significant reduction of growth and a significant increase of S. Heidelberg adhesion at both temperatures, indicating that the acidified medium favors the biofilm formation process. The adrA and sidA genes showed higher detection frequencies than csgD. Experiments analyzing the biofilm production process by S. Heidelberg strains are not common, and further studies are necessary to understand this complex process.


Assuntos
Biofilmes , Concentração de Íons de Hidrogênio , Norepinefrina/farmacologia , Salmonella enterica/crescimento & desenvolvimento , Animais , Proteínas de Bactérias/genética , Biofilmes/efeitos dos fármacos , Biofilmes/crescimento & desenvolvimento , Doenças Transmitidas por Alimentos/microbiologia , Genes Bacterianos , Norepinefrina/administração & dosagem , Aves Domésticas/microbiologia , Percepção de Quorum/efeitos dos fármacos , Percepção de Quorum/genética , Percepção de Quorum/fisiologia , Salmonella enterica/efeitos dos fármacos , Salmonella enterica/genética , Salmonella enterica/metabolismo , Virulência , Fatores de Virulência/genética
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA