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1.
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
2.
Am J Respir Crit Care Med ; 202(6): 830-842, 2020 09 15.
Artigo em Inglês | MEDLINE | ID: mdl-32520577

RESUMO

Rationale: Sepsis is characterized by a dysregulated immune response to infection. Norepinephrine, the cornerstone vasopressor used in septic shock, may contribute to immune dysregulation and impact host defense.Objectives: To investigate effects of norepinephrine and the alternative vasopressor vasopressin on the immune response and host defense.Methods: Leukocytes from six to nine donors were stimulated in the presence or absence of norepinephrine and vasopressin. A total of 190 C57BL/6J mice received a continuous infusion of norepinephrine or vasopressin via microosmotic pumps and were challenged with LPS or underwent cecal ligation and puncture. Thirty healthy volunteers were randomized to a 5-hour infusion of norepinephrine, vasopressin, or saline and intravenously challenged with LPS. The relationship between the norepinephrine infusion rate and the use of ß-blockers and plasma cytokines was assessed in 195 patients with septic shock.Measurements and Main Results: Norepinephrine attenuated the production of proinflammatory mediators and reactive oxygen species and augmented antiinflammatory IL-10 production both in vitro and in LPS-challenged mice. Norepinephrine infusion during cecal ligation and puncture resulted in increased bacterial dissemination to the spleen, liver, and blood. In LPS-challenged volunteers, norepinephrine enhanced plasma IL-10 concentrations and attenuated the release of the proinflammatory cytokine IFN-γ-induced protein 10. Vasopressin exerted no immunomodulatory effects across these experimental setups. In patients, higher norepinephrine infusion rates were correlated with a more antiinflammatory cytokine balance, whereas ß-blocker use was associated with a more proinflammatory cytokine balance.Conclusions: Norepinephrine dysregulates the immune response in mice and humans and compromises host defense. Therefore, it may significantly contribute to sepsis-induced immunoparalysis, whereas vasopressin does not have untoward immunologic effects.


Assuntos
Imunidade Ativa/efeitos dos fármacos , Norepinefrina/efeitos adversos , Norepinefrina/imunologia , Choque Séptico/tratamento farmacológico , Choque Séptico/imunologia , Vasoconstritores/efeitos adversos , Vasoconstritores/imunologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Animais , Anti-Inflamatórios/efeitos adversos , Anti-Inflamatórios/imunologia , Anti-Inflamatórios/uso terapêutico , Humanos , Masculino , Camundongos Endogâmicos C57BL , Pessoa de Meia-Idade , Modelos Animais , Países Baixos , Norepinefrina/uso terapêutico , Kit de Reagentes para Diagnóstico , Vasoconstritores/uso terapêutico
3.
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
4.
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
5.
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
6.
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
7.
BMJ Case Rep ; 12(12)2019 Dec 02.
Artigo em Inglês | MEDLINE | ID: mdl-31796448

RESUMO

In the perioperative setting, norepinephrine is used to increase blood pressure, an effect mediated mostly via arterial and venous vasoconstriction. Thus, norepinephrine is, allegedly, less likely to cause or worsen left ventricular outflow tract obstruction (LVOTO) than other inotropes. We report a case of norepinephrine-associated dynamic LVOTO and systolic anterior movement in a predisposed patient. This report highlights that unrecognised dynamic LVOTO may worsen shock parameters in patients treated with norepinephrine who have underlying myocardial hypertrophy.


Assuntos
Norepinefrina/efeitos adversos , Vasoconstritores/efeitos adversos , Obstrução do Fluxo Ventricular Externo/induzido quimicamente , Idoso de 80 Anos ou mais , Cardiomiopatia Hipertrófica/complicações , Cardiomiopatia Hipertrófica/terapia , Ecocardiografia Doppler em Cores , Evolução Fatal , Humanos , Masculino , Valva Mitral/fisiopatologia , Norepinefrina/administração & dosagem , Norepinefrina/farmacologia , Vasoconstritores/administração & dosagem , Vasoconstritores/farmacologia
10.
Intensive Care Med ; 45(11): 1503-1517, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31646370

RESUMO

BACKGROUND: Vasopressors are administered to critically ill patients with vasodilatory shock not responsive to volume resuscitation, and less often in cardiogenic shock, and hypovolemic shock. OBJECTIVES: The objectives are to review safety and efficacy of vasopressors, pathophysiology, agents that decrease vasopressor dose, predictive biomarkers, ß1-blockers, and directions for research. METHODS: The quality of evidence was evaluated using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). RESULTS: Vasopressors bind adrenergic: α1, α2, ß1, ß2; vasopressin: AVPR1a, AVPR1B, AVPR2; angiotensin II: AG1, AG2; and dopamine: DA1, DA2 receptors inducing vasoconstriction. Vasopressor choice and dose vary because of patients and physician practice. Adverse effects include excessive vasoconstriction, organ ischemia, hyperglycemia, hyperlactatemia, tachycardia, and tachyarrhythmias. No randomized controlled trials of vasopressors showed a significant difference in 28-day mortality rate. Norepinephrine is the first-choice vasopressor in vasodilatory shock after adequate volume resuscitation. Some strategies that decrease norepinephrine dose (vasopressin, angiotensin II) have not decreased 28-day mortality while corticosteroids have decreased 28-day mortality significantly in some (two large trials) but not all trials. In norepinephrine-refractory patients, vasopressin or epinephrine may be added. A new vasopressor, angiotensin II, may be useful in profoundly hypotensive patients. Dobutamine may be added because vasopressors may decrease ventricular contractility. Dopamine is recommended only in bradycardic patients. There are potent vasopressors with limited evidence (e.g. methylene blue, metaraminol) and novel vasopressors in development (selepressin). CONCLUSIONS: Norepinephrine is first choice followed by vasopressin or epinephrine. Angiotensin II and dopamine have limited indications. In future, predictive biomarkers may guide vasopressor selection and novel vasopressors may emerge.


Assuntos
Choque/tratamento farmacológico , Vasoconstritores/farmacologia , Angiotensina II/efeitos adversos , Angiotensina II/farmacologia , Angiotensina II/uso terapêutico , Estado Terminal/terapia , Dopamina/efeitos adversos , Dopamina/farmacologia , Dopamina/uso terapêutico , Epinefrina/efeitos adversos , Epinefrina/farmacologia , Epinefrina/uso terapêutico , Humanos , Azul de Metileno/efeitos adversos , Azul de Metileno/farmacologia , Azul de Metileno/uso terapêutico , Norepinefrina/efeitos adversos , Norepinefrina/farmacologia , Norepinefrina/uso terapêutico , Fenilefrina/efeitos adversos , Fenilefrina/farmacologia , Fenilefrina/uso terapêutico , Choque/fisiopatologia , Terlipressina/efeitos adversos , Terlipressina/farmacologia , Terlipressina/uso terapêutico , Vasoconstritores/efeitos adversos , Vasoconstritores/uso terapêutico , Vasopressinas/efeitos adversos , Vasopressinas/farmacologia , Vasopressinas/uso terapêutico
11.
Anaesth Crit Care Pain Med ; 38(6): 601-607, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-30935897

RESUMO

BACKGROUND: Prophylactic vasopressors are fundamental during caesarean delivery under spinal anaesthesia. The aim of this work is to compare the efficacy and safety of phenylephrine and norepinephrine when used in variable infusion rate during caesarean delivery. METHODS: A randomised, double-blinded, controlled trial was conducted including mothers scheduled for elective caesarean delivery under spinal anaesthesia. Participants were allocated to two groups norepinephrine group (n = 60), and phenylephrine group (n = 63). Participants received prophylactic vasopressors after spinal block at rate started at 0.05 mcg/kg/min and 0.75 mcg/kg/min respectively. The rate of vasopressor infusion was manually adjusted according to maternal systolic blood pressure. Both groups were compared according to incidence of post-spinal hypotension (the primary outcome), incidence of bradycardia, incidence of reactive hypertension, systolic blood pressure, heart rate, rescue vasopressor consumption, number of physician interventions, and neonatal outcomes. RESULTS: One hundred and twenty-three mothers were available for final analysis. Both groups were comparable in the incidence of post-spinal hypotension (32% versus 30%, P = 0.8). The number of physician intervention was lower in norepinephrine group. The incidence of bradycardia and the incidence of reactive hypertension were potentially lower in norepinephrine group without reaching statistical significance, (13% vs. 21%, P = 0.3) and (12% vs. 24%, P = 0.1). Rescue vasopressor consumption, and neonatal outcomes were comparable between both groups. CONCLUSION: When given in a manually adjusted infusion, norepinephrine effectively maintained maternal SBP during caesarean delivery under spinal anaesthesia with lower number of physician interventions, and likely less incidence of reactive hypertension and bradycardia compared to phenylephrine.


Assuntos
Raquianestesia/efeitos adversos , Cesárea , Hipotensão/prevenção & controle , Complicações Intraoperatórias/prevenção & controle , Norepinefrina/uso terapêutico , Fenilefrina/uso terapêutico , Vasoconstritores/uso terapêutico , Adolescente , Adulto , Bradicardia/epidemiologia , Bradicardia/etiologia , Bradicardia/prevenção & controle , Método Duplo-Cego , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Hipertensão/epidemiologia , Hipertensão/etiologia , Hipertensão/prevenção & controle , Hipotensão/epidemiologia , Hipotensão/etiologia , Incidência , Recém-Nascido , Infusões Intravenosas , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/etiologia , Monitorização Intraoperatória , Norepinefrina/administração & dosagem , Norepinefrina/efeitos adversos , Fenilefrina/administração & dosagem , Fenilefrina/efeitos adversos , Náusea e Vômito Pós-Operatórios/etiologia , Gravidez , Vasoconstritores/administração & dosagem , Adulto Jovem
12.
Rev Bras Ter Intensiva ; 31(1): 15-20, 2019.
Artigo em Português, Inglês | MEDLINE | ID: mdl-30843950

RESUMO

OBJECTIVE: To describe the incidence of clinical and non-clinical events during intrahospital transport of critically ill patients and to analyze the associated risk factors. METHODS: Cohort study with retrospective data collected from October 2016 to October 2017. All cases of intrahospital transport for diagnostic and therapeutic purposes in a large hospital with six adult intensive care units were analyzed, and the adverse events and related risk factors were evaluated. RESULTS: During the study period, 1,559 intrahospital transports were performed with 1,348 patients, with a mean age of 66 ± 17 years and a mean transport time of 43 ± 34 minutes. During transport, 19.8% of the patients were using vasoactive drugs; 13.7% were under sedation; and 10.6% were under mechanical ventilation. Clinical events occurred in 117 transports (7.5%), and non-clinical events occurred in 125 (8.0%) transports. Communication failures were prevalent; however, the multivariate analysis showed that the use of sedatives, noradrenaline and nitroprusside and a transport time greater than 36.5 minutes were associated with adverse clinical events. The use of dobutamine and a transport time greater than 36.5 minutes were associated with non-clinical events. At the end of transport, 98.1% of the patients presented unchanged clinical conditions compared with baseline. CONCLUSION: Intrahospital transport is related to a high incidence of adverse events, and transport time and the use of sedatives and vasoactive drugs were related to these events.


Assuntos
Estado Terminal , Unidades de Terapia Intensiva , Transporte de Pacientes/métodos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Hospitais , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Nitroprussiato/administração & dosagem , Nitroprussiato/efeitos adversos , Norepinefrina/administração & dosagem , Norepinefrina/efeitos adversos , Respiração Artificial/efeitos adversos , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo
13.
Rev. bras. ter. intensiva ; 31(1): 15-20, jan.-mar. 2019. tab
Artigo em Português | LILACS | ID: biblio-1003626

RESUMO

RESUMO Objetivo: Descrever a incidência de eventos clínicos e não clínicos durante o transporte intra-hospitalar de pacientes críticos e analisar os fatores de risco associados. Métodos: Estudo de coorte, com coleta retrospectiva, no período de outubro de 2016 a outubro de 2017, tendo sido analisados todos os transportes intra-hospitalares para fins diagnósticos e terapêuticos em hospital de grande porte, que contava com seis unidades de terapia intensiva adulto, sendo avaliados os eventos adversos e os fatores de risco relacionados. Resultados: No período, foram realizados 1.559 transportes intra-hospitalares, em 1.348 pacientes, com média de idade de 66 ± 17 anos, tempo médio de transporte de 43 ± 34 minutos. Durante o transporte, 19,8% dos pacientes estavam em uso de drogas vasoativas; 13,7% em uso de sedativos e 10,6% estavam sob ventilação mecânica. Eventos clínicos ocorreram em 117 transportes (7,5%) e não clínicos em 125 transportes (8,0%). Falhas de comunicação foram prevalentes, no entanto, aplicando-se análise multivariada, uso de sedativos, noradrenalina e nitroprussiato, e o tempo de transporte maior que 36,5 minutos estiveram associados a eventos adversos clínicos. Uso de dobutamina e tempo de transporte superior a 36,5 minutos estiveram associados a eventos não clínicos. Ao final do transporte, 98,1% dos pacientes apresentaram condições clínicas inalteradas em relação ao seu estado basal. Conclusão: Transportes intra-hospitalares estão relacionados à alta incidência de eventos adversos; o tempo de transporte e a utilização de sedativos e drogas vasoativas estiveram relacionados a esses eventos.


ABSTRACT Objective: To describe the incidence of clinical and non-clinical events during intrahospital transport of critically ill patients and to analyze the associated risk factors. Methods: Cohort study with retrospective data collected from October 2016 to October 2017. All cases of intrahospital transport for diagnostic and therapeutic purposes in a large hospital with six adult intensive care units were analyzed, and the adverse events and related risk factors were evaluated. Results: During the study period, 1,559 intrahospital transports were performed with 1,348 patients, with a mean age of 66 ± 17 years and a mean transport time of 43 ± 34 minutes. During transport, 19.8% of the patients were using vasoactive drugs; 13.7% were under sedation; and 10.6% were under mechanical ventilation. Clinical events occurred in 117 transports (7.5%), and non-clinical events occurred in 125 (8.0%) transports. Communication failures were prevalent; however, the multivariate analysis showed that the use of sedatives, noradrenaline and nitroprusside and a transport time greater than 36.5 minutes were associated with adverse clinical events. The use of dobutamine and a transport time greater than 36.5 minutes were associated with non-clinical events. At the end of transport, 98.1% of the patients presented unchanged clinical conditions compared with baseline. Conclusion: Intrahospital transport is related to a high incidence of adverse events, and transport time and the use of sedatives and vasoactive drugs were related to these events.


Assuntos
Humanos , Masculino , Feminino , Idoso , Idoso de 80 Anos ou mais , Transporte de Pacientes/métodos , Estado Terminal , Unidades de Terapia Intensiva , Respiração Artificial/efeitos adversos , Respiração Artificial/estatística & dados numéricos , Fatores de Tempo , Nitroprussiato/administração & dosagem , Nitroprussiato/efeitos adversos , Norepinefrina/administração & dosagem , Norepinefrina/efeitos adversos , Análise Multivariada , Estudos Retrospectivos , Fatores de Risco , Estudos de Coortes , Hospitais , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Pessoa de Meia-Idade
14.
J Thromb Haemost ; 17(4): 657-665, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30762945

RESUMO

Essentials Strategies to improve platelet function may reduce excessive bleeding during cardiac surgery. Patients were randomized to standard care or standard care + noradrenaline infusion. Low-dose noradrenaline improved intraoperative platelet aggregation and clot formation. Noradrenaline may be considered to improve intraoperative hemostasis during cardiac surgery. SUMMARY: Background New approaches to prevent bleeding complications during cardiac surgery are needed. Objective To investigate if noradrenaline (NA) enhances platelet aggregation in patients undergoing coronary artery bypass grafting (CABG). Patients/Methods Twenty-four patients undergoing coronary artery bypass grafting (CABG) were included in a prospective parallel-group randomized study. All patients but one were treated with acetylsalicylic acid (ASA). In the treatment group (n = 12), mean arterial blood pressure (MAP) was maintained at pre-induction levels by NA infusion. In the control group (n = 12), NA was administered only if MAP decreased below 60 mmHg. Platelet aggregation (impedance aggregometry with ADP, arachidonic acid [AA] and thrombin-receptor activating peptide [TRAP] as initiators) and clot formation (clotting time, clot formation time and maximum clot firmness by EXTEM, INTEM and FIBTEM tests with thromboelastometry) were assessed before and 50 min after anesthesia induction (before cardiopulmonary bypass was initiated). Results All patients in the treatment group received NA (median dose after 50 min 0.09 (range 0-0.26) µg kg-1  min-1 ). Four patients in the control group also received NA (0.03-0.12 µg kg-1  min-1 ). There were differences between the treatment group and the control group in ADP- and AA-induced aggregation changes (ADP, +16 [25th-75th percentiles, 5-26] vs. -7 [-19 to -1] U; AA, +12 [-4 to 16] vs. -9 [-13 to 1] U). INTEM maximum clot firmness increased in the treatment group but not in the control group. Conclusion Infusion of clinically relevant doses of NA enhanced platelet aggregation and clot firmness in ASA-treated CABG patients. NA infusion is hence a potential new method to acutely improve platelet reactivity in patients on antiplatelet therapy undergoing surgery.


Assuntos
Aspirina/administração & dosagem , Perda Sanguínea Cirúrgica/prevenção & controle , Ponte de Artéria Coronária , Hemostáticos/administração & dosagem , Cuidados Intraoperatórios , Norepinefrina/administração & dosagem , Inibidores da Agregação de Plaquetas/administração & dosagem , Agregação Plaquetária/efeitos dos fármacos , Idoso , Aspirina/efeitos adversos , Ponte de Artéria Coronária/efeitos adversos , Esquema de Medicação , Feminino , Hemostáticos/efeitos adversos , Humanos , Infusões Parenterais , Cuidados Intraoperatórios/efeitos adversos , Masculino , Pessoa de Meia-Idade , Norepinefrina/efeitos adversos , Inibidores da Agregação de Plaquetas/efeitos adversos , Estudos Prospectivos , Suécia , Fatores de Tempo , Resultado do Tratamento
15.
Ugeskr Laeger ; 181(7)2019 Feb 11.
Artigo em Dinamarquês | MEDLINE | ID: mdl-30777590

RESUMO

In this case report, we present a 28-year-old woman who was admitted to a neuro-intensive care unit with sub-arachnoid haemorrhage. She was intubated and haemodynamically unstable. Over five days the need for norepinephrine reached the level of 1.2 µg/kg/min to insure a sufficient cerebral perfusion pressure. Epinephrine and vasopressin were without effect in raising the blood pressure. On suspicion of tachyphylaxis the norepinephrine infusion was stopped, and no decline in blood pressure was observed. After two days without use of any vasopressor agents, the efficacy of norepinephrine returned to normal.


Assuntos
Circulação Cerebrovascular/efeitos dos fármacos , Hemorragia Subaracnóidea/tratamento farmacológico , Taquifilaxia , Vasoconstritores/efeitos adversos , Vasopressinas/efeitos adversos , Adulto , Pressão Sanguínea/efeitos dos fármacos , Epinefrina/efeitos adversos , Epinefrina/uso terapêutico , Feminino , Humanos , Norepinefrina/efeitos adversos , Norepinefrina/uso terapêutico , Hemorragia Subaracnóidea/fisiopatologia , Vasoconstritores/uso terapêutico , Vasopressinas/uso terapêutico
16.
J Intensive Care Med ; 34(9): 761-765, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28750598

RESUMO

RATIONALE: Vasopressors such as norepinephrine are first line for support of mean arterial pressure (MAP) in the management of septic shock. Their use, however, is commonly associated with many adverse events. These detriments frequently trigger the use of alternative, noncatecholamine therapies, including vasopressin. Vasopressin deficiency is a known physiologic consequence of septic shock, and while guidelines recommend vasopressin in addition to norepinephrine, no consensus exists on the duration of deficiency or ideal time of cessation. Studies have suggested that vasopressin discontinuation prior to other vasopressors may lead to hypotension; however, data are limited. This study evaluates the optimal sequence for the discontinuation of vasopressin therapy in septic shock. METHODS: This was a 1-year retrospective study of 152 patients admitted to the medical intensive care unit (ICU) with septic shock who received concurrent norepinephrine and vasopressin for vasoactive support. Patients were excluded if death occurred on vasopressors, within 24 hours after discontinuation of vasopressors, or within 48 hours of ICU admission. The primary outcome of hemodynamic instability included incidence of hypotension after vasopressor discontinuation (2 consecutive MAPs < 60 mm Hg), fluid bolus administration, greater than 0.05 µg/kg/min increase in norepinephrine requirements, or addition of an alternative vasopressor. Secondary outcomes included time to hypotension, total vasopressor duration, arrhythmias, mortality, and length of stay. RESULTS: Ninety-one patients met exclusion criteria, resulting in 61 patients for evaluation. Vasopressin was the first vasoactive therapy to be discontinued in 19 patients and last in 42 patients. Baseline characteristics and the use of potentially confounding treatments known to effect MAP were similar between groups. Discontinuation of vasopressin first was associated with a significant increase in hemodynamic instability (74% vs 16.7%, P < .01), with a shorter time to hemodynamic instability (5 vs 15 hours, P < .01). Secondary outcomes were similar. CONCLUSION: Vasopressin discontinuation prior to cessation of norepinephrine infusion was associated with an increased risk of hemodynamic instability.


Assuntos
Cuidados Críticos/métodos , Hemodinâmica/efeitos dos fármacos , Norepinefrina , Choque Séptico , Vasopressinas , Suspensão de Tratamento , Feminino , Humanos , Hipotensão/diagnóstico , Hipotensão/etiologia , Masculino , Pessoa de Meia-Idade , Norepinefrina/administração & dosagem , Norepinefrina/efeitos adversos , Avaliação de Processos e Resultados em Cuidados de Saúde , Estudos Retrospectivos , Choque Séptico/tratamento farmacológico , Choque Séptico/fisiopatologia , Estados Unidos/epidemiologia , Vasoconstritores/administração & dosagem , Vasoconstritores/efeitos adversos , Vasopressinas/administração & dosagem , Vasopressinas/efeitos adversos
17.
J Med Microbiol ; 68(1): 31-40, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30516469

RESUMO

PURPOSE: Acinetobacter baumannii is a major cause of multidrug-resistant nosocomial infections. The characteristics of A. baumannii at two hospitals in a city in Central Brazil are described by analysing the phenotypes and molecular profiles of isolates recovered from 87 patients. METHODOLOGY: The isolates were identified and their antimicrobial susceptibility was evaluated using the the Bact/Alert 3D and Vitek2 methods. Patients' clinical data were obtained from medical files. Genes associated with resistance to carbapenems were analysed by multilocus sequence typing, clinical and bacteriological variables were analysed by descriptive statistics, and logistic models were generated to adjust the associations. RESULTS: Sixty-four (73.5 %) out of 87 A. baumannii isolates analysed were from patients in intensive care. The mortality rate was 43.7 %. Eighty (91.9 %) isolates were resistant to imipenem and 86 were susceptible to colistin (98.8 %). The blaOXA-23 gene (78.2 %) and its upstream insertion ISAba1 (55.2 %) were predominant, followed by blaOXA-24 (55.2 %) and blaOXA-143 (28.7 %). The blaOXA-23 gene and ISAba1 were independently associated with resistance to imipenem (P<0.05). There were 13 different sequence types (STs) among the 35 isolates. ST1 (nine; 25.7 %), ST162 (eight; 22.8 %) and ST730 (six; 17.1 %) were the most common, and four new STs were identified. The isolates were grouped into five clonal complexes (CC1, CC15, CC79, CC108 and CC162) plus a singleton using eburst. CONCLUSION: Respiratory infection, age >60 years and use of noradrenaline were factors associated with fatality. ST730 (CC79) was associated with higher mortality (P<0.05) and ST162 (CC162) was associated with increased survival probability (P<0.05).


Assuntos
Infecções por Acinetobacter/microbiologia , Acinetobacter baumannii/genética , Carbapenêmicos/farmacologia , Infecção Hospitalar/microbiologia , Farmacorresistência Bacteriana Múltipla , Infecções Respiratórias/microbiologia , Infecções por Acinetobacter/epidemiologia , Infecções por Acinetobacter/mortalidade , Acinetobacter baumannii/efeitos dos fármacos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/farmacologia , Proteínas de Bactérias/genética , Brasil/epidemiologia , Criança , Pré-Escolar , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/mortalidade , Feminino , Variação Genética , Hospitais , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Epidemiologia Molecular , Norepinefrina/efeitos adversos , Infecções Respiratórias/epidemiologia , Infecções Respiratórias/mortalidade , Adulto Jovem , beta-Lactamases/genética
18.
J Cell Biochem ; 120(6): 9345-9355, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30520144

RESUMO

Pulmonary arterial hypertension (PAH) is a progressive disease of the pulmonary vasculature characterized by excessive proliferation of pulmonary artery smooth muscle cells (PASMCs). Some studies have demonstrated the sympathetic nervous system is activated in PAH and norepinephrine (NE) released is closely linked with its activation. However, the subtypes of adrenoreceptor (AR) and the downstream molecular cascades which are involved in the proliferation of PASMCs are still unclear. In this study, adult male Wistar rats were exposed to chronic hypoxia and PASMCs were cultured in hypoxic condition. Significant upregulation of α1A -AR was identified by Western blot analysis or immunofluorescence in all of the pulmonary arteries, lung tissues, and cell hypoxic models. Western blot analysis, flow cytometry, and immunofluorescence were applied to detect the roles of α1A -AR in NE mediated proliferation of PASMCs. We revealed 5-methylurapidil (5-MU) reversed NE-induced upregulation of PCNA, CyclinA and CyclinE, more cells from G0 /G1 phase to G2 /M+S phase, enhancement of the microtubule formation. In addition, we found calcium/calmodulin(CaM)-dependent protein kinase type II (CaMKII) pathway was involved in α1A -AR-mediated cell proliferation. [Ca2+ ]i measurements showed that an increase of [Ca2+ ]i caused by NE or/and hypoxia could be blocked by 5-MU in PASMCs. Western blot analysis results demonstrated the augmentation of CaMKII phosphorylation level was caused by hypoxia or NE in pulmonary arteries, lung tissues, and PASMCs. KN62 attenuated NE-induced proliferation of PASMCs under normoxia and hypoxia. In conclusion, those results suggested NE which stimulated α1A -AR-mediated the proliferation of PASMCs, which may be via the CaMKII pathway, and it could be used as a novel treatment strategy in PAH.


Assuntos
Proteína Quinase Tipo 2 Dependente de Cálcio-Calmodulina/genética , Hipóxia Celular/genética , Hipertensão Arterial Pulmonar/genética , Receptores Adrenérgicos alfa 1/genética , Animais , Movimento Celular/efeitos dos fármacos , Proliferação de Células/efeitos dos fármacos , Modelos Animais de Doenças , Humanos , Miócitos de Músculo Liso , Norepinefrina/efeitos adversos , Fosforilação , Hipertensão Arterial Pulmonar/induzido quimicamente , Hipertensão Arterial Pulmonar/patologia , Artéria Pulmonar/efeitos dos fármacos , Artéria Pulmonar/metabolismo , Artéria Pulmonar/patologia , Ratos , Transdução de Sinais/efeitos dos fármacos , Sistema Nervoso Simpático/efeitos dos fármacos , Sistema Nervoso Simpático/metabolismo
20.
Biosci Rep ; 38(6)2018 12 21.
Artigo em Inglês | MEDLINE | ID: mdl-30355657

RESUMO

Aims: Acute increases in left ventricular end diastolic pressure (LVEDP) can induce pulmonary edema (PE). The mechanism(s) for this rapid onset edema may involve more than just increased fluid filtration. Lung endothelial cell permeability is regulated by pressure-dependent activation of nitric oxide synthase (NOS). Herein, we demonstrate that pressure-dependent NOS activation contributes to vascular failure and PE in a model of acute heart failure (AHF) caused by hypertension.Methods and results: Male Sprague-Dawley rats were anesthetized and mechanically ventilated. Acute hypertension was induced by norepinephrine (NE) infusion and resulted in an increase in LVEDP and pulmonary artery pressure (Ppa) that were associated with a rapid fall in PaO2, and increases in lung wet/dry ratio and injury scores. Heart failure (HF) lungs showed increased nitrotyrosine content and ROS levels. L-NAME pretreatment mitigated the development of PE and reduced lung ROS concentrations to sham levels. Apocynin (Apo) pretreatment inhibited PE. Addition of tetrahydrobiopterin (BH4) to AHF rats lung lysates and pretreatment of AHF rats with folic acid (FA) prevented ROS production indicating endothelial NOS (eNOS) uncoupling.Conclusion: Pressure-dependent NOS activation leads to acute endothelial hyperpermeability and rapid PE by an increase in NO and ROS in a model of AHF. Acute increases in pulmonary vascular pressure, without NOS activation, was insufficient to cause significant PE. These results suggest a clinically relevant role of endothelial mechanotransduction in the pathogenesis of AHF and further highlights the concept of active barrier failure in AHF. Therapies targetting the prevention or reversal of endothelial hyperpermeability may be a novel therapeutic strategy in AHF.


Assuntos
Insuficiência Cardíaca/enzimologia , Hipertensão Pulmonar/enzimologia , Mecanotransdução Celular , Óxido Nítrico Sintase/genética , Edema Pulmonar/enzimologia , Animais , Biopterina/administração & dosagem , Biopterina/análogos & derivados , Pressão Sanguínea/efeitos dos fármacos , Permeabilidade Capilar/efeitos dos fármacos , Modelos Animais de Doenças , Células Endoteliais/enzimologia , Células Endoteliais/patologia , Ácido Fólico/administração & dosagem , Insuficiência Cardíaca/fisiopatologia , Humanos , Hipertensão Pulmonar/induzido quimicamente , Hipertensão Pulmonar/patologia , Pulmão/efeitos dos fármacos , Pulmão/metabolismo , Pulmão/patologia , NG-Nitroarginina Metil Éster/administração & dosagem , Óxido Nítrico/metabolismo , Óxido Nítrico Sintase/metabolismo , Norepinefrina/efeitos adversos , Artéria Pulmonar/efeitos dos fármacos , Artéria Pulmonar/patologia , Edema Pulmonar/metabolismo , Edema Pulmonar/patologia , Ratos , Espécies Reativas de Oxigênio/metabolismo , Tirosina/administração & dosagem , Tirosina/análogos & derivados
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