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2.
Am J Respir Crit Care Med ; 202(9): 1253-1261, 2020 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-32609011

RESUMO

Rationale: Exogenous angiotensin II increases mean arterial pressure in patients with catecholamine-resistant vasodilatory shock (CRVS). We hypothesized that renin concentrations may identify patients most likely to benefit from such therapy.Objectives: To test the kinetic changes in renin concentrations and their prognostic value in patients with CRVS.Methods: We analyzed serum samples from patients enrolled in the ATHOS-3 (Angiotensin II for the Treatment of High-Output Shock) trial for renin, angiotensin I, and angiotensin II concentrations before the start of administration of angiotensin II or placebo and after 3 hours.Measurements and Main Results: Baseline serum renin concentration (normal range, 2.13-58.78 pg/ml) was above the upper limits of normal in 194 of 255 (76%) study patients with a median renin concentration of 172.7 pg/ml (interquartile range [IQR], 60.7 to 440.6 pg/ml), approximately threefold higher than the upper limit of normal. Renin concentrations correlated positively with angiotensin I/II ratios (r = 0.39; P < 0.001). At 3 hours after initiation of angiotensin II therapy, there was a 54.3% reduction (IQR, 37.9% to 66.5% reduction) in renin concentration compared with a 14.1% reduction (IQR, 37.6% reduction to 5.1% increase) with placebo (P < 0.0001). In patients with renin concentrations above the study population median, angiotensin II significantly reduced 28-day mortality to 28 of 55 (50.9%) patients compared with 51 of 73 patients (69.9%) treated with placebo (unstratified hazard ratio, 0.56; 95% confidence interval, 0.35 to 0.88; P = 0.012) (P = 0.048 for the interaction).Conclusions: The serum renin concentration is markedly elevated in CRVS and may identify patients for whom treatment with angiotensin II has a beneficial effect on clinical outcomes.Clinical trial registered with www.clinicaltrials.gov (NCT02338843).


Assuntos
Angiotensina II/sangue , Catecolaminas/efeitos adversos , Catecolaminas/uso terapêutico , Renina/sangue , Choque/sangue , Choque/tratamento farmacológico , Vasoconstritores/efeitos adversos , Vasoconstritores/uso terapêutico , Idoso , Biomarcadores/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes
3.
Am J Respir Crit Care Med ; 202(10): 1407-1418, 2020 11 15.
Artigo em Inglês | MEDLINE | ID: mdl-32614244

RESUMO

Rationale: There are no prospective observational studies exploring the relationship between relative hypotension and adverse kidney-related outcomes among critically ill patients with shock.Objectives: To investigate the magnitude of relative hypotension during vasopressor support among critically ill patients with shock and to determine whether such relative hypotension is associated with new significant acute kidney injury (AKI) or major adverse kidney events (MAKE) within 14 days of vasopressor initiation.Methods: At seven multidisciplinary ICUs, 302 patients, aged ≥40 years and requiring ≥4 hours of vasopressor support for nonhemorrhagic shock, were prospectively enrolled. We assessed the time-weighted average of the mean perfusion pressure (MPP) deficit (i.e., the percentage difference between patients' preillness basal MPP and achieved MPP) during vasopressor support and the percentage of time points with an MPP deficit > 20% as key exposure variables. New significant AKI was defined as an AKI-stage increase of two or more (Kidney Disease: Improving Global Outcome creatinine-based criteria).Measurements and Main Results: The median MPP deficit was 19% (interquartile range, 13-25), and 54% (interquartile range, 19-82) of time points were spent with an MPP deficit > 20%. Seventy-three (24%) patients developed new significant AKI; 86 (29%) patients developed MAKE. For every percentage increase in the time-weighted average MPP deficit, multivariable-adjusted odds of developing new significant AKI and MAKE increased by 5.6% (95% confidence interval, 2.2-9.1; P = 0.001) and 5.9% (95% confidence interval, 2.2-9.8; P = 0.002), respectively. Likewise, for every one-unit increase in the percentage of time points with an MPP deficit > 20%, multivariable-adjusted odds of developing new significant AKI and MAKE increased by 1.2% (0.3-2.2; P = 0.008) and 1.4% (0.4-2.4; P = 0.004), respectively.Conclusions: Vasopressor-treated patients with shock are often exposed to a significant degree and duration of relative hypotension, which is associated with new-onset, adverse kidney-related outcomes.Study registered with Australian New Zealand Clinical Trial Registry (ACTRN 12613001368729).


Assuntos
Lesão Renal Aguda/induzido quimicamente , Lesão Renal Aguda/terapia , Estado Terminal/terapia , Hipotensão/induzido quimicamente , Hipotensão/terapia , Choque/complicações , Vasoconstritores/efeitos adversos , Idoso , Austrália , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Choque/tratamento farmacológico , Vasoconstritores/uso terapêutico
4.
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
6.
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
7.
Plast Reconstr Surg ; 146(1): 54e-60e, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32590653

RESUMO

BACKGROUND: The wide-awake local anesthesia no tourniquet (WALANT) technique in hand surgery is gaining popularity. The authors aimed to prospectively analyze the frequency and type of arrhythmias in patients undergoing hand surgery under local anesthesia and to examine whether the addition of adrenaline affects their incidence. METHODS: Adult patients undergoing hand surgery under local anesthesia were randomized into two groups: group 1, local anesthesia with lidocaine and tourniquet; and group 2, local anesthesia with lidocaine and adrenaline (WALANT). Patients with a history of arrhythmias were excluded. Patients were connected to Holter electrocardiographic monitoring before surgery and up until discharge. The records were blindly compared between the groups regarding types of arrhythmias, and frequency and timing relative to injection and tourniquet inflation. RESULTS: One hundred two patients were included between August of 2018 and August of 2019 (age, 59.7 ± 13.6 years; 71 percent women; 51 in each group). No major arrhythmia (ventricular tachycardia, ventricular fibrillation, atrial fibrillation) or arrhythmia-related symptoms were recorded for either group. Minor arrhythmias (including atrial premature beats, ventricular premature beats, and atrial tachycardia) were recorded in 68 patients (66.6 percent), with no statistical difference between the groups. There were three patients with minor arrhythmias during inflation of the tourniquet. Patients in the adrenaline group had 2 percent sinus tachycardia during injection and 4 percent asymptomatic bradyarrhythmias. These findings do not require any further treatment. CONCLUSIONS: The authors' results show that hand operations using WALANT technique in patients with no history of arrhythmia are safe and are not arrhythmogenic; therefore, there is no need for routine perioperative continuous electrocardiographic monitoring. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.


Assuntos
Agonistas Adrenérgicos beta/efeitos adversos , Anestesia Local/métodos , Arritmias Cardíacas , Epinefrina/efeitos adversos , Mãos/cirurgia , Vasoconstritores/efeitos adversos , Adulto , Idoso , Anestesia Local/efeitos adversos , Arritmias Cardíacas/induzido quimicamente , Arritmias Cardíacas/epidemiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
8.
J Trauma Acute Care Surg ; 88(6): 783-788, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32459446

RESUMO

BACKGROUND: Delayed graft function (DGF), the need for dialysis in the first week following kidney transplant, affects approximately one quarter of deceased-donor kidney transplant recipients. Donor demographics, donor serum creatinine, and graft cold ischemia time are associated with DGF. However, there is no consensus on the optimal management of hemodynamic instability in organ donors after brain death (DBDs). Our objective was to determine the relationship between vasopressor selection during donor management and the development of DGF. METHODS: Prospective observational data, including demographic and critical care parameters, were collected for all DBDs managed by 17 organ procurement organizations from nine Organ Procurement and Transplantation Network Regions between 2012 and 2018. Recipient outcome data were linked with donor data through donor identification numbers. Donor critical care parameters, including type of vasopressor and doses, were recorded at three standardized time points during donor management. The analysis included only donors who received at least one vasopressor at all three time points. Vasopressor doses were converted to norepinephrine equivalent doses and analyzed as continuous variables. Univariate analyses were conducted to determine the association between donor variables and DGF. Results were adjusted for known predictors of DGF using binary logistic regression. RESULTS: Complete data were available for 5,554 kidney transplant recipients and 2,985 DBDs. On univariate analysis, donor serum creatinine, donor age, donor subtype, kidney donor profile index, graft cold ischemia time, phenylephrine dose, and dopamine dose were associated with DGF. After multivariable analysis, increased donor serum creatinine, donor age, kidney donor profile index, graft cold ischemia time, and phenylephrine dose remained independent predictors of DGF. CONCLUSION: Higher doses of phenylephrine were an independent predictor of DGF. With the exception of phenylephrine, the selection and dose of vasopressor during donor management did not predict the development of DGF. LEVEL OF EVIDENCE: Prognostic study, Level III.


Assuntos
Morte Encefálica/fisiopatologia , Cuidados Críticos/estatística & dados numéricos , Função Retardada do Enxerto/epidemiologia , Transplante de Rim/efeitos adversos , Rim/efeitos dos fármacos , Vasoconstritores/efeitos adversos , Adulto , Fatores Etários , Isquemia Fria/efeitos adversos , Cuidados Críticos/métodos , Função Retardada do Enxerto/etiologia , Função Retardada do Enxerto/prevenção & controle , Relação Dose-Resposta a Droga , Feminino , Humanos , Rim/irrigação sanguínea , Rim/fisiopatologia , Transplante de Rim/métodos , Transplante de Rim/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Fenilefrina/administração & dosagem , Fenilefrina/efeitos adversos , Estudos Prospectivos , Medição de Risco , Obtenção de Tecidos e Órgãos/métodos , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Vasoconstritores/administração & dosagem , Adulto Jovem
9.
Curr Opin Anaesthesiol ; 33(3): 291-298, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32371631

RESUMO

PURPOSE OF REVIEW: Hypotension during cesarean section remains a frequent complication of spinal anesthesia and is associated with adverse maternal and fetal events. RECENT FINDINGS: Despite ongoing research, no single measure for sufficient treatment of spinal-induced hypotension was identified so far. Current literature discusses the efficacy of low-dose spinal anesthesia, timing and solutions for adequate fluid therapy and various vasopressor regimens. Present guidelines favor the use of phenylephrine over ephedrine because of decreased umbilical cord pH values, while norepinephrine is discussed as a probable superior alternative with regard to maternal bradycardia, although supporting data is limited. Alternative pharmacological approaches, such as 5HT3-receptor antagonists and physical methods may be taken into consideration to further improve hemodynamic stability. SUMMARY: Current evidence favors a combined approach of low-dose spinal anesthesia, adequate fluid therapy and vasopressor support to address maternal spinal-induced hypotension. As none of the available vasopressors is associated with relevantly impaired maternal and fetal outcomes, none of them should be abandoned from obstetric practice. Rapid crystalloid co-loading is of equivalent efficacy as compared with colloids and should be preferred because of a more favorable risk profile.


Assuntos
Anestesia Obstétrica/efeitos adversos , Raquianestesia/efeitos adversos , Cesárea , Hipotensão/induzido quimicamente , Vasoconstritores/efeitos adversos , Feminino , Humanos , Doença Iatrogênica , Gravidez , Simpatectomia
10.
J Card Surg ; 35(6): 1228-1236, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32333454

RESUMO

BACKGROUND: Cardiac surgery using cardiopulmonary bypass is a well-established procedure. However, up to 20% to 30% of patients require high dose vasopressor or inotropic support following surgery, enhancing the risk of organ dysfunction and impacting mortality. Nonalcoholic fatty liver disease (NAFLD) is a frequent finding in these patients and may be involved in the pathophysiology of vasoplegia and cardiac failure. METHODS: Retrospective analysis of 463 patients undergoing elective cardiac surgery in 2014 at our institution. NAFLD was defined using the NAFLD fibrosis score and the vasoactive-inotropy score was used to determine postoperative vasopressor and inotropic dependency. RESULTS: Patients with NAFLD more often presented with high vasopressor or inotropic support compared to patients without NAFLD, resulting in significant differences after 6 hours (n = 20 [27.0%] of 74 patients), 12 hours (n = 20 [27.0%] of 74 patients), and on the first postoperative day (n = 12 [16.4%] of 73 patients) of intensive care unit (ICU) treatment. Multivariate analysis revealed time of catecholamine application (P = .001), preoperative left ventricular ejection fraction (P = .001), type of surgery (P = .001), model of endstage liver disease on hospital admission (P = .002), pre-existing pulmonary hypertension (P = .004) and NAFLD-time interaction (P = .05) as independent predictors of high vasopressor and inotropic support. Patients with NAFLD had higher degrees of extrahepatic organ dysfunction, were more dependent on hemodialysis, spent more days in the ICU and within the hospital. Patients with NAFLD and high catecholamine support had the highest mortality rates among the study population. CONCLUSIONS: NAFLD is a common finding in elective cardiac surgery patients. Anesthesiologists and intensivists should be sensitive for the specific risk profile of this population.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Ponte Cardiopulmonar , Catecolaminas/administração & dosagem , Catecolaminas/efeitos adversos , Hepatopatias/etiologia , Complicações Pós-Operatórias/etiologia , Vasoconstritores/administração & dosagem , Vasoconstritores/efeitos adversos , Idoso , Procedimentos Cirúrgicos Cardíacos/mortalidade , Cardiotônicos/administração & dosagem , Cardiotônicos/efeitos adversos , Feminino , Insuficiência Cardíaca/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Hepatopatia Gordurosa não Alcoólica/complicações , Período Pós-Operatório , Estudos Retrospectivos , Risco , Volume Sistólico , Vasoplegia/etiologia , Função Ventricular Esquerda
11.
Cochrane Database Syst Rev ; 4: CD004198, 2020 04 06.
Artigo em Inglês | MEDLINE | ID: mdl-32251534

RESUMO

BACKGROUND: Sickle cell disease comprises a group of genetic haemoglobin disorders. The predominant symptom associated with sickle cell disease is pain resulting from the occlusion of small blood vessels by abnormally 'sickle-shaped' red blood cells. There are other complications, including chronic organ damage and prolonged painful erection of the penis, known as priapism. Severity of sickle cell disease is variable, and treatment is usually symptomatic. Priapism affects up to half of all men with sickle cell disease, however, there is no consistency in treatment. We therefore need to know the best way of treating this complication in order to offer an effective interventional approach to all affected individuals. This is an update of a previously published review. OBJECTIVES: To assess the benefits and risks of different treatments for stuttering (repeated short episodes) and fulminant (lasting for six hours or more) priapism in sickle cell disease. SEARCH METHODS: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Haemoglobinopathies Trials Register, which comprises references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also searched trial registries. Date of the most recent search of the Group's Haemoglobinopathies Trials Register: 09 September 2019. Date of most recent search of trial registries and of Embase: 01 October 2019. SELECTION CRITERIA: All randomised or quasi-randomised controlled trials comparing non-surgical or surgical treatment with placebo or no treatment, or with another intervention for stuttering or fulminant priapism. DATA COLLECTION AND ANALYSIS: The authors independently extracted data and assessed the risk of bias of the trials. MAIN RESULTS: Three trials with 102 participants were identified and met the criteria for inclusion in this review. These trials compared stilboestrol to placebo, sildenafil to placebo and a four-arm trial which compared ephedrine or etilefrine to placebo and ranged in duration from two weeks to six months. All of the trials were conducted in an outpatient setting in Jamaica, Nigeria and the UK. None of the trials measured our first primary outcome, detumescence. However, all three trials reported on the reduction in frequency of stuttering priapism, our second primary outcome; and from the evidence included in this review, we are uncertain whether stilboestrol, etilefrine or ephedrine reduce the frequency of stuttering priapism as the certainty of the evidence has been assessed as very low. Additionally, we conclude that sildenafil may make little or no difference (low-certainty evidence). Two trials reported on immediate side effects and we are uncertain whether etilefrine or ephedrine reduce the occurrence of these (very low-certainty of evidence) and also conclude that sildenafil may make little or no difference in side effects (low-quality evidence). Given that all of the trials were at risk of bias and all had low participant numbers, we considered the certainty of the evidence to be low to very low. AUTHORS' CONCLUSIONS: There is a lack of evidence for the benefits or risks of the different treatments for both stuttering and fulminant priapism in sickle cell disease. This systematic review has clearly identified the need for well-designed, adequately-powered, multicentre randomised controlled trials assessing the effectiveness of specific interventions for priapism in sickle cell disease.


Assuntos
Anemia Falciforme/complicações , Dietilestilbestrol/uso terapêutico , Estrogênios não Esteroides/uso terapêutico , Priapismo/tratamento farmacológico , Vasoconstritores/uso terapêutico , Adrenérgicos/efeitos adversos , Adrenérgicos/uso terapêutico , Efedrina/efeitos adversos , Efedrina/uso terapêutico , Etilefrina/efeitos adversos , Etilefrina/uso terapêutico , Humanos , Masculino , Priapismo/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Citrato de Sildenafila/uso terapêutico , Taquicardia/induzido quimicamente , Vasoconstritores/efeitos adversos , Adulto Jovem
12.
Orv Hetil ; 161(15): 583-587, 2020 04 01.
Artigo em Húngaro | MEDLINE | ID: mdl-32323522

RESUMO

Introduction: Variceal bleeding is a life-threatening complication of portal hypertension with a six-week mortality rate of approximately 20%. Aim: To analyse whether the changes introduced in the treatment of variceal gastrointestinal haemorrhage in our department affected the mortality rate of these patients. Method: A retrospective method was used to compare the data of patients treated with variceal bleeding in 2014 and 2015. In 2015, two changes were made in the treatment of patients with variceal bleeding: all patients were treated in the subintensive care unit and terlipressin was administered to all patients susceptible to variceal haemorrhage. Bleeding was mitigated by means of sclerotherapy and/or ligation. Significance was calculated using Student's t-test, then we performed logistic regression to find out what treatment factors affect mortality rate. Patients: 2014 vs. 2015 figures ­ number of patients: 24 vs. 30, average age: 59.8 vs. 57.6 years, male (%): 70.8 vs. 66.7. There were no significant differences between the Child­Pugh stages of the two years, p = 0.53. For the analysis we also grouped patients based on whether irrespective of the year of treatment they were administered terlipressin or not. Number of patients: 22 vs. 32, average age: 60.4 vs. 57.4, male (%): 63.6 vs. 70.6. Results: Mortality in 2015 and 2014: 23% and 33%, respectively. Mortality of patients treated with terlipressin: 18.2 vs. 34.4, p = 0.09. Child­Pugh stages had the strongest influence on mortality (stage A vs. B p = 0.05, stage A vs. C p = 0.02). Terlipressin administered in Child­Pugh stage C reduced mortality at a rate bordering on significance (p = 0.055). Conclusion: Despite the comparatively small number of cases, the changes introduced in our department in 2015 in the treatment of variceal gastrointestinal haemorrhages resulted in a significant reduction of hospital mortality rates. Orv Hetil. 2020; 161(15): 583­587.


Assuntos
Varizes Esofágicas e Gástricas/terapia , Hemorragia Gastrointestinal/terapia , Cirrose Hepática/complicações , Terlipressina/uso terapêutico , Vasoconstritores/uso terapêutico , Idoso , Varizes Esofágicas e Gástricas/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Terlipressina/efeitos adversos , Resultado do Tratamento , Varizes/fisiopatologia , Vasoconstritores/efeitos adversos
14.
Ann Pharmacother ; 54(8): 804-814, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32054312

RESUMO

Objective: Commonly used drugs may be dangerous in case of extravasation. The lack of information from health care teams can lead to delays in both diagnosis and treatments. This review aims at alerting health care professionals about drugs and risk factors for extravasation and outlines recommendations for the diagnosis and treatment of extravasation. Data Source: A literature search of MEDLINE/PubMed, Scopus, the Cochrane Library, and Google Scholar was performed from 2000 to December 2019 using the following terms: extravasation, central venous line, peripheral venous line, irritant, and vesicant. Study Selection and Data Extraction: Overall, 140 articles dealing with drug extravasation were considered potentially relevant. Each article was critically appraised independently by 2 authors, leading to the inclusion of 80 relevant studies, guidelines, and reviews. Articles discussing incidents of extravasation in the neonatal and pediatric population of patients were excluded. Data Synthesis: Training of health care teams and writing care protocols are important for an optimal management of extravasations. A prompt consultation should be achieved by a specialist surgeon. The surgical procedure, if necessary, will consist of wound debridement followed by an abundant lavage. Relevance to Patient Care and Clinical Practice: This review discusses the management of drug extravasations according to their mechanism(s) of toxicity on tissues. It highlights the importance of a close monitoring of patients and the training of health care teams likely to face this type of adverse event. Conclusions: Extravasations still contribute to significant morbidity and mortality. A good knowledge of risk factors and the implementation of easily and quickly accessible standardized care protocols are 2 key elements in both prevention and treatment of extravasations.


Assuntos
Extravasamento de Materiais Terapêuticos e Diagnósticos , Vasoconstritores , Extravasamento de Materiais Terapêuticos e Diagnósticos/diagnóstico , Extravasamento de Materiais Terapêuticos e Diagnósticos/etiologia , Extravasamento de Materiais Terapêuticos e Diagnósticos/terapia , Humanos , Concentração Osmolar , Fatores de Risco , Irrigação Terapêutica , Vasoconstritores/administração & dosagem , Vasoconstritores/efeitos adversos , Vasoconstritores/química
15.
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
16.
Trials ; 21(1): 42, 2020 Jan 08.
Artigo em Inglês | MEDLINE | ID: mdl-31915072

RESUMO

BACKGROUND: Sepsis is a health problem of global importance; treatments focus on controlling infection and supporting failing organs. Recent clinical research suggests that intravenous vitamin C may decrease mortality in sepsis. We have designed a randomized controlled trial (RCT) to ascertain the effect of vitamin C on the composite endpoint of death or persistent organ dysfunction at 28 days in patients with sepsis. METHODS: LOVIT (Lessening Organ dysfunction with VITamin C) is a multicenter, parallel-group, blinded (participants, clinicians, study personnel, Steering Committee members, data analysts), superiority RCT (minimum n = 800). Eligible patients have sepsis as the diagnosis for admission to the intensive care unit (ICU) and are receiving vasopressors. Those admitted to the ICU for more than 24 h are excluded. Eligible patients are randomized to high-dose intravenous vitamin C (50 mg/kg every 6 h for 96 h) or placebo. The primary outcome is a composite of death or persistent organ dysfunction (need for vasopressors, invasive mechanical ventilation, or new and persisting renal replacement therapy) at day 28. Secondary outcomes include persistent organ dysfunction-free days to day 28, mortality and health-related quality of life at 6 months, biomarkers of dysoxia, inflammation, infection, endothelial function, and adverse effects (hemolysis, acute kidney injury, and hypoglycemia). Six subgroup analyses are planned. DISCUSSION: This RCT will provide evidence of the effect of high-dose intravenous vitamin C on patient-important outcomes in patients with sepsis. TRIAL REGISTRATION: clinicaltrials.gov, NCT03680274, first posted 21 September 2018.


Assuntos
Antioxidantes/administração & dosagem , Ácido Ascórbico/administração & dosagem , Insuficiência de Múltiplos Órgãos/epidemiologia , Sepse/tratamento farmacológico , Vasoconstritores/administração & dosagem , Lesão Renal Aguda/induzido quimicamente , Lesão Renal Aguda/epidemiologia , Administração Intravenosa , Adulto , Antioxidantes/efeitos adversos , Ácido Ascórbico/efeitos adversos , Ensaios Clínicos Fase III como Assunto , Relação Dose-Resposta a Droga , Quimioterapia Combinada/efeitos adversos , Quimioterapia Combinada/métodos , Feminino , Hemólise/efeitos dos fármacos , Mortalidade Hospitalar , Humanos , Hipoglicemia/induzido quimicamente , Hipoglicemia/epidemiologia , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/etiologia , Insuficiência de Múltiplos Órgãos/prevenção & controle , Qualidade de Vida , Sepse/complicações , Sepse/mortalidade , Resultado do Tratamento , Vasoconstritores/efeitos adversos
17.
Am J Emerg Med ; 38(6): 1297.e1-1297.e3, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31983596

RESUMO

A previously healthy 60-year-old man presented to our emergency department with anaphylactic shock. We initiated fluid resuscitation with Ringer's lactate solution; injected 0.3 mg epinephrine intramuscularly; and administered d-chlorpheniramine maleate 5 mg, famotidine 20 mg, and methylprednisolone 80 mg intravenously. His symptoms resolved within 10 min. Thirty minutes after the epinephrine injection, he complained of sudden chest discomfort. Physical examination provided no evidence of anaphylaxis. The 12-lead electrocardiogram (ECG) showed ST-segment depression on leads II, III, aVF, and V3-6. Transthoracic echocardiography revealed normal ventricular contraction. After administration of 0.3 mg of sublingual nitroglycerin, his chest pain resolved immediately and his ECG normalized. A coronary angiogram showed normal coronary artery perfusion. The next day, his high-sensitivity troponin I was slightly elevated. We suspected that he had myocardial ischemia caused by coronary artery spasm. The symptoms of biphasic reaction of anaphylaxis are inconsistent, and using epinephrine for myocardial ischemia following anaphylaxis may aggravate the condition. Nonetheless, epinephrine is the drug of choice for treating anaphylaxis with critical airway, respiratory, and circulatory compromise. Thus, physicians should not hesitate to use epinephrine for patients who present with life-threatening conditions due to suspected anaphylaxis. Physicians should observe patients closely following epinephrine administration, and if they develop some symptoms, should carefully examine the patients because the treatments of anaphylaxis and myocardial ischemia differs. Physicians should be alert to the risk of myocardial ischemia after treatment of anaphylaxis, especially following epinephrine administration.


Assuntos
Anafilaxia/etiologia , Epinefrina/efeitos adversos , Isquemia Miocárdica/tratamento farmacológico , Anafilaxia/fisiopatologia , Dor no Peito/etiologia , Eletrocardiografia/métodos , Serviço Hospitalar de Emergência/organização & administração , Epinefrina/uso terapêutico , Feminino , Humanos , Pessoa de Meia-Idade , Isquemia Miocárdica/fisiopatologia , Vasoconstritores/efeitos adversos , Vasoconstritores/uso terapêutico
18.
Rev Col Bras Cir ; 46(6): e20192269, 2020.
Artigo em Português, Inglês | MEDLINE | ID: mdl-31967242

RESUMO

Conventionally, the association of local anesthetics with vasoconstrictors is avoided at extremities due to the risk of ischemia. However, recent studies suggest that there is safety in the use of vasoconstrictors at extremities. Thus, we sought to evaluate the effectiveness and safety of vasoconstrictor use combined with local anesthetics in digital nerve block compared to the use of anesthetics without vasoconstrictors, through a systematic review with meta-analysis of randomized clinical trials. Until May 2019 we searched MEDLINE, LILACS, SciELO, ScienceDirect, Scopus, ClinicalTrials.gov, and gray literature databases, without date or language restrictions. The keywords were the following: digital block, vasoconstrictor, and ischemia. We included randomized clinical trials in which there was the use of local anesthetics with associated or not with vasoconstrictors in digital blocks. In the primary variables, the occurrence of ischemic complications and the duration of anesthesia were analysed; in the secondary variables, the need for anesthetic reapplication, bleeding control, and latency were observed. Ten studies were included in this review. The occurrence of ischemia was not observed, regardless of the use of vasoconstrictors or not. The use of vasoconstrictors at a concentration of 1:100,000 or less was associated with longer anesthesia duration (P<0.00001), lower need for anesthetic reapplication (P=0.02), lower need for bleeding control (P=0.00006), and lower latency (P<0.00001). We could conclude that the use of vasoconstrictors associated with local anesthetics in digital block proved to be a safe and effective technique.


Assuntos
Anestésicos Locais/administração & dosagem , Bloqueio Nervoso/métodos , Vasoconstritores/administração & dosagem , Anestésicos Locais/efeitos adversos , Humanos , Bloqueio Nervoso/efeitos adversos , Vasoconstritores/efeitos adversos
19.
Anesth Analg ; 130(1): 187-193, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-30829668

RESUMO

BACKGROUND: Prophylactic IV infusion of phenylephrine has been recommended to prevent hypotension during spinal anesthesia for cesarean delivery. However, the optimal infusion dose is unknown. This study aimed to determine the infusion dose of phenylephrine that would be effective in preventing hypotension in 50% (ED50) and 90% (ED90) of patients when administered as a prophylactic infusion at a fixed rate based on the individual body weight. METHODS: Eighty parturients scheduled for elective cesarean delivery were randomly allocated to receive IV infusion of prophylactic phenylephrine at 0.25, 0.375, 0.5, or 0.625 µg/kg/min (n = 20 per group) started immediately after intrathecal injection of 10 mg hyperbaric bupivacaine and 5 µg sufentanil using a combined spinal-epidural technique. An effective dose was defined by the occurrence of no hypotension (defined as a decrease in systolic blood pressure by ≥20% below baseline and to <90 mm Hg) during the interval from the initiation of spinal anesthesia to delivery of the infant. Values for ED50 and ED90 of prophylactic phenylephrine were calculated using probit analysis. RESULTS: Hypotension occurred in 13/20, 8/20, 2/20, and 1/20 patients in the groups that received phenylephrine infusion at 0.25, 0.375, 0.5, or 0.625 µg/kg/min, respectively. The calculated values for ED50 and ED90 were 0.31 (95% CI, 0.24-0.36) and 0.54 (95% CI, 0.46-0.76) µg/kg/min, respectively. No difference was found in the incidence of adverse effects and neonatal outcomes among groups. CONCLUSIONS: Under the conditions of this study, when phenylephrine was given as a fixed-rate prophylactic infusion during spinal anesthesia for cesarean delivery to prevent hypotension, the values for ED50 and ED90 were 0.31 (95% CI, 0.24-0.36) and 0.54 (95% CI, 0.46-0.76) µg/kg/min, respectively.


Assuntos
Agonistas de Receptores Adrenérgicos alfa 1/administração & dosagem , Anestesia Obstétrica , Raquianestesia , Pressão Sanguínea/efeitos dos fármacos , Cesárea , Hipotensão/prevenção & controle , Parto , Fenilefrina/administração & dosagem , Vasoconstritores/administração & dosagem , Agonistas de Receptores Adrenérgicos alfa 1/efeitos adversos , Anestesia Epidural/efeitos adversos , Raquianestesia/efeitos adversos , Peso Corporal , Cesárea/efeitos adversos , China , Relação Dose-Resposta a Droga , Método Duplo-Cego , Cálculos da Dosagem de Medicamento , Feminino , Humanos , Hipotensão/diagnóstico , Hipotensão/etiologia , Hipotensão/fisiopatologia , Infusões Intravenosas , Fenilefrina/efeitos adversos , Gravidez , Fatores de Tempo , Resultado do Tratamento , Vasoconstritores/efeitos adversos
20.
Anesth Analg ; 130(1): 15-30, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31348056

RESUMO

Understanding the different mechanisms of vasoconstrictors is crucial to their optimal application to clinically diverse shock states. We present a comprehensive review of conventional, rescue, and novel vasoactive agents including their pharmacology and evidence supporting their use in vasodilatory shock. The role of each drug in relation to the Surviving Sepsis Guidelines is discussed to provide a context of how each one fits into the algorithm for treating vasodilatory shock. Rescue agents can be utilized when conventional medications fail, although there are varying levels of evidence on their clinical effectiveness. In addition, novel agents for the treatment of vasodilatory shock have recently emerged such as ascorbic acid and angiotensin II. Ascorbic acid has been used with some success in vasoplegia and is currently undergoing a more rigorous evaluation of its utility. Angiotensin II (Ang-2) is the newest available vasopressor for the treatment of vasodilatory shock. In addition to its catecholamine-sparing properties, it has been shown to hold promising mortality benefits in certain subsets of critically ill patients.


Assuntos
Pressão Sanguínea/efeitos dos fármacos , Choque Séptico/tratamento farmacológico , Vasoconstritores/uso terapêutico , Vasodilatação/efeitos dos fármacos , Animais , Estado Terminal , Humanos , Fatores de Risco , Choque Séptico/etiologia , Choque Séptico/mortalidade , Choque Séptico/fisiopatologia , Transdução de Sinais , Resultado do Tratamento , Vasoconstritores/efeitos adversos
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