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1.
Georgian Med News ; (314): 125-128, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-34248041

RESUMO

Hepatorenal syndrome is a severe complication of liver cirrhosis which is difficult to treat because of a very fast course and lack of adequate dosing recommendations due to the stage of the disease. In this study we aimed to refine the treatment of hepatorenal syndrome type I by modifying the dose of terlipressin, depending on the stage of acute kidney injury (AKI). Objective - to improve the treatment method of hepatorenal syndrome type I in patients with alcoholic liver cirrhosis by selecting the dose of terlipressin depending on the stage of acute kidney injury. For this study were enrolled 161 patients with diagnosis alcoholic liver cirrhosis, complicated with the hepatorenal syndrome. All patients were were randomly divided into control (group 1) (n=79) and study (group 2) (n=82) groups depending on the treatment received (terlipressin in the standard dosage or modified by the response-guided titration method). If the serum creatinine level decreased less than 25% from the baseline, the dose of terlipressin was gradually increased but did not accede 12 mg/24 hours. The stage of AKI was diagnosed using the criteria of Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Acute Kidney Injury, 2012. The risk of short term mortality (within the first 29 days) was prognosed by Model for End-Stage Liver Disease (MELD) score. The kidney function improved better in persons with a modified dose of terlipressin: the complete response rate in them was 81.7%. The response rate in those who received the standard treatment, was 66.7% only (p˂0.05). It was found that the effective dosage of terlipressin is 3 mg/24 for AKI stage I; 6 mg/24 - for AKI stage II; 12 mg/24 - for AKI stage III. The relapse of the disease occurred only in 23.2% patients with modified treatment against 40.1% in the control group (p˂0.05). Short term survival was also significantly higher in the study group - 54.9%, while in the control group it was 37% only (p˂0.05). Thus, correction of terlipressin dosage could improve the results of the treatment and reduce mortality in patients with hepatorenal syndrome type I.


Assuntos
Injúria Renal Aguda , Doença Hepática Terminal , Síndrome Hepatorrenal , Injúria Renal Aguda/tratamento farmacológico , Injúria Renal Aguda/etiologia , Doença Hepática Terminal/tratamento farmacológico , Síndrome Hepatorrenal/tratamento farmacológico , Humanos , Cirrose Hepática/complicações , Cirrose Hepática/tratamento farmacológico , Índice de Gravidade de Doença , Vasoconstritores/uso terapêutico
2.
BMJ Open ; 11(7): e044357, 2021 07 15.
Artigo em Inglês | MEDLINE | ID: mdl-34266837

RESUMO

OBJECTIVES: There is a lack of evidence about the use of local anaesthetics (LAs) in patients with cardiovascular diseases (CVD) in dental procedures. Thus, this study evaluated the safety of using LA with vasoconstrictor to determine the risk of cardiovascular events in patients with CVD. DESIGN: Systematic review and meta-analysis. METHODS: We have searched in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via Ovid), EMBASE (via Ovid), Healthstar (via Ovid), CINAHL, Web of Science and ClinicalTrials.gov for randomised controlled trials (RCTs) up to January 2020. We have included RCTs involving adults with CVD within two groups: intervention group with LA with vasoconstrictor and control group with LA without vasoconstrictor. The primary outcomes assessed were death, mortality by a specific cause, stroke, acute myocardial infarction, hospitalisation, pain, bleeding and arrhythmias. The secondary outcomes were ST segment depression, anxiety, adverse effects and changes in haemodynamic parameters. The data were pooled using random effects meta-analyses and the confidence in the estimates was verified using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS: Ten RCTs (n=478 participants) were included. Most of them had a high risk of bias. There were more cases of pain and bleeding in groups without vasoconstrictor. Meta-analysis demonstrated a decrease in the systolic blood pressure with the use of LA with vasoconstrictor (standard mean difference -0.95, 95% CI -1.35 to -0.55) after procedure. Overall, for the other outcomes assessed there was no statistical difference. The quality of evidence was considered low according to the GRADE profile. CONCLUSIONS: The results suggest that the use of LA with vasoconstrictors (epinephrine in low doses) is safe in patients with some types of CVD. However, the low quality of evidence demonstrated that literature needs further studies in order to confirm these results. PROTOCOL REGISTRATION: PROSPERO (CRD42016045421).


Assuntos
Doenças Cardiovasculares , Infarto do Miocárdio , Adulto , Anestesia Local , Anestésicos Locais , Humanos , Vasoconstritores/uso terapêutico
6.
Am J Cardiol ; 153: 101-108, 2021 08 15.
Artigo em Inglês | MEDLINE | ID: mdl-34210502

RESUMO

Pulmonary hypertension (PH) is common in patients with left heart disease and is present in varying degrees in patients with severe mitral valve disease. There is paucity of data regarding outcomes following transcatheter mitral valve repair (TMVr) in patients with PH. For this study, we analyzed NIS data from 2014 to 2018 using the ICD-9-CM and 10-CM codes. Baseline characteristics were compared using a Pearson chi-squared test for categorical variables and independent samples t-test for continuous variables. To account for selection bias, a 1:1 propensity match cohort was derived using logistic regression. Trend analysis was- done using linear regression. Of 21,505 encounters, 6780 encounters had PH. 6610 PH encounters were matched with 6610 encounters without PH. In-hospital mortality (3.3% versus 1.9%, p <0.01) was higher in PH population. Complications such as blood transfusion (3.6% versus 1.7%, p <0.01), GI bleed (1.4% versus 1%, p = 0.04), vascular complications (5.3% versus 3.3%, p <0.01), vasopressors use (2.9% versus 1.7%, p <0.01) and pacemaker placement (1.3% versus 0.8%, p = 0.01) remained significantly higher for encounters with PH. Multiple Logistic regression showed PH was associated with higher mortality (adjusted odds ratio [AOR], 1.68 [95% confidence interval [CI], 1.39-2.05], p <0.01). The mean length of stay (6.2 versus 5.3 days, p <0.01) and cost per hospitalization ($53,780 versus $50,801, p <0.01) remained significantly higher in the PH group when compared to group without PH. In conclusion, TMVr in PH as compared to without PH is associated with higher mortality, post-procedure complication rates, length of stay, and cost of stay.


Assuntos
Cateterismo Cardíaco , Mortalidade Hospitalar , Hipertensão Pulmonar/epidemiologia , Anuloplastia da Valva Mitral , Insuficiência da Valva Mitral/cirurgia , Complicações Pós-Operatórias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue/estatística & dados numéricos , Comorbidade , Feminino , Hemorragia Gastrointestinal/epidemiologia , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Insuficiência da Valva Mitral/epidemiologia , Razão de Chances , Marca-Passo Artificial , Hemorragia Pós-Operatória/epidemiologia , Vasoconstritores/uso terapêutico
7.
Artigo em Alemão | MEDLINE | ID: mdl-34187073

RESUMO

Vasopressors are widely used in anaesthesiology and critical care medicine, to treat harmless (e.g. anaesthesia-induced hypotension) as well as life-threatening conditions (e.g. septic shock). Some clinically used vasopressors resemble endogenous substances - such as norepinephrine - while others have been artificially synthesized (e.g. phenylephrine). Most of the substances used in different clinical scenarios have various effects except for vasoconstriction alone. Therefore, a thorough understanding of the pharmacology and clinical profile of every single substance is of highest importance prior to practical usage. Furthermore, the fundamentals of vascular physiology and vasotonic regulation are mandatory to safely provide vasopressor-based therapies. This article covers the essentials of physiology and pharmacology of vasopressors, and the clinical settings they are used in (e.g. septic shock, vasoplegic shock after cardiac surgery, trauma-induced hypotension).


Assuntos
Choque Séptico , Choque , Humanos , Norepinefrina , Fenilefrina , Choque Séptico/tratamento farmacológico , Vasoconstritores/uso terapêutico
8.
Artigo em Alemão | MEDLINE | ID: mdl-34187075

RESUMO

Vasopressors (synthetic catecholamines) play an important role in the management of hemodynamics and are being used by perioperative anaesthesiologists and intensive care physicians around the world on a daily basis. However, vasopressors require a cautious use and may inflict serious harm if applied in an inappropriate manner or in the wrong situation. Whether it is during a caesarean section in healthy young women, in multimorbid patients in the intensive care unit or in in the preclinical setting: Knowing the basics of pharmacodynamics and -kinetics of the commonly used vasopressors is crucial for the outcome of patients and is the focus of this article.


Assuntos
Catecolaminas , Cesárea , Feminino , Hemodinâmica , Humanos , Unidades de Terapia Intensiva , Gravidez , Vasoconstritores/uso terapêutico
9.
BMJ Open ; 11(6): e046102, 2021 06 14.
Artigo em Inglês | MEDLINE | ID: mdl-34127491

RESUMO

OBJECTIVES: We have previously established a method to measure transfer of nutrients between mother, placenta and fetus in vivo. The method includes measurements of maternal and fetal blood flow by Doppler ultrasound prior to spinal anaesthesia. Spinal anaesthesia affects maternal blood pressure and cardiac output. We aimed to determine the effect of spinal anaesthesia in mothers undergoing an elective caesarean section on blood pressure, heart rate and cardiac output, and whether cardiac output levels were comparable before induction of spinal anaesthesia and before delivery. DESIGN: Prospective cohort study. SETTING: Tertiary hospital in Norway. PARTICIPANTS: 76 healthy women with uneventful pregnancies undergoing an elective caesarean section. INTERVENTIONS: We induced spinal anaesthesia with a standard prevention of hypotension including intravenous fluid coloading and phenylephrine infusion. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome measure was maternal cardiac output, and secondary outcome measures were invasive systolic blood pressure and heart rate. We measured heart rate and blood pressure by continuous invasive monitoring with a cannula in the radial artery. Cardiac output was estimated based on continuous arterial waveform. We compared maternal parameters 30 s before induction of spinal anaesthesia to 30 s before delivery. RESULTS: Median age at delivery was 34.5 (range 21-43) years and 17 of 76 women were nulliparous. The most prevalent indications were previous caesarean section and maternal request. Among 76 included women, 71 had sufficient data for analysis of endpoints. Median cardiac output was 6.51 (IQR (5.56-7.54) L/min before spinal anaesthesia and 6.40 (5.83-7.56) L/min before delivery (p=0.40)). Median invasive systolic blood pressure increased from 128.5 (120.1-142.7) mm Hg to 134.1 (124.0-146.6) mm Hg (p=0.014), and mean heart rate decreased from 86.0 (SD 13.9) to 75.2 (14.2) (p<0.001). CONCLUSIONS: Maternal cardiac output at the time of caesarean delivery is comparable to levels before induction of spinal anaesthesia. TRIAL REGISTRATION NUMBER: NCT00977769.


Assuntos
Anestesia Obstétrica , Raquianestesia , Hipotensão , Adulto , Pressão Sanguínea , Débito Cardíaco , Cesárea , Feminino , Humanos , Hipotensão/etiologia , Noruega , Gravidez , Estudos Prospectivos , Vasoconstritores/uso terapêutico , Adulto Jovem
10.
Liver Int ; 41 Suppl 1: 119-127, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-34155791

RESUMO

Hepatorenal syndrome (HRS) is a serious complication of cirrhosis with high morbidity and mortality rates. Recently, the definition of HRS type 1 has been updated and is now called HRS-AKI. This new definition reduces the risk of delaying HRS treatment and eliminates the need to establish a minimum creatinine cut-off for the diagnosis of HRS-AKI. From a pathophysiological point of view, newly identified mechanisms involved in the development of HRS are related to the inflammatory response, conditioning the development of extrahepatic organ dysfunction in patients with cirrhosis. One of the main challenges for the diagnosis of HRS is the validation of new biomarkers to obtain an early and differential diagnosis of kidney injury (eg HRS vs. ATN). Treatment of HRS is based on the use of vasoconstrictive agents in combination with albumin and terlipressin is the most widely used vasoconstrictor drug, with a high response rate. The effects of a continuous infusion of terlipressin at a dose of 2-12 mg/day was similar to bolus administration, but with lower rates of adverse events. Finally, MELD/MELD-Na which includes creatinine as one of its main determinants gives AKI-HRS patients priority on the waiting list (WL) for liver transplant (LT). However, the MELD and MELD-Na scores are reduced in responding patients, resulting a longer waiting time in these patients than in non-responders. Thus, the initial MELD/MELD-Na score (pre-treatment value) should be used to prioritize patients on the WL for LT in these cases.


Assuntos
Injúria Renal Aguda , Doença Hepática Terminal , Síndrome Hepatorrenal , Injúria Renal Aguda/tratamento farmacológico , Doença Hepática Terminal/tratamento farmacológico , Síndrome Hepatorrenal/diagnóstico , Síndrome Hepatorrenal/etiologia , Síndrome Hepatorrenal/terapia , Humanos , Cirrose Hepática/complicações , Cirrose Hepática/tratamento farmacológico , Terlipressina , Vasoconstritores/uso terapêutico
11.
J Int Med Res ; 49(5): 3000605211013176, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33990145

RESUMO

OBJECTIVE: To investigate the effect of focused ultrasonography on clinical outcomes of septic shock. METHODS: Patients with septic shock were randomized into an integrated cardiopulmonary ultrasonography (ICUS) group and conventional (CON) group. Within 1 hour of admission, the ICUS group underwent ICUS examination for hemodynamic decision-making, while the CON group received standard treatment. The primary endpoint was 28-day mortality after admission. The secondary endpoints were cumulative fluid administration in the first 6, 24, and 72 hours; use of vasoactive drugs; lactate clearance; duration of ventilation; and ICU stay. RESULTS: Ninety-four qualified patients were enrolled (ICUS group, 49; CON group, 45). ICUS showed no significant effect on 28-day mortality. Within the initial 6 hours, the ICUS group tended to have a higher fluid balance and fluid intake than the CON group. The duration of vasopressor support was shorter in the ICUS group. There were no differences in the cumulative fluid infusion within 24 or 72 hours, lactate clearance, ICU stay, or duration of ventilation. CONCLUSIONS: The initially focused ICUS did not affect the clinical outcomes of septic shock, but it tended to be associated with a higher fluid balance within the initial 6 hours and shorter duration of vasopressor support.


Assuntos
Choque Séptico , Hidratação , Hemodinâmica , Humanos , Choque Séptico/diagnóstico por imagem , Choque Séptico/tratamento farmacológico , Ultrassonografia , Vasoconstritores/uso terapêutico
12.
West J Emerg Med ; 22(2): 196-203, 2021 Feb 16.
Artigo em Inglês | MEDLINE | ID: mdl-33856300

RESUMO

INTRODUCTION: Most experts recommend norepinephrine as the first-line agent in septic shock. Our objective was to determine the effectiveness and safety of norepinephrine in patients with septic shock. METHODS: We searched the Cochrane Central Register of Controlled Trials and Epistemonikos, as well as MEDLINE from 1966 till August 2019. Screening of full texts, evaluation for eligibility, and data extraction were done by four independent reviewers. We estimated risk ratios (RR) and mean differences (MD) using a random-effects model with 95% confidence intervals (CI). The primary outcomes included the number of participants who achieved the target mean arterial pressure (MAP), time to achieve the target MAP, and number of participants with all-cause 28-day mortality. The secondary outcomes included the length of stay in the intensive care unit, length of hospital stay, incidence of arrhythmia and myocardial infarction, vasopressor-free days, and number of participants with all-cause 90-day mortality. RESULTS: We identified 11 randomized controlled trials with a total of 4,803 participants. There was no difference in the number of participants who achieved the target MAP between those patients receiving norepinephrine and other vasopressors (RR 1.44; 95% CI, 0.32 to 6.54; P = 0.640; I2 = 94%; two trials, 116 participants). There was no significant difference in time to achieve the target MAP (MD -0.05; 95%, CI, -0.32 to 0.21; P = 0.690; I2 = 26%; two trials, 1763 participants) and all-cause 28-day mortality (RR 0.95; 95% CI, 0.89 to 1.02; P = 0.160; I2 = 0%; seven trials, 4,139 participants). Regarding the secondary outcome, norepinephrine may significantly reduce the incidence of arrhythmia as compared to other vasopressors (RR 0.64; 95% CI, 0.42 to 0.97; P = 0.030; I2 = 64%; six trials, 3974 participants). There was no difference in the incidence of myocardial infarction (RR 1.28; 95% CI, 0.79 to 2.09), vasopressor-free day (RR 0.46; 95% CI, -1.82 to 2.74) and all-cause 90-day mortality (RR 1.08; 95% CI, 0.96 to 1.21) between norepinephrine and vasopressors. CONCLUSION: In minimizing the occurrence of an arrhythmia, norepinephrine is superior to other vasopressors, making it safe to be used in septic shock. However, there was insufficient evidence concerning mortality and achievement of the target MAP outcomes.


Assuntos
Norepinefrina/uso terapêutico , Choque Séptico/tratamento farmacológico , Vasoconstritores/uso terapêutico , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Choque Séptico/mortalidade
13.
Curr Opin Crit Care ; 27(3): 269-273, 2021 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-33852500

RESUMO

PURPOSE OF REVIEW: Current goals of resuscitation in septic shock are mainly a fixed volume of fluids and vasopressors to correct hypotension and improve tissue perfusion indicated by decreasing lactate levels. RECENT FINDINGS: Abnormal peripheral perfusion by objective and subjective parameters are associated with increased mortality in various phases of the treatment of critically ill patients including patients with septic shock. Ongoing resuscitation in septic shock patients with normal peripheral perfusion is not associated with improved outcome, rather with increased mortality. Mitigation of fluid resuscitation by using parameters of peripheral perfusion in septic shock seems to be safe. SUMMARY: Septic shock patients with normal peripheral perfusion represent a different clinical phenotype of patients that might benefit from limited resuscitation efforts. Parameters of peripheral perfusion could be used to guide the individualization of patients with septic shock.


Assuntos
Choque Séptico , Hidratação , Humanos , Perfusão , Ressuscitação , Choque Séptico/tratamento farmacológico , Vasoconstritores/uso terapêutico
14.
Anesth Analg ; 133(1): 68-79, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-33908898

RESUMO

Vasopressor use in severely injured trauma patients is discouraged due to concerns that vasoconstriction will worsen organ perfusion and result in increased mortality and organ failure in hypotensive trauma patients. Hypotensive resuscitation is advocated based on limited data that lower systolic blood pressure and mean arterial pressure will result in improved mortality. It is classically taught that hypotension and hypovolemia in trauma are associated with peripheral vasoconstriction. However, the pathophysiology of traumatic shock is complex and involves multiple neurohormonal interactions that are ultimately manifested by an initial sympathoexcitatory phase that attempts to compensate for acute blood loss and is characterized by vasoconstriction, tachycardia, and preserved mean arterial blood pressure. The subsequent hypotension observed in hemorrhagic shock reflects a sympathoinhibitory vasodilation phase. The objectives of hemodynamic resuscitation in hypotensive trauma patients are restoring adequate intravascular volume with a balanced ratio of blood products, correcting pathologic coagulopathy, and maintaining organ perfusion. Persistent hypotension and hypoperfusion are associated with worse coagulopathy and organ function. The practice of hypotensive resuscitation would appear counterintuitive to the goals of traumatic shock resuscitation and is not supported by consistent clinical data. In addition, excessive volume resuscitation is associated with adverse clinical outcomes. Therefore, in the resuscitation of traumatic shock, it is necessary to target an appropriate balance with intravascular volume and vascular tone. It would appear logical that vasopressors may be useful in traumatic shock resuscitation to counteract vasodilation in hemorrhage as well as other clinical conditions such as traumatic brain injury, spinal cord injury, multiple organ dysfunction syndrome, and vasodilation of general anesthetics. The purpose of this article is to discuss the controversy of vasopressors in hypotensive trauma patients and advocate for a nuanced approach to vasopressor administration in the resuscitation of traumatic shock.


Assuntos
Lesões Encefálicas Traumáticas/tratamento farmacológico , Hipotensão/tratamento farmacológico , Choque Hemorrágico/tratamento farmacológico , Traumatismos da Medula Espinal/tratamento farmacológico , Vasoconstritores/uso terapêutico , Lesões Encefálicas Traumáticas/fisiopatologia , Humanos , Hipotensão/fisiopatologia , Guias de Prática Clínica como Assunto/normas , Estudos Retrospectivos , Choque Hemorrágico/fisiopatologia , Traumatismos da Medula Espinal/fisiopatologia , Ferimentos e Lesões/tratamento farmacológico , Ferimentos e Lesões/fisiopatologia
15.
Curr Opin Crit Care ; 27(4): 426-432, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-33797431

RESUMO

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


Assuntos
Fármacos Cardiovasculares , Choque , Cardiotônicos/uso terapêutico , Fármacos Cardiovasculares/uso terapêutico , Dobutamina/uso terapêutico , Humanos , Choque Cardiogênico/tratamento farmacológico , Vasoconstritores/uso terapêutico
16.
J Comp Eff Res ; 10(8): 673-683, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33860672

RESUMO

Background: The effect of midodrine on lactate clearance has not been assessed in critically ill patients yet. Objective: The goal of this study was to assess the effect of adjunctive midodrine therapy on lactate clearance in patients with septic shock. Materials & methods: Patients with septic shock were assigned to receive either adjunctive midodrine 10 mg three-times a day for 5 days (midodrine group = 15 patients) or not (control group = 13 patients). Results: The lactate clearance was significantly faster in the midodrine group than the control group (p = 0.049) with a large effect size (ηp2 = 0.141). Conclusion: When midodrine was added to intravenous vasopressors, it significantly accelerated lactate clearance in patients with septic shock. Trial registration number: IRCT20100228003449N25 (Clinicaltrials.gov).


Assuntos
Midodrina , Choque Séptico , Humanos , Ácido Láctico , Midodrina/uso terapêutico , Projetos Piloto , Choque Séptico/tratamento farmacológico , Vasoconstritores/uso terapêutico
17.
Liver Transpl ; 27(8): 1095-1105, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33837624

RESUMO

Vasoconstrictors are the treatment of choice for hepatorenal syndrome (HRS). We evaluate the real-life effectiveness of a sequential vasoconstrictor regimen of midodrine-octreotide followed by norepinephrine in a nonintensive care unit (non-ICU) setting in the United States, where terlipressin is not available. The diagnosis of HRS and definitions of response to therapy were based on 2015 guidelines from the International Club of Ascites. In adult patients with HRS without partial or full response to oral midodrine and subcutaneous octreotide, norepinephrine was administered at a starting dose of 5 mcg/minute, with a goal to achieve a mean arterial pressure (MAP) of 10 mm Hg above baseline. We assessed predictors of response and treatment outcomes. A total of 61 patients were administered midodrine and octreotide for the treatment of HRS, with a 28% response rate. The median MELD-Na (Model for End-Stage Liver Disease-sodium) score was 30 (interquartile range [IQR] 24-35). Responders were more likely to have alcohol-related liver disease and lower Acute-on-Chronic Liver Failure (ACLF) grade. Of the nonresponders, 20 were then administered norepinephrine, of whom 45% achieved full or partial response. Achieving an MAP increase of ≥10 mm Hg was associated with a greater probability of response. Patients who responded to norepinephrine experienced improved transplant-free survival at 90 days (88% versus 27%; P = 0.02); 5 of 20 patients experienced norepinephrine treatment-related adverse events, namely arrhythmias. Norepinephrine can be effectively used in a non-ICU setting as rescue therapy in patients who have not responded to midodrine and octreotide. Based on these data, we propose a practical stepwise algorithm for vasoconstrictor therapy to manage HRS in situations where terlipressin is not an option.


Assuntos
Doença Hepática Terminal , Síndrome Hepatorrenal , Transplante de Fígado , Adulto , Cuidados Críticos , Doença Hepática Terminal/tratamento farmacológico , Estudos de Viabilidade , Síndrome Hepatorrenal/diagnóstico , Síndrome Hepatorrenal/tratamento farmacológico , Humanos , Lipressina/uso terapêutico , Norepinefrina/uso terapêutico , Índice de Gravidade de Doença , Resultado do Tratamento , Vasoconstritores/uso terapêutico
18.
Liver Transpl ; 27(8): 1191-1202, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33848394

RESUMO

Acute kidney injury (AKI) in the setting of cirrhosis (hepatorenal syndrome [HRS]-AKI) is a severe and often fatal complication of end-stage liver disease. The goals of treatment are to reverse renal failure and prolong survival in patients who are critically ill. However, interventions have limited efficacy, and mortality rates remain high. In the United States, the mainstay of pharmacologic therapy consists of the off-label use of vasoconstrictive agents in combination with plasma expanders, a strategy that produces modest effects. Liver transplantation is the ultimate solution but is only an option in a minority of patients because contraindications to transplantation are common and organ availability is limited. Renal replacement therapy is a temporary option but is known to confer an extremely poor short-term prognosis in patients with HRS-AKI and at best serves as a bridge to liver transplantation for the minority of patients who are transplantation candidates. The high mortality rate associated with HRS-AKI in the United States is a reflection of the suboptimal standard of care. Improved therapeutic options to treat HRS-AKI are sought. Terlipressin is a drug approved in Europe for treatment of HRS-AKI and supported by recommendations for first-line therapy by some liver societies and experts around the world. This review article will discuss the substantial unmet medical need associated with HRS-AKI and the potential benefits if terlipressin was approved in the United States.


Assuntos
Injúria Renal Aguda , Síndrome Hepatorrenal , Transplante de Fígado , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/tratamento farmacológico , Síndrome Hepatorrenal/diagnóstico , Síndrome Hepatorrenal/tratamento farmacológico , Humanos , Cirrose Hepática/complicações , Cirrose Hepática/tratamento farmacológico , Transplante de Fígado/efeitos adversos , Terlipressina , Estados Unidos/epidemiologia , Vasoconstritores/uso terapêutico
19.
Crit Care ; 25(1): 146, 2021 04 16.
Artigo em Inglês | MEDLINE | ID: mdl-33863361

RESUMO

BACKGROUND: It is unclear whether vasopressors can be safely administered through a peripheral intravenous (PIV). Systematic review and meta-analysis methodology was used to examine the incidence of local anatomic adverse events associated with PIV vasopressor administration in patients of any age cared for in any acute care environment. METHODS: MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of controlled trials, and the Database of Abstracts of Reviews of Effects were searched without restriction from inception to October 2019. References of included studies and related reviews, as well as relevant conference proceedings were also searched. Studies were included if they were: (1) cohort, quasi-experimental, or randomized controlled trial study design; (2) conducted in humans of any age or clinical setting; and (3) reported on local anatomic adverse events associated with PIV vasopressor administration. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials or the Joanna Briggs Institute checklist for prevalence studies where appropriate. Incidence estimates were pooled using random effects meta-analysis. Subgroup analyses were used to explore sources of heterogeneity. RESULTS: Twenty-three studies were included in the systematic review, of which 16 and 7 described adults and children, respectively. Meta-analysis from 11 adult studies including 16,055 patients demonstrated a pooled incidence proportion of adverse events associated with PIV vasopressor administration as 1.8% (95% CI 0.1-4.8%, I2 = 93.7%). In children, meta-analysis from four studies and 388 patients demonstrated a pooled incidence proportion of adverse events as 3.3% (95% CI 0.0-10.1%, I2 = 82.4%). Subgroup analyses did not detect any statistically significant effects associated with stratification based on differences in clinical location, risk of bias or design between studies, PIV location and size, or vasopressor type or duration. Most studies had high or some concern for risk of bias. CONCLUSION: The incidence of adverse events associated with PIV vasopressor administration is low. Additional research is required to examine the effects of PIV location and size, vasopressor type and dose, and patient characteristics on the safety of PIV vasopressor administration.


Assuntos
Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/etiologia , Vasoconstritores/efeitos adversos , Cateterismo Periférico/métodos , Humanos , Vasoconstritores/uso terapêutico
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