Doses Of Norepinephrine Research Articles

A MAST KNOWN CAUSE OF SHOCK

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: The main types of shock include cardiogenic, hypovolemic, distributive, and neurogenic shock. Management of shock requires identifying and correcting the underlying cause, and supporting end-organ perfusion with fluid resuscitation and vasoactive medications. Here we present a rare cause of distributive shock. CASE PRESENTATION: A 65-year-old man presented with 2-month history of progressive weakness. Laboratory studies reviewed new thrombocytopenia to 25 x10(9)/L and acute renal failure with creatinine of 3.24 mg/dL. His bone marrow biopsy was concerning for acute mast cell leukemia, and he was started on treatment with 1 gram of methylprednisolone. About 1 hour after receiving this infusion, he developed chest pain, tachycardia and tachypnea. He was urgently transferred to the ICU. In the ICU, his condition progressed into ventricular fibrillation requiring CPR, defibrillation, and intubation. He was in refractory circulatory shock requiring high doses of norepinephrine, epinephrine, vasopressin, and stress dose steroids. Given his underlying mast cell leukemia, empirical treatment for mast cell activation syndrome was started. He received scheduled diphenhydramine, famotidine, montelukast and cromolyn. Patient was quickly weaned off vasoactive medications in the next 24 hours. Tryptase obtained at time of his hypotensive event was markedly elevated at greater than 2000 ng/mL. He had worsening renal failure requiring renal replacement therapy, and given his underlying diagnosis of mast cell leukemia, a rare hematological malignancy with limited treatment options and high mortality, the focus of his care was transitioned to concentrate solely on his comfort. DISCUSSION: Mast cell disorders include cutaneous and systemic mastocytosis, allergic diseases, and idiopathic disorders. Acute mast cell leukemia is a rare form of systemic mastocytosis characterized by at least 20% immature mast cells in bone marrow. Sudden mast cell activation leads to degranulation of mast cell and release of pre-formed mediators including histamine. It also stimulates de novo synthesis of other cytokines and chemokines. Typical symptoms include flushing, lightheadedness and abdominal cramping, but can progress to syncope and distributive shock, as seen in our patient. Treatment includes identification and avoidance of triggers, and supportive care with antihistamines (both H1 and H2 blockers) and cromolyn (mast cell stabilizer). CONCLUSIONS: It is essential for critical care clinicians to recognize mast cell activation syndrome as a potential cause of refractory shock, especially in at risk patients with systemic mastocytosis. Prompt treatment with antihistamines and cromolyn can facilitate resolution of shock. REFERENCE #1: Akin C, Valent P, Metcalfe DD. Mast cell activation syndrome: Proposed diagnostic criteria. J Allergy Clin Immunol. 2010;126(6):1099-104.e4. doi:10.1016/j.jaci.2010.08.035 REFERENCE #2: Molderings GJ, Haenisch B, Brettner S, et al. Pharmacological treatment options for mast cell activation disease. Naunyn Schmiedebergs Arch Pharmacol. 2016;389(7):671-694. doi:10.1007/s00210-016-1247-1 DISCLOSURES: No relevant relationships by Alice Gallo De Moraes, source=Web Response No relevant relationships by Zhenmei Zhang, source=Web Response

Effects of Terlipressin on Management of Hypotensive Brain-Dead Patients Who are Potential Organ Donors: A Retrospective Study.

Background: Administration of terlipressin can reverse hypotension in potential organ donors with norepinephrine-resistance. The aim of this study was to determine the effects of terlipressin on the hemodynamics, liver function, and renal function of hypotensive brain-dead patients who were potential organ donors. Methods: A retrospective study was conducted by using the ICU database of one hospital. 18 patients in a total of 294 brain-dead cases were enrolled and administered terlipressin intravenously. All physiological parameters of recruited patients were obtained at baseline, 24 and 72 h after administration, and immediately before organ procurement. Results: Terlipressin induced significant increases in mean arterial pressure (MAP) from 69.56 ± 10.68 mm Hg (baseline) to 101.82 ± 19.27 mm Hg (immediately before organ procurement) and systolic blood pressure (SBP) from 89.78 ± 8.53 mm Hg (baseline) to 133.42 ± 26.11 mm Hg (immediately before organ procurement) in all patients. The increases in MAP were accompanied by significant decreases in heart rate (HR) from 113.56 ± 28.43 bpm (baseline) to 83.89 ± 11.70 bpm (immediately before organ procurement), which resulted in the decrease of norepinephrine dose over time from 0.8 ± 0.2 μg/kg/min (baseline) to 0.09 ± 0.02 μg/kg/min (immediately before organ procurement). There were no changes in central venous pressure, liver function including aspartate aminotransferase (AST), alanine aminotransferase (ALT), and bilirubin. Renal function, assessed by serum creatinine (SCr), urine output (UOP), creatinine clearance rate (CCr), and estimated glomerular filtration rate (eGFR), improved significantly. Conclusion: Our analysis of brain-dead patients with hypotension indicates that administration of terlipressin can significantly increases MAP, SBP, UOP, CCr, and eGFR, while decreases HR and Scr. Terlipressin appears to help maintain hemodynamic stability, reduce vasoactive support, and improve renal function.

Quantification of the negative impact of sedation and inotropic support on achieving early mobility in burn patients in ICU: A single center observational study

IntroductionEarly rehabilitation for burns survivors in the intensive care unit (ICU) is arguably more challenging than the general population. Early achievement of functional verticality milestones (FVMs) has the potential to ameliorate the detrimental effects of bed rest and immobility observed in ICU patients and reduce healthcare costs. However, the time to achieving FVMs after burn injury is influenced by factors such as sedation practices, cardiovascular stability, mechanical ventilation, acute skin reconstruction and length of stay (LOS) during the acute intensive care period. Objectives/AimsThe aims of this study were to identify the association between early achievement of FVMs and factors influencing cessation of bedrest in adult patients with burns receiving ICU care, and to explore barriers to achievement of FVMs as recorded by clinicians. MethodsA 5-year retrospective observational cohort study was conducted. The digital medical records were reviewed for each case to explore episodes of FVMs and patient factors which may contribute to persistent bed rest, such as use of infused sedative and/or inotropic medication, mechanical ventilation, burn surgery, total body surface area (TBSA), ICU length of stay and pre-ICU practices. Logistic regression was used to examine the association between FVM achievement and treatment and injury factors in ICU survivors. ResultsThe total sample available for analysis included 64 patients. When sedation/agitation score was within recommended limits, odds of achieving FVMs was 21 times greater than periods outside those limits. When deep sedatives were infused, the odds of achieving FVMs decreased by 87% compared to periods when there was no infusion of these medications. In addition, the odds of achieving FVMs was reduced by 13% for each increase of 1 mL/h in the daily maximum noradrenaline dose. Discussion and ConclusionMaintaining sedation and agitation scores within the optimal range, and minimising sedative infusion and inotropic support enhances the likelihood of early and frequent mobilization in patients with burns admitted to ICU. Additional barriers identified were mechanical ventilation, burns surgery, pre-ICU practices and ICU length of stay. The challenge for clinicians moving forward is to determine how these factors may be modified to increase early mobilization of burn patients in ICU.

Norepinephrine versus phenylephrine for maintenance of blood pressure during spinal anaesthesia for caesarean delivery - A randomized double blind controlled study

: Currently phenylephrine is a preferred 1 line vasopressor for maintenance of blood pressure during spinal anaesthesia, may be associated with reflex bradycardia and decreased cardiac output, posing risk to mother or foetus. Norepinephrine may be an useful alternative as being potent alpha with weak beta adrenergic agonist activity. : This study compared the effectiveness of prophylactic and treatment boluses of norepinephrine and phenylephrine to maintain systolic blood pressure at or above 80% of baseline value during spinal anesthesia for cesarean delivery with the primary aim to compare cardiac output. Secondary aims were total doses of study drug required, neonatal outcome and perioperative complications.: Total 100, term pregnant women with ASA status II undergoing caesarean delivery under spinal anaesthesia were enrolled in this prospective, double blind controlled study. Patients were randomized to receive prophylactic bolus dose of norepinephrine (6 µg) or phenylephrine (100 µg) immediately after spinal anaesthesia. Systolic blood pressure, cardiac output and heart rate were monitored. Intermittent bolus doses were repeated whenever required. Student ‘t’ test and chi square test were used for analysing the data. : Both the drugs were able to maintain the systolic blood pressure ≥ 80% of baseline (p=0.356). Significant difference observed in cardiac output while comparing both the groups from 3 to 15 minutes after spinal anesthesia (p=0.014). The incidence of bradycardia was lower in norepinephrine group as compared to phenylephrine group (P=0.018). : Norepinephrine is as effective as phenylephrine for maintenance of blood pressure after spinal anaesthesia for caesarean delivery with stable heart rate and cardiac output.

Milrinone is better choice for controlled low central venous pressure during hepatectomy: A randomized, controlled trial comparing with nitroglycerin

BackgroundTo explore the feasibility and effectiveness of controlled low central venous pressure(CLCVP)induced by milrinone during hepatectomy, and its influence on perioperative hemodynamics, blood loss and patients’ recovery, comparing with the traditional method by nitroglycerin. Methods52 patients who underwent elective open hepatectomy were enrolled in the study and randomly divided into two groups: milrinone (M) group and nitroglycerin (NG) group. Milrinone was infused with the rate of 0.5 μg/kg/min in group M, while nitroglycerin was given 0.2–0.5 μg/kg/min in group NG to maintain CVP≤ 5 mmHg during liver resection. The demographic variables, data of the operative procedure and intraoperative hemodynamics were recorded. The postoperative recovery profiles and pre- and post-operative haematological markers of vital organs were also collected and compared. Results1. The blood loss of group M, no matter during liver resection or in the whole procedure, was both less than that of group NG (P < 0.05), so did the hemoglobin detected by blood gas analysis (P < 0.05). Meanwhile, time of hepatectomy and hepatic hilum occlusion were shorter in group M (P < 0.05). 2. Compared with the NG group, cardiac index (CI) and stroke volume index (SVR) were higher in group M in the operation. The norepinephrine dosage necessary in the operation was of no difference in two groups (P > 0.05). 3. Drainage indwelling time and postoperative hospital stay of group M were shorter than that of group NG (P < 0.05). Most of the blood biomarkers increased on postoperative day (POD)-1, and returned to the preoperative level on POD-7 without inter-group difference (P > 0.05). Brain natriuretic peptide precursor (Pro-BNP) in group M was higher than NG group on POD-1 (P < 0.05), and the statistical difference disappeared on POD-7. ConclusionMilrinone can effectively maintain a controlled low central venous pressure during hepatectomy. Compared with nitroglycerin, milrinone can reduce the amount of blood loss, with the benefit of better manifestation of hemodynamics and enhanced postoperative recovery.

敗血症性ショックと鑑別が困難であった成人Still病の1例(A patient diagnosed with adult onset still’s disease mimicking sepsis: a case report)

要旨成人Still病は，不明熱の重要な鑑別疾患の一つであるが，致死的な経過をたどることは稀である。今回我々は，致死的となりうる敗血症性ショック様の病態を呈した成人Still病の1例を経験したため報告する。症例は，特記すべき既往のない27歳の男性で，頭痛と発熱を主訴に当院を受診した。全身に皮疹を認めたが，特異的なものではなく，ヘラルドパッチと診断された。重症感染症の疑いで入院となり，入院後に血圧低下を来したため集中治療室入室となった。当初は，皮疹とハイキング歴から，リケッチア感染を筆頭とした敗血症性ショックを念頭においてミノサイクリンを含めた広域抗菌薬で治療を開始したが，抗菌薬の効果がなかったこと，山口の診断基準で，大項目2つ，小項目4つ該当し，フェリチンが1,900ng/mLと高値であったことから心筋炎を合併した成人Still病を疑った。呼吸不全の進行など，全身状態が悪化し，救命のためステロイドパルス療法による治療を開始した。ステロイド治療が著効し，循環動態，呼吸不全は急速に回復したため第12病日には集中治療室を退室し，第40病日に自宅退院となった。血液培養と各種感染症の抗体価は陰性であり，悪性腫瘍や膠原病も疑う所見がなかったため，成人Still病と確定診断した。

Effect of early rehabilitation exercise on blood pressure of elderly patients with septic shock: a single-center, prospective, randomized controlled study

To observe the effect of early rehabilitation exercise on blood pressure of elderly patients with septic shock. A single-center, prospective, randomized controlled study was conducted in elderly patients with septic shock who were hospitalized in the department of critical care medicine of Huangshan Shoukang Hospital (High-tech Zone Central Hospital of Huangshan) from December 2018 to November 2020. According to the principle of simple random, all patients were divided into control group and intervention group. Both groups were treated with lower limb barometry to prevent deep vein thrombosis, 3 times a day, 30 minutes each time. After comprehensive treatment in the intensive care unit (ICU), the severity of patients was gradually improved, the hemodynamics was relatively stable, and the norepinephrine was reduced to 0.5 μg×kg-1×min-1. The control group continued to receive lower limb barometric treatment without rehabilitation training, while the intervention group began rehabilitation training when the dose of norepinephrine was reduced to 0.5 μg×kg-1×min-1. The duration of norepinephrine use, the length of ICU stay, and the occurrence of adverse events during rehabilitation training in intervention group was recorded. Seventy-two patients were included in the final analysis, 35 in intervention group and 37 in control group. There was no significant difference in gender, age, Oxford acute severity of illness score (OASIS), acute physiology and chronic health evaluation II (APACHE II), mean arterial pressure (MAP) of 3 times and underlying diseases between two groups. Compared with control group, the length of ICU stay and duration of dose of norepinephrine ≤ 0.5 μg×kg-1×min-1 in intervention group were significantly shorter [length of ICU stay (hours): 193.0 (145.5, 312.0) vs. 242.5 (180.0, 483.5), P < 0.05; duration of dose of norepinephrine ≤ 0.5 μg×kg-1×min-1 (hours): 120.0 (72.0, 144.0) vs. 144.5 (120.0, 192.0), Z = 2.976, P = 0.003]. In intervention group, 35 patients did not show acute myocardial infarction, arrhythmia, syncope, central venous catheter detachment, and gastric tube detachment during the rehabilitation period, except 1 patient suffered from naked hematuria due to urinary catheter traction, which disappeared the next day after symptomatic treatment. The early rehabilitation exercise was beneficial to the recovery of autonomic blood pressure in elderly patients with septic shock, shorten the time of norepinephrine use and ICU stay.

Increasing mean arterial pressure or cardiac output in comatose out-of-hospital cardiac arrest patients undergoing targeted temperature management: Effects on cerebral tissue oxygenation and systemic hemodynamics

IntroductionFew data exist on the effects of increasing norepinephrine doses or increasing arterial CO2 (PaCO2) on hemodynamics and cerebral oxygenation in comatose out-of-hospital cardiac arrest (OHCA) patients. MethodsWe prospectively studied 10 resuscitated OHCA-patients undergoing targeted temperature management (36C°). The trial consisted of 5 phases with 20 minutes steady state in-between: Phase 1–4 were increasing doses of norepinephrine to reach targets of mean arterial pressure (MAP). First 65, second 75, third 85, fourth 65 mmHg again. In the fifth phase, MAP was constant while PaCO2 was increased to 6.5–7.3 kPa to increase cardiac output. Primary outcome was cerebral near-infrared spectroscopy (NIRS). Secondary outcomes were hemodynamic variables from Swan-Ganz catheters and blood samples from the radial artery and jugular bulb. ResultsTo reach a MAP at 85 mmHg, norepinephrine was increased from 0.11 ± 0.02 to 0.18 ± 0.02 µg/kg/min (P < 0.001). Norepinephrine uptitration significantly increased systemic vascular resistance (SVR) and pulmonary vascular resistance, without affecting cardiac output, heart rate or cerebral oxygenation.Increasing PaCO2, resulted in a significant increase in cardiac output and cerebral NIRS, but arterial-venous cerebral oxygen-uptake decreased. Norepinephrine demand to keep MAP at 65 mmHg was unaffected by increasing PaCO2. ConclusionsA short-term increase in MAP with norepinephrine in resuscitated comatose cardiac arrest-patients is associated with increased SVR and pulmonary vascular resistance without affecting cardiac output or cerebral NIRS. Increased cardiac output caused by an increase in PaCO2 increased cerebral NIRS, but not cerebral oxygen uptake.

Therapeutic plasma exchange (TPE); A Management Strategy for Critically ill Covid-19 patients

Objective: To determine the effectiveness of therapeutic plasma exchange (TPE) in management of critically ill Covid-19 patients Materials and Methods: In this study non-randomized controlled trial, a total of 47 patients were included after thorough screening of the admitted patients in Covid ITC CMH, Multan from July-2020 to May-2021.Single administration of TPE was done to determine the results. The parameters assessed in this study included the efficacy of TPE in terms of improvement of critical end points such as Norepinephrine dose to maintain MAP of more than 65mmHg, 6-hour balance of fluid, MAP, CRP (C reactive protein), WBC count (white blood cell), platelets, INR (international normalized ratio), IL-6. Results: The variations before and after TPE in clinical and biochemical parameters shown in table. II. In clinical parameters and in gas exchange parameters no significant difference was found. Inflammatory biomarkers, before and after TPE, the parameters had not significant different, (p&gt;0.005). The differences before and after TPE between acid base balance, cytokines and vasoactive substances were also statistically insignificant, (p&gt;0.005). Conclusion: Even though there is evidence of slight improvement in clinical endpoints of Covid-19 patients with TPE, overall efficacy of TPE is still a question that needs an answer as no significant improvement could be seen in outcome values after TPE. Keywords: Therapeutic Plasma Exchange (TPE), Hemodynamics, Acute Respiratory Distress Syndrome (ARDS).

Norepinephrine potentiates the efficacy of volume expansion on mean systemic pressure in septic shock

BackgroundThrough venous contraction, norepinephrine (NE) increases stressed blood volume and mean systemic pressure (Pms) and exerts a “fluid-like” effect. When both fluid and NE are administered, Pms may not only result from the sum of the effects of both drugs. Indeed, norepinephrine may enhance the effects of volume expansion: because fluid dilutes into a more constricted, smaller, venous network, fluid may increase Pms to a larger extent at a higher than at a lower dose of NE. We tested this hypothesis, by mimicking the effects of fluid by passive leg raising (PLR).MethodsIn 30 septic shock patients, norepinephrine was decreased to reach a predefined target of mean arterial pressure (65–70 mmHg by default, 80–85 mmHg in previously hypertensive patients). We measured the PLR-induced increase in Pms (heart–lung interactions method) under high and low doses of norepinephrine. Preload responsiveness was defined by a PLR-induced increase in cardiac index ≥ 10%.ResultsNorepinephrine was decreased from 0.32 [0.18–0.62] to 0.26 [0.13–0.50] µg/kg/min (p < 0.0001). This significantly decreased the mean arterial pressure by 10 [7–20]% and Pms by 9 [4–19]%. The increase in Pms (∆Pms) induced by PLR was 13 [9–19]% at the higher dose of norepinephrine and 11 [6–16]% at the lower dose (p < 0.0001). Pms reached during PLR at the high dose of NE was higher than expected by the sum of Pms at baseline at low dose, ∆Pms induced by changing the norepinephrine dose and ∆Pms induced by PLR at low dose of NE (35.6 [11.2] mmHg vs. 33.6 [10.9] mmHg, respectively, p < 0.01). The number of preload responders was 8 (27%) at the high dose of NE and 15 (50%) at the low dose.ConclusionsNorepinephrine enhances the Pms increase induced by PLR. These results suggest that a bolus of fluid of the same volume has a greater haemodynamic effect at a high dose than at a low dose of norepinephrine during septic shock.

Anaesthetic management using remimazolam in a patient with severe aortic stenosis: a case report

BackgroundThe administration of general anaesthesia in patients with aortic stenosis (AS) requires careful attention to haemodynamics. We used remimazolam for the induction and maintenance of anaesthesia in a woman with severe AS undergoing a total mastectomy.Case presentationAn 81-year-old woman with severe AS was scheduled to undergo a total mastectomy. We decided to administer total intravenous anaesthesia with remimazolam to minimize haemodynamic changes. Although the patient showed transient hypotension after anaesthesia induction, the cardiac index was preserved with a low dose of continuous noradrenaline. The anaesthesia was then safely maintained without a decrease in the patient’s cardiac index.ConclusionsGeneral anaesthesia using remimazolam preserved cardiac output in this patient; therefore, remimazolam can be safely used to avoid the risk of cardiac suppression in patients with severe AS.

Effect of remimazolam induction on hemodynamics in patients undergoing valve replacement surgery: A randomized, double-blind, controlled trial.

BackgroundThe stability of hemodynamics during anesthesia induction in patients undergoing valve replacement surgery is particularly important. Remimazolam is a new type of benzodiazepine drug, with supposed advantages of rapid induction, rapid recovery, stable hemodynamics, and mild respiratory inhibition.AimTo evaluate the effect of remimazolam anesthesia induction on hemodynamics in patients undergoing valve replacement surgery.MethodsThis randomized, double‐blind, controlled trial enrolled consecutive patients undergoing mitral valve replacement (MVR)/aortic valve replacement (AVR)/double‐valve replacement (DVR) surgery on cardiopulmonary bypass (CPB). The study was conducted according to the Consolidated Standards of Reporting Trials statement. Participants were randomly assigned to receive either remimazolam or propofol induction of 30 patients each. All patients, data collectors, and data analyzers were blinded to the group allocation. The primary outcomes were the fluctuations in hemodynamic parameters (the difference of maximum or minimum heart rate to baseline, ▲HR, the difference of maximum or minimum mean arterial pressure to baseline, ▲MAP), the occurrence of cardiovascular events (hypotension, severe bradycardia), and the cumulative norepinephrine doses used per patient, averaged per group during induction. The secondary outcomes were hemodynamic parameters (heart rate, HR, mean arterial pressure, MAP, bispectral index, BIS, plasma lactic acid, Lac, and blood glucose, Glu values).ResultsA total of 60 patients with heart valve replacement were included in the final analysis, with 30 patients in each group. The ▲MAP was significantly lower in the remimazolam group than in the propofol group during induction (p < .05). The incidences of hypotension and the cumulative norepinephrine doses used per patient, averaged per group during induction were significantly lower in the remimazolam group than in the propofol group (p < .05).ConclusionRemimazolam may be safe and effective for induction and may as an alternative to propofol during anesthesia induction in patients undergoing valve replacement surgery.

A Case of Heart Transplantation after Ischaemic Preconditioning

A case of successful heart transplantation from a donor that suffered an out of hospital cardiac arrest lasting approximately one hour is presented. The recipient, a 27-year-old female nurse, was diagnosed with arrhythmogenic right ventricular cardiomyopathy in 2012. The donor was a 24-year-old male who after consuming an unknown quantity of alcohol and cocaine aboard a yacht was found floating face-down in the sea. The patient to be pulseless and CPR commenced after 7 minutes. The length of time that he spent in the sea was unknown. Return of spontaneous circulation (ROSC) occurred after 20 minutes of CPR on site. However, the patient arrested again in the ambulance and CPR was performed until he arrived Hospital, still in cardiac arrest. The patient arrested three more times before achieving a stable circulation. He was transferred to the intensive care unit on high doses of Noradrenaline and Adrenaline to maintain an adequate mean arterial blood pressure. An initial echocardiogram (ECHO) revealed a hypocontractile left ventricle (LV) with an estimated ejection fraction (EF) of 30%.Over the following 3 days the patient’s cardiac function improved. He was weaned off inotropic support and a repeat ECHO showed a normal LV with an EF of 70%. A brain MRI showed diffuse swelling consistent with global hypoxic injury with wide areas of cortical and basal ganglia infarction. The patient’s parents gave their consent and he was offered for organ transplantation on day 6. The operation was successful, with the recipient making an uneventful recovery. She received immunosuppressive treatment with cyclosporine, prednisolone and azathioprine and experienced one episode of early mild rejection with full resolution. She remains well 8 months later.

The additional use of methylene blue has a decatecholaminisation effect on cardiac vasoplegic syndrome after cardiac surgery

BackgroundPostoperative vasoplegia with minimal responsiveness to vasopressors is common after cardiac surgery. Called cardiac vasoplegic syndrome (CVS), it is caused by multiple factors. Treating CVS involves a high dose of fluids and catecholamines, however high doses of catecholamines and fluids are associated with serious side effects. There is evidence that new therapeutic strategies can lead to a reduction in norepinephrine doses and mortality in CVS. Specifically, the use of non-adrenergic vasopressors such as methylene blue (MB) can be beneficial.MethodsWe retrospectively analyzed the electronic records of 8716 adult cardiac surgery patients from November 2008 to December 2016. Medication, hemodynamic and outcome parameter data were analyzed for CVS until discharge. We determined CVS according to the following parameters: a postoperative onset of ≤24 h, a reduced mean arterial pressure (MAP) of < 70 mmHg, a dose of norepinephrine ≥0.8 mg*h− 1 and a continuously increasing need for catecholamine, without ventricular dysfunction.ResultsWe identified 513 patients with CVS. Perioperative risk factors were higher in patients treated with methylene blue (MB). Before MB administration patients had a significantly higher dose of norepinephrine, and MAP increased after MB administration. Norepinephrine could be reduced after MB administration and MAP remained stable at the same level even after the reduction of norepinephrine.ConclusionsCVS patients have a severe systemic disease accompanied by significant operative stress and a high catecholamine requirement. The administration of MB in addition to standard treatment for CVS in the first 24 h was accompanied by an increase in MAP followed by a decrease in vasopressor requirement, indicating that early MB administration can be beneficial.

Predictors of Lethal Outcomes in Patients with Refractory Septic Shock

Early prediction of disease severity helps clinicians prevent adverse events and/or minimize losses in the event of a life-threatening complication. This provision fully applies to refractory septic shock, in which norepinephrine administration at a dose exceeding 0.5 μg/kg-1/min-1 is needed to maintain mean arterial pressure.The objective: to determine predictors of lethal outcomes in patients with refractory septic shock.Subjects and methods. A retrospective study included 79 patients with refractory septic shock aged from 42 to 74 years (59.7 ± 7.8), with severity of the condition as per SOFA varying from 8 to 16 scores. The predictive value of indicators was assessed using univariate and multivariate analyses.Results. In multivariate analysis, the only significant predictor of an unfavorable outcome was the SOFA score (adj. OR: 1.626 [95% CI: 1.313; 2.014], p &lt; 0.001). Other putative indicators (age, oxygenation index, lactate and procalcitonin concentrations, and norepinephrine dose) had no predictive value.Conclusion: The SOFA score is an independent predictor of lethality in adult patients with refractory septic shock (аdj. OR: 1.26 [95% CI: 1.313; 2.014], p &lt; 0.001). According to the results of the ROC analysis, along with SOFA, norepinephrine dose was also a significant predictor (AUC 0.989 [95% CI 0.934; 1.000], p &lt; 0.001).

Individualized resuscitation strategy for septic shock formalized by finite mixture modeling and dynamic treatment regimen

BackgroundSeptic shock comprises a heterogeneous population, and individualized resuscitation strategy is of vital importance. The study aimed to identify subclasses of septic shock with non-supervised learning algorithms, so as to tailor resuscitation strategy for each class.MethodsPatients with septic shock in 25 tertiary care teaching hospitals in China from January 2016 to December 2017 were enrolled in the study. Clinical and laboratory variables were collected on days 0, 1, 2, 3 and 7 after ICU admission. Subclasses of septic shock were identified by both finite mixture modeling and K-means clustering. Individualized fluid volume and norepinephrine dose were estimated using dynamic treatment regime (DTR) model to optimize the final mortality outcome. DTR models were validated in the eICU Collaborative Research Database (eICU-CRD) dataset.ResultsA total of 1437 patients with a mortality rate of 29% were included for analysis. The finite mixture modeling and K-means clustering robustly identified five classes of septic shock. Class 1 (baseline class) accounted for the majority of patients over all days; class 2 (critical class) had the highest severity of illness; class 3 (renal dysfunction) was characterized by renal dysfunction; class 4 (respiratory failure class) was characterized by respiratory failure; and class 5 (mild class) was characterized by the lowest mortality rate (21%). The optimal fluid infusion followed the resuscitation/de-resuscitation phases with initial large volume infusion and late restricted volume infusion. While class 1 transitioned to de-resuscitation phase on day 3, class 3 transitioned on day 1. Classes 1 and 3 might benefit from early use of norepinephrine, and class 2 can benefit from delayed use of norepinephrine while waiting for adequate fluid infusion.ConclusionsSeptic shock comprises a heterogeneous population that can be robustly classified into five phenotypes. These classes can be easily identified with routine clinical variables and can help to tailor resuscitation strategy in the context of precise medicine.

Predictors of prolonged hypotension requiring vasopressor support after resection of pheochromocytoma and paraganglioma.

Prolonged hypotension is a common complication after resection of pheochromocytoma (PCC) or paraganglioma (PGL). The objective of our study was to identify preoperative or intraoperative clinical factors that can predict prolonged hypotension after PCC/PGL resection. A total of 414 patients who underwent resection of PCC or PGL at our institution between January 2013 and January 2020 were included. Patients were divided into two groups according to whether or not vasopressor support was required postoperatively. Associations between preoperative and intraoperative variables and prolonged hypotension were evaluated. Two hundred and one (48.6%) patients had postoperative hypotension that required vasopressor support with a median duration of 20 h. Multivariable analysis demonstrated that increased 24-hurinary norepinephrine (NE) levels (odds ratio [OR] = 1.091, 95% confidence interval [CI]: 1.052-1.132, p < .001), longer operative time (OR = 1.008, CI: 1.004-1.011, p < .001)and lower preoperative phenoxybenzamine dose (OR = 0.336, CI: 0.150-0.753, p = .008) were predictors of prolonged hypotension. Moreover, operative time, body mass index, 24-hurinary level of NEand preoperative phenoxybenzamine dose were significantly correlated with the duration of postoperative vasopressor support. Increased urine NE level, longer operative timeand lower preoperative phenoxybenzamine dose were predictors of prolonged hypotension requiring vasopressor support. Clinicians can identify these factors to manage their patients better and prevent severe complications.

The ED50 and ED95 of Prophylactic Norepinephrine for Preventing Post-Spinal Hypotension During Cesarean Delivery Under Combined Spinal-Epidural Anesthesia: A Prospective Dose-Finding Study.

Background: Hypotension commonly occurs with spinal anesthesia during cesarean delivery. Norepinephrine is an alternative to phenylephrine which can be used to prevent or treat hypotension, with better maintained cardiac output and less bradycardia. However, an appropriate initial prophylactic infusion dose of norepinephrine remains unclear. The aim of this study was to describe the dose-response relationship of prophylactic norepinephrine infusion during cesarean delivery under combined spinal-epidural anesthesia. Methods: We performed a prospective, randomized, double-blinded dose-finding study. One hundred patients undergoing elective cesarean delivery were randomly assigned to receive an infusion of norepinephrine at 0, 0.025, 0.05, 0.075 or 0.1 μg/kg/min initiated immediately after intrathecal injection of 10 mg bupivacaine combined with 5 µg sufentanil. An effective dose was considered when there was no hypotension (systolic blood pressure < 90 mm Hg or < 80% of baseline) during the time period from injection of intrathecal local anesthetic to delivery of the neonate. The primary aim was to determine the dose-response relationship of norepinephrine to prevent spinal anesthesia-induced hypotension. The median effective dose (ED50) and 95% effective dose (ED95) for norepinephrine were calculated utilizing probit analysis. Results: The proportion of patients with hypotension was 80, 70, 40, 15 and 5% at norepinephrine doses of 0, 0.025, 0.05, 0.075 and 0.1 μg/kg/min, respectively. The ED50 and ED95 were 0.042 (95% CI, 0.025–0.053) µg/kg/min and 0.097 (95% CI, 0.081–0.134) µg/kg/min, respectively. There were no differences in the Apgar scores (p = 0.685) or umbilical arterial pH (p = 0.485) measurements of the newborns among the treatment groups. Conclusion: A norepinephrine infusion of 0.1 μg/kg/min as an initial starting dose was effective for the prevention of spinal-induced hypotension.

Impact of combined nerve blocks on the outcome of hip replacement in elderly patients with acute cerebral infarction

Objective: To investigate the impact of ultrasound-guided lumbar plexus, sciatic nerve and L1 paravertebral combined nerve blocks on the outcomes of elderly acute cerebral infarction patients with femoral neck fracture who underwent hip replacement. Methods: The clinical data of 114 elderly acute cerebral infarction patients with femoral neck fracture and underwent artificial hip replacement surgery from May 2013 to September 2018 in Renmin Hospital of Wuhan University were retrospectively analyzed. The patients were divided into two groups based on the different anesthetic methods they received: general anesthesia (G group, n=48), lumbar plexus, sciatic nerve and L1 paravertebral combined nerve blocks (N group, n=66). The operation time, anesthesia time, blood loss, urine volume, norepinephrine dose, length of intensive care unit (ICU) stay, hospital mortality and postoperative 6-month mortality were observed and compared between the two groups. The mini-mental state examination (MMSE) scores and the national institute of health stroke scale (NIHSS) scores were evaluated, respectively. Meanwhile, plasma D-Dimer and S100β levels were measured 1 d before surgery, 3 d and 7 d after surgery. Results: There were no significant differences in the baseline characteristics, operation time, anesthesia time, blood loss and length of ICU stay between the two groups (all P>0.05). Compared with group G, the dosage of norepinephrine [(86±23) μg vs (184±28) μg], hospital mortality [7.6% (5/66) vs 25.0% (12/48)] and postoperative 6-month mortality [12.1% (8/66) vs 31.3% (15/48)] were significantly decreased in group N, while the urine volume [(265±58) ml vs (160±55) ml] was significantly increased (all P<0.01). The MMSE scores (9.9±3.0 vs 14.6±2.4) in group N were significantly higher than those in the group G 3 d after surgery, while the NIHSS scores (15.3±3.2 vs 9.9±3.5), plasma D-Dimer [(10.8±2.5) mg/L vs (7.3±2.2) mg/L] and S100β levels [(326±35) ng/L vs (276±29) ng/L] were significantly lower than those in group G (all P<0.01). Conclusion: Combined nerve blocks can reduce the mortality of acute cerebral infarction patients undergoing hip replacement surgery, and improve the brain function and prognosis of the patients.

Associations between peripheral perfusion disorders, mean arterial pressure and dose of norepinephrine administrated in the early phase of septic shock.

The aim of the study was to explore the correlations between peripheral perfusion, mean arterial pressure and the dose-rate of norepinephrine (NE) infused for the treatment of septic shock. The study is retrospective analysis of data acquired prospectively on 57 patients during the first 24hours after the occurrence of the shock. Clinical and haemodynamic characteristics, skin perfusion parameters (capillary refill time [CRT], mottling score and temperature gradients) and the dose rate of NE infusion were collected. Negative correlations between mean arterial pressure (MAP) and temperature gradients (core-to-toe: P=.03, core-to-index: P=.04) were found and abnormal CRT was associated with lower MAP (P=.02). The dose rate of NE was negatively correlated with temperature gradients (core-to-toe: P=.02, core-to-index: P=.01, forearm-to-index: P=.008) in the overall population. In patients receiving NE for at least 12hours, the NE dose rate positively was correlated with the mottling score (P=.006), temperature gradients (core-to-toe: P=.04, forearm-to-index: P=.02, core-to-index: P=.005) and CRT (P=.001). The dose of NE administrated was associated with 14-days mortality (odds ration [OR]=1.21 [1.06-1.38], P=.006) and with 28-days mortality (OR=1.17 [1.01-1.36], P=0.04). In conclusion, the study described the presence of correlations between peripheral perfusion and MAP and between peripheral perfusion and the dose rate of NE infusion.