Vasopressor Dose Research Articles

Vasopressin and methylprednisolone and hemodynamics after in-hospital cardiac arrest – A post hoc analysis of the VAM-IHCA trial

IntroductionThe Vasopressin and Methylprednisolone for In-Hospital Cardiac Arrest (VAM-IHCA) trial demonstrated a significant improvement in return of spontaneous circulation (ROSC) with no clear effect on long-term outcomes. The objective of the current manuscript was to evaluate the hemodynamic effects of intra-cardiac arrest vasopressin and methylprednisolone during the first 24 hours after ROSC. MethodsThe VAM-IHCA trial randomized patients with in-hospital cardiac arrest to a combination of vasopressin and methylprednisolone or placebo during the cardiac arrest. This study is a post hoc analysis focused on the hemodynamic effects of the intervention after ROSC. Post-ROSC data on the administration of glucocorticoids, mean arterial blood pressure, heart rate, blood gases, vasopressor and inotropic therapy, and sedation were collected. Total vasopressor dose between the two groups was calculated based on noradrenaline-equivalent doses for adrenaline, phenylephrine, terlipressin, and vasopressin. ResultsThe present study included all 186 patients who achieved ROSC in the VAM IHCA-trial of which 100 patients received vasopressin and methylprednisolone and 86 received placebo. The number of patients receiving glucocorticoids during the first 24 hours was 22/86 (26%) in the placebo group and 14/100 (14%) in the methylprednisolone group with no difference in the cumulative hydrocortisone-equivalent dose. There was no significant difference between the groups in the mean cumulative noradrenaline-equivalent dose (vasopressin and methylprednisolone: 603 ug/kg [95CI% 227; 979] vs. placebo: 651 ug/kg [95CI% 296; 1007], mean difference −48 ug/kg [95CI% −140; 42.9], p = 0.30), mean arterial blood pressure, or lactate levels. There was no difference between groups in arterial blood gas values and vital signs. ConclusionTreatment with vasopressin and methylprednisolone during cardiac arrest caused no difference in mean arterial blood pressure, vasopressor use, or arterial blood gases within the first 24 hours after ROSC when compared to placebo.

Identification of indications for albumin administration in septic patients with liver cirrhosis

BackgroundAlbumin infusion is the primary therapeutic strategy for septic patients with liver cirrhosis. Although recent studies have investigated the efficacy of albumin in the resuscitation stage of septic patients with liver cirrhosis, it remains unclear whether daily albumin administration can improve outcomes. Furthermore, the indications for initiating albumin therapy are not well defined.MethodsSeptic patients with liver cirrhosis were obtained from the Medical Information Mart for Intensive Care (MIMIC-IV 2.0) database. Marginal structural Cox models were employed to investigate the association between daily albumin infusion and 28-day mortality. We also aimed to explore under what circumstances enrolled patients could benefit most from albumin administration, based on the clinical parameters collected on the day of albumin infusion, including serum albumin concentration, serum lactate concentration, mean arterial pressure (MAP), and vasopressor dosage.ResultsA total of 2265 patients were included in the final analysis, of whom 1093 (48.3%) had received albumin treatment at least once. The overall 28-day mortality was 29.6%. After marginal structural modeling, daily albumin infusion was associated with a reduced risk of 28-day death (hazard ratio, 0.76; 95% CI 0.61–0.94). We found that patients benefit most from albumin infusion when initiated on the day of serum albumin concentration between 2.5 and 3.0 g/dL, serum lactate concentration greater than or equal to 2 mmol/L, MAP less than 60 mmHg, or vasopressor dosage between 0.2 and 0.3 mcg/kg/min (norepinephrine equivalent, NEE).ConclusionsAlbumin infusion is associated with a reduction in mortality in septic patients with liver cirrhosis under specific circumstances. Serum albumin concentration, serum lactate, MAP, and vasopressor dosage were found to be modifiers of treatment effectiveness and should be considered when deciding to initial albumin infusion.

Balanced volatile sedation with isoflurane in critically ill patients with aneurysmal subarachnoid hemorrhage - a retrospective observational study.

In patients with severe aneurysmal subarachnoid hemorrhage (SAH) deep sedation is often used early in the course of the disease in order to control brain edema formation and thus intracranial hypertension. However, some patients do not reach an adequate sedation depth despite high doses of common intravenous sedatives. Balanced sedation protocols incorporating low-dose volatile isoflurane administration might improve insufficient sedation depth in these patients. We retrospectively analyzed ICU patients with severe aneurysmal SAH who received isoflurane in addition to intravenous anesthetics in order to improve insufficient sedation depth. Routinely recorded data from neuromonitoring, laboratory and hemodynamic parameters were compared before and up to 6 days after initiation of isoflurane. Sedation depth measured using the bispectral index improved in thirty-six SAH patients (-15.16; p = 0.005) who received additional isoflurane for a mean period of 9.73 ± 7.56 days. Initiation of isoflurane sedation caused a decline in mean arterial pressure (-4.67 mmHg; p = 0.014) and cerebral perfusion pressure (-4.21 mmHg; p = 0.013) which had to be balanced by increased doses of vasopressors. Patients required increased minute ventilation in order to adjust for the increase in PaCO2 (+2.90 mmHg; p < 0.001). We did not detect significant increases in mean intracranial pressure. However, isoflurane therapy had to be terminated prematurely in 25% of the patients after a median of 30 h due to episodes of intracranial hypertension or refractory hypercapnia. A balanced sedation protocol including isoflurane is feasible for SAH patients experiencing inadequately shallow sedation. However, therapy should be restricted to patients without impaired lung function, hemodynamic instability and impending intracranial hypertension.

#3436 EFFICACY OF ADJUNCT HEMOPERFUSION VERSUS STANDARD MEDICAL THERAPY ON 28-DAY MORTALITY IN LEPTOSPIROSIS PATIENTS WITH RENAL FAILURE AND SHOCK

Abstract Background and Aims Leptospirosis, a ubiquitous zoonotic infection in the Philippines, is a classic representation of sepsis-induced multi-organ dysfunction with its life-threatening complications: pulmonary hemorrhage, renal and liver failure. Despite pre-established treatment guidelines, leptospirosis- induced morbidity and mortality continue to rise. Hemoperfusion with HA 330 is a promising adjunct therapy as it removes rogue cytokines responsible for the dysregulated inflammatory response in severe sepsis. However, studies on its survival benefit have yielded conflicting results, so far. This study was designed to assess the efficacy and safety of hemoperfusion among leptospirosis patients in septic shock and renal failure, in terms of improvement in 28-day mortality, SOFA score, level of inflammatory markers, hemodynamics, renal and pulmonary function. Method This is an open-label randomized controlled trial which enrolled a total of 37 adult presumptive leptospirosis patients with early signs of septic shock and acute renal failure. The study participants were randomized into either of the two treatment arms: 1. standard medical therapy (SMT) alone or 2. SMT + HA330 Hemoperfusion (HP). All patients were managed based on the NKTI Leptospirosis treatment protocol (hydration, antibiotics, three-day steroid pulsing, single cyclophosphamide dose and respective organ support) and were placed on daily intermittent hemodialysis. Subjects randomized to the HP group received three hemoperfusion sessions (on top of SMT). Vital signs, urine output, vasopressor dose, P/F ratio and biochemical parameters (including level of inflammatory markers) of patients from each treatment arm were measured at baseline, day 3 and day 7 and compared subsequently. Monitoring of participants continued until 28 days post-randomization. Descriptive statistics was used to summarize the general and clinical characteristics of the participants. Independent Sample T-test, Mann-Whitney U test, and Fisher's Exact/Chi-square test was used to determine the difference of mean, median and frequency between hemoperfusion group and control group, respectively. Mean, median, or risk difference and their corresponding 95% confidence intervals were calculated. Friedman test or Wilcoxon's signed-rank test were used to determine whether differences between groups were significant over time. Intention to treat and per protocol analyses were performed. Null hypothesis was rejected at 0.05α-level of significance. Stata 15.0 (StataCorp LLC, TX) was used for data analysis. Results Hemoperfusion conferred a 36.84% (p = 0.017) risk reduction in 28-day mortality. Serial monitoring of inflammatory markers and SOFA score of patients showed significant improvement in sepsis score (p = 0.018 HP, 0.002 SMT) and levels of procalcitonin (p = 0.013 HP, 0.003 SMT), IL6 (p = 0.033 HP, 0.020 SMT) and lactate (p&amp;lt; 0.001 HP, 0.021 SMT) in both treatment arms, from baseline to Day 7. There is, however, no statistically significant difference in the change in SOFA (p = 0.965) and inflammatory marker levels if we compare HP versus SMT (p = 0.997, 0.451, 0.858, 0.052 for hsCRP, procalcitonin, IL6 and lactate, respectively). Statistically significant improvement in serum creatinine (p = 0.04) and PF ratio (p = 0.045) were observed in the hemoperfusion cohort as early as Day 3. Vasopressor dose did not differ significantly between two groups (p = 0.792). No adverse events were observed in both treatment arms. Conclusion Hemoperfusion is a safe and effective adjunct therapy in managing severe sepsis. It promotes earlier renal and pulmonary function recovery and, in doing so, improves survival of septic shock patients.

Lack of Association of Initial Vasopressor Dosing with Survival and Cardiac Re-Arrest Likelihood After Return of Spontaneous Circulation

BackgroundCardiac arrest occurs in approximately 350,000 patients outside the hospital and approximately 30,000 patients in the emergency department (ED) annually in the United States. When return of spontaneous circulation (ROSC) is achieved, hypotension is a common complication. However, optimal dosing of vasopressors is not clear. ObjectiveThe objective of this study was to determine if initial vasopressor dosing was associated with cardiac re-arrest in patients after ROSC. MethodsThis was a retrospective, single-center analysis of adult patients experiencing cardiac arrest prior to arrival or within the ED. Patients were assigned to one of four groups based on starting dose of vasopressor: low dose (LD; < 0.25 µg/kg/min), medium dose (MD; 0.25–0.49 µg/kg/min), high dose (HD; 0.5–0.99 µg/kg/min), and very high dose (VHD; ≥ 1 µg/kg/min). Data collection was performed primarily via manual chart review of medical records. The primary outcome was incidence of cardiac re-arrest within 1 h of vasopressor initiation. Multivariate logistic regression analysis was conducted to identify any covariates strongly associated with the primary outcome. ResultsNo difference in cardiac re-arrest incidence was noted between groups. The VHD group was significantly more likely to require a second vasopressor (p = 0.003). The HD group had lower survival rates to hospital discharge compared with the LD and MD groups (p = 0.0033 and p = 0.0147). In the multivariate regression, longer duration of pre-vasopressor re-arrests and hyperkalemic cardiac arrest etiology were significant predictors of cardiac re-arrest after vasopressor initiation. ConclusionsInitial vasopressor dosing was not found to be associated with risk of cardiac re-arrest or, conversely, risk of adverse events.

P3: ECMO and Calcium Channel Blocker Overdose: A Systematic Review

Introduction: The increasing indications and prevalence of extracorporeal membrane oxygenation (ECMO) are evident by the exponential increase in ECMO in the last decade. In recent literature, ECMO use has sustained patients who have intentionally or unintentionally overdosed on cardiac medications. Specifically, calcium channel blocker overdose (CCBOD) can lead to significant cardiopulmonary dysfunction and has increased in recent years. Calcium channel blockers (CCB) block L-type voltage gated calcium channels throughout the body, and overdose results in cardiac depression, vasoplegia, and hyperglycemia. Expert consensus and poison control centers both recommend treatment with calcium, high dose insulin, inotropes, and vasopressors. Our systematic review evaluated when to initiate ECMO in the CCBOD population and the mortality rate with ECMO use. Methods: An electronic literature review was conducted to identify all relevant studies for CCB use and ECMO. PRISMA guidelines for systematic review were followed. Rayyan was used as a screening tool for blinding the authors from each other, and abstracts and full texts were reviewed by three independent authors. Inclusion criteria were strictly limited to CCB ingestion without polypharmacy. A data collection tool was devised and data was independently collected by two authors prior to statistical analysis. Data points included demographics, a list of currently recommended medical treatments for CCBOD, ECMO cannulation type, and survival to hospital discharge. Results: After exclusion of duplicates, 314 abstracts were reviewed; of these 25 papers were included from 6 different countries, with the median year of the study publication 2019. From the 25 papers, 26 patients were studied with an average patient age of 32.7 years with 42% male and 58% female. Between male and female there was no significant difference in age, type of CCB taken, or days on ECMO. Average time on ECMO was 4.3 days. Venoarterial and venovenous ECMO use were 92.3% and 7.7%, respectively. Survival to hospital discharge was 84.6%. Prior to ECMO cannulation, patients received up to six medical treatments for CCBOD, with the majority receiving four to five treatments (53.8%). There was no correlation between number of therapies and days on ECMO (r=0.092, P=0.684). Conclusion: Our systematic review demonstrates that ECMO is a newly used and possibly valuable therapy for CCBOD when medical treatment fails. Most patients received aggressive medical therapies and still were unstable enough to require ECMO. Survival to discharge after ECMO for CCBOD is substantially higher than standard VV or VA ECMO uses. While medical management is still the main therapy for CCBOD, our results show that a persistently unstable patient may benefit from prompt evaluation at an ECMO center for treatment.

Amiodarone induced myxedema coma presenting with cardiogenic shock and junctional rhythm

We describe the case of an elderly female, with no prior history of thyroid dysfunction, who presented with facial swelling and worsening fatigue. She was found to have myxedema coma, with thyroid-stimulating hormone (TSH) 98.90 uIU/mL and free thyroxine (fT4) 0.8 ng/dL, following two months of amiodarone therapy for paroxysmal atrial fibrillation. The patient developed cardiogenic shock and received liothyronine, levothyroxine, stress dose steroids, inotropic and vasopressor therapy while in the intensive care unit (ICU). She was weaned off vasopressors and switched to oral levothyroxine with a gradual steroid taper. Two months following hospital discharge, the patient remained asymptomatic while on oral levothyroxine. Literature lacks cases of amiodarone-induced myxedema coma and to our knowledge, myxedema coma secondary to amiodarone use has never been reported in patient on treatment for as short as two months. This case demonstrates the significance of early diagnosis and prompt treatment for rapid progression of signs and symptoms of amiodarone-induced myxedema coma to optimize outcomes. Although transient changes are seen while on amiodarone therapy, continuous monitoring is essential to examine for apparent thyroid dysfunction. Thyroid function testing prior to initiation of amiodarone and in cases of cardiac dysrhythmias or cardiogenic shock can help to avoid potentially fatal complication of hypothyroidism.

Immediate Norepinephrine in Endotoxic Shock: Effects on Regional and Microcirculatory Flow.

To investigate the effects of immediate start of norepinephrine versus initial fluid loading followed by norepinephrine on macro hemodynamics, regional splanchnic and intestinal microcirculatory flows in endotoxic shock. Animal experimental study. University translational research laboratory. Fifteen Landrace pigs. Shock was induced by escalating dose of lipopolysaccharide. Animals were allocated to immediate start of norepinephrine (i-NE) ( n = 6) versus mandatory 1-hour fluid loading (30 mL/kg) followed by norepinephrine (i-FL) ( n = 6). Once mean arterial pressure greater than or equal to 75 mm Hg was, respectively, achieved, successive mini-fluid boluses of 4 mL/kg of Ringer Lactate were given whenever: a) arterial lactate greater than 2.0 mmol/L or decrease less than 10% per 30 min and b) fluid responsiveness was judged to be positive. Three additional animals were used as controls (Sham) ( n = 3). Time × group interactions were evaluated by repeated-measures analysis of variance. Hypotension was significantly shorter in i-NE group (7.5 min [5.5-22.0 min] vs 49.3 min [29.5-60.0 min]; p < 0.001). Regional mesenteric and microcirculatory flows at jejunal mucosa and serosa were significantly higher in i-NE group at 4 and 6 hours after initiation of therapy ( p = 0.011, p = 0.032, and p = 0.017, respectively). Misdistribution of intestinal microcirculatory blood flow at the onset of shock was significantly reversed in i-NE group ( p < 0.001), which agreed with dynamic changes in mesenteric-lactate levels ( p = 0.01) and venous-to-arterial carbon dioxide differences ( p = 0.001). Animals allocated to i-NE showed significantly higher global end-diastolic volumes ( p = 0.015) and required significantly less resuscitation fluids ( p < 0.001) and lower doses of norepinephrine ( p = 0.001) at the end of the experiment. Pulmonary vascular permeability and extravascular lung water indexes were significantly lower in i-NE group ( p = 0.021 and p = 0.004, respectively). In endotoxemic shock, immediate start of norepinephrine significantly improved regional splanchnic and intestinal microcirculatory flows when compared with mandatory fixed-dose fluid loading preceding norepinephrine. Immediate norepinephrine strategy was related with less resuscitation fluids and lower vasopressor doses at the end of the experiment.

Temporal relationship between vasopressor and sedative administration and cerebrovascular response in traumatic brain injury: a time-series analysis

BackgroundAlthough vasopressor and sedative agents are commonly used within the intensive care unit to mediate systemic and cerebral physiology, the full impact such agents have on cerebrovascular reactivity remains unclear. Using a prospectively maintained database of high-resolution critical care and physiology, the time-series relationship between vasopressor/sedative administration, and cerebrovascular reactivity was interrogated. Cerebrovascular reactivity was assessed through intracranial pressure and near infrared spectroscopy measures. Using these derived measures, the relationship between hourly dose of medication and hourly index values could be evaluated. The individual medication dose change and their corresponding physiological response was compared. Given the high number of doses of propofol and norepinephrine, a latent profile analysis was used to identify any underlying demographic or variable relationships. Finally, using time-series methodologies of Granger causality and vector impulse response functions, the relationships between the cerebrovascular reactivity derived variables were compared.ResultsFrom this retrospective observational study of 103 TBI patients, the evaluation between the changes in vasopressor or sedative agent dosing and the previously described cerebral physiologies was completed. The assessment of the physiology pre/post infusion agent change resulted in similar overall values (Wilcoxon signed-ranked p value > 0.05). Time series methodologies demonstrated that the basic physiological relationships were identical before and after an infusion agent was changed (Granger causality demonstrated the same directional impact in over 95% of the moments, with response function being graphically identical).ConclusionsThis study suggests that overall, there was a limited association between the changes in vasopressor or sedative agent dosing and the previously described cerebral physiologies including that of cerebrovascular reactivity. Thus, current regimens of administered sedative and vasopressor agents appear to have little to no impact on cerebrovascular reactivity in TBI.

Cardioprotective role of the coenzyme Q10 and coconut oil in acute aluminum phosphide poisoning: a randomized controlled clinical trial.

Aluminum phosphide (ALP)-induced cardiotoxicity is a major cause of high mortality rates. As there is no specific antidote, restoring cardiac hemodynamics is the cornerstone for saving patients. Based on oxidative stress theory in acute ALP poisoning, we examined the cardioprotective role of coconut oil and Coenzyme Q10 (COQ10) in ALP poisoning, focusing on their antioxidant capacity. This study was a randomized, controlled, single-blind, phase II clinical trial conducted at Tanta Poison Control Center over 1 year. Eighty-four ALP poisoned patients received supportive treatment and were randomly allocated to three equal groups. Gastric lavage was performed using sodium bicarbonate 8.4% with saline in group I. Alternatively, group II received 50ml coconut oil, and group III initially received 600mg CoQ10 dissolved in 50ml coconut oil; and repeated 12hours later. In addition to patient characteristics, clinical, laboratory, electrocardiography (ECG), and total antioxidant capacity (TAC) data were recorded and repeated 12hours later. Patient outcomes were evaluated. There was no significant difference among groups considering patient characteristics, initial cardiotoxicity severity, vital, laboratory data, ECG changes, and TAC. However, 12hours post-admissions, group III was significantly improved in all clinical, laboratory, and ECG parameters than comparable groups. Significant correlations were observed between elevated TAC in groups II and III with hemodynamic, serum troponin, and ECG variables. Accordingly, the need for intubation, mechanical ventilation, and the total vasopressor dose was significantly decreased in group III compared with other groups. Therefore, coconut oil and COQ10 are promising cardioprotective adjuvant therapy ameliorating the ALP-induced cardiotoxicity.

Efficacy and safety of remimazolam tosilate versus propofol in patients undergoing day surgery: a prospective randomized controlled trial

BackgroundRemimazolam tosilate (RT) is a novel short-acting GABA (A) receptor agonist that has a rapid recovery from procedural sedation and can be fully reversed by flumazenil. To date, there have been relatively few articles comparing RT and propofol for general anesthesia. This study aimed to assess the efficacy and safety of RT with or without flumazenil compared with propofol in general anesthesia for day surgery.Methods115 patients scheduled for day surgery were randomized into three groups: RT (n = 39), RT + flumazenil (n = 38) and propofol (n = 38). The primary endpoints were anesthesia induction time and time until fully alert. Anesthesia success rate, bispectral index (BIS) values, injection pain, opioid and vasopressor dosages, postoperative recovery profiles and perioperative inflammatory and cognitive changes were assessed. Any adverse events were recorded.ResultsInduction times were similar among the three groups (P = 0.437), but the median time until fully alert in patients treated with RT was longer than that of the propofol or RT + flumazenil groups (17.6 min vs. 12.3 min vs. 12.3 min, P < 0.001). The three groups had comparable postoperative recovery quality and inflammatory and cognitive state changes (P > 0.05). Smaller percentages of patients who received RT (26.3%) and RT + flumazenil (31.6%) developed hypotension during anesthesia maintenance compared with propofol (68.4%), and consequently less ephedrine (P < 0.001) and phenylephrine (P = 0.015) were needed in the RT group. Furthermore, serum triglyceride levels were lower (P < 0.001) and injection pain was much less frequent in the RT with or without flumazenil groups compared with the propofol group (5.3% vs. 0% vs. 18.4%).ConclusionRT permits rapid induction and comparable recovery profile compared with propofol in general anesthesia for day surgery, but has a prolonged recovery time without flumazenil. The safety profile of RT was superior to propofol in terms of hypotension and injection pain.Trial registrationThe study was registered at Chinese Clinical Trial Registry http://www.chictr.org.cn/ (Registration date: 19/7/2021; Trial ID: ChiCTR2100048904).

Fetal heart rate changes and labor neuraxial analgesia: a machine learning approach

BackgroundNeuraxial labor analgesia has been associated with fetal heart rate changes. Fetal bradycardia is multifactorial, and predicting it poses a significant challenge to clinicians. Machine learning algorithms may assist the clinician to predict fetal bradycardia and identify predictors associated with its presentation.MethodsA retrospective analysis of 1077 healthy laboring parturients receiving neuraxial analgesia was conducted. We compared a principal components regression model with tree-based random forest, ridge regression, multiple regression, a general additive model, and elastic net in terms of prediction accuracy and interpretability for inference purposes.ResultsMultiple regression identified combined spinal-epidural (CSE) (p = 0.02), interaction between CSE and dose of phenylephrine (p < 0.0001), decelerations (p < 0.001), and the total dose of bupivacaine (p = 0.03) as associated with decrease in fetal heart rate. Random forest exhibited good predictive accuracy (mean standard error of 0.92).ConclusionUse of CSE, presence of decelerations, total dose of bupivacaine, and total dose of vasopressors after CSE are associated with decreases in fetal heart rate in healthy parturients during labor. Prediction of changes in fetal heart rate can be approached with a tree-based random forest model with good accuracy with important variables that are key for the prediction, such as CSE, BMI, duration of stage 1 of labor, and dose of bupivacaine.

Preemptive parasternal intercostal nerve block for patients undergoing off-pump coronary artery bypass grafting: a double-blind, randomized, controlled trial.

Parasternal intercostal nerve block has been increasingly used for postoperative analgesia and has shown that this technique can provide effective postoperative analgesia. This study aimed to investigate the effect of preemptive parasternal intercostal nerve block on the opioid and vasoactive drug dose required for intraoperative hemodynamic stability and postoperative analgesia in patients undergoing off-pump coronary artery bypass grafting. In this prospective, randomized controlled study, 64 participants aged 45-75 years scheduled for off-pump coronary artery bypass grafting at The Second Xiangya Hospital of Central South University. Patients were randomized into two groups and preoperatively administered ropivacaine (group R) and saline (group S), in the parasternal intercostal spaces with ultrasound-guided bilateral nerve block. The primary outcome was intraoperative sufentanil and vasopressor dosage. The secondary outcomes were intraoperative hemodynamics, postoperative pain scores, and anesthesia recovery, postoperative use of rescue dezocine, stay in intensive care unit, and length of hospital stay. The consumption of intraoperative sufentanil and vasopressor was significantly lower in group R than in group S. The visual analog score in group R was significantly lower than that in group S up to 12 h postoperatively. The time to anesthesia recovery was significantly less in group R than in group S. Most patients in group S required rescue dezocine, whereas most patients in group R did not. The hemodynamic variables were stable in all patients. A preemptive parasternal intercostal nerve block effectively reduced the required intraoperative sufentanil and norepinephrine dose and provided adequate analgesia for the first 12 h after surgery. Therefore, a preemptive parasternal intercostal nerve block is a good option for patients undergoing off-pump coronary artery bypass grafting. chictr.org.cn, identifier ChiCTR1800017210.

To Compare the Side Effect of Dexmedetomidine and Clonidine as an Adjuvant to Intrathecal Bupivacaine in Patients Undergoing Total Abdominal Hysterectomy

Background: Addition of adjuvants to routinely used intrathecal drugs is cornerstone in safe and effective prolongation of single shot spinal block for gynecological surgery. In resource deficient countries, where epidural anaesthesia is usually not used because of cost factor, adjuvants are routinely used to prolong the effect of regional anaesthesia. Alpha 2 agonists are considered best drugs as adjuvants, but there is inconclusive data in literature about the block characteristic, dose at which to be used and side effect after use of these drugs.&#x0D; Methods: A prospective randomized single blind study was conducted in the Department of Anaesthesia IGMC SHIMLA at Kamla Nehru state hospital.&#x0D; Results: Hypotension was seen in 5 patients of Group C and 4 patients of Group D. Three patients in both the groups required 2 doses of Inj mephenteramine and 2 patients in Group C and 1 in Group D required single dose of Vasopressor (Inj mephentermine). (p=0.83). Five patients had bradycardia, 3 Nausea and 3 had shivering in Group C, while only 2 patients had side effects in Group D i.e one patient had bradycardia and another nausea, vomiting. (p= 0.657)&#x0D; Conclusion: We observed hypotension, bradycardia, nausea vomiting and post operative shivering in our patients during the study period but there was no statistical significance achieved amongst the groups. (p&gt;0.05).

Initiating angiotensin II at lower vasopressor doses in vasodilatory shock: an exploratory post-hoc analysis of the ATHOS-3 clinical trial

BackgroundHigh dose vasopressors portend poor outcome in vasodilatory shock. We aimed to evaluate the impact of baseline vasopressor dose on outcomes in patients treated with angiotensin II (AT II).MethodsExploratory post-hoc analysis of the Angiotensin II for the Treatment of High-Output Shock (ATHOS-3) trial data. The ATHOS-3 trial randomized 321 patients with vasodilatory shock, who remained hypotensive (mean arterial pressure of 55–70 mmHg) despite receiving standard of care vasopressor support at a norepinephrine-equivalent dose (NED) > 0.2 µg/kg/min, to receive AT II or placebo, both in addition to standard of care vasopressors. Patients were grouped into low (≤ 0.25 µg/kg/min; n = 104) or high (> 0.25 µg/kg/min; n = 217) NED at the time of study drug initiation. The primary outcome was the difference in 28-day survival between the AT II and placebo subgroups in those with a baseline NED ≤ 0.25 µg/kg/min at the time of study drug initiation.ResultsOf 321 patients, the median baseline NED in the low-NED subgroup was similar in the AT II (n = 56) and placebo (n = 48) groups (median of each arm 0.21 µg/kg/min, p = 0.45). In the high-NED subgroup, the median baseline NEDs were also similar (0.47 µg/kg/min AT II group, n = 107 vs. 0.45 µg/kg/min placebo group, n = 110, p = 0.75). After adjusting for severity of illness, those randomized to AT II in the low-NED subgroup were half as likely to die at 28-days compared to placebo (HR 0.509; 95% CI 0.274–0.945, p = 0.03). No differences in 28-day survival between AT II and placebo groups were found in the high-NED subgroup (HR 0.933; 95% CI 0.644–1.350, p = 0.71). Serious adverse events were less frequent in the low-NED AT II subgroup compared to the placebo low-NED subgroup, though differences were not statistically significant, and were comparable in the high-NED subgroups.ConclusionsThis exploratory post-hoc analysis of phase 3 clinical trial data suggests a potential benefit of AT II introduction at lower doses of other vasopressor agents. These data may inform design of a prospective trial.Trial registration: The ATHOS-3 trial was registered in the clinicaltrials.gov repository (no. NCT02338843). Registered 14 January 2015.

Modifications of peripheral perfusion in patients with vasopressor-dependent septic shock treated with polymyxin B-direct hemoperfusion

Abnormal peripheral perfusion (PP) worsens the prognosis of patients with septic shock. Polymyxin B-direct hemoperfusion (PMX-DHP) increases blood pressure and reduces vasopressor doses. However, the modification of PP following administration of PMX-DHP in patients with vasopressor-dependent septic shock have not yet been elucidated. A retrospective exploratory observational study was conducted in patients with septic shock treated with PMX-DHP. Pulse-amplitude index (PAI), vasoactive inotropic score (VIS), and cumulative fluid balance data were extracted at PMX-DHP initiation (T0) and after 24 (T24) and 48 (T48) h. Changes in these data were analyzed in all patients and two subgroups (abnormal PP [PAI < 1] and normal PP [PAI ≥ 1]) based on the PAI at PMX-DHP initiation. Overall, 122 patients (abnormal PP group, n = 67; normal PP group, n = 55) were evaluated. Overall and in the abnormal PP group, PAI increased significantly at T24 and T48 compared with that at T0, with a significant decrease in VIS. Cumulative 24-h fluid balance after PMX-DHP initiation was significantly higher in the abnormal PP group. PMX-DHP may be an effective intervention to improve PP in patients with abnormal PP; however, caution should be exercised as fluid requirements may differ from that of patients with normal PP.

Comparison of the effect of dexmedetomidine and midazolam under spinal anesthesia for cesarean delivery: a randomized controlled trial, single center study in South Korea.

Cesarean section under spinal anesthesia may cause anxiety and hypotension. Administration of sedative drugs after delivery can diminish these side-effects, but may increase hemodynamic instability. We evaluated the effect of the administration of 0.7 μg/kg dexmedetomidine and compared it with that of 0.03 mg/kg midazolam for usefulness of sedation of the parturient after delivery during cesarean section. After obtaining written consent and the ethics board approval, 60 parturients aged 20-43 years who underwent elective cesarean delivery under spinal anesthesia were recruited. A total of 0.5% hyperbaric bupivacaine (8-10 mg) and intrathecal fentanyl (10 μg) was given to induce anesthesia. Parturients were then randomly allocated to receive either midazolam (0.03 mg/kg; group M) or dexmedetomidine 0.7 (μg/kg; group D) after delivery. The primary outcome measure was patient satisfaction score. Secondary outcomes included vital signs; vasopressor dosage; incidence of shivering, nausea, and vomiting; incidence of bradycardia; time to sensory and motor recovery; postoperative nausea and vomiting score; and postoperative pain visual analog scale at 6, 24, and 48 h. Satisfaction scores for sedation were similar between the two groups. The systolic blood pressure, heart rate, oximetry saturation, and tympanic temperature were comparable between the two groups. The predicted mean systolic blood pressure of group D was 106.3 mmHg and that of group M was 107.5 mmHg. Both groups showed comparable adverse intraoperative and postoperative outcomes. Dexmedetomidine and midazolam showed similar hemodynamic effects and patient satisfaction in parturients under spinal anesthesia.

The Early Mobilization of Patients on Extracorporeal Membrane Oxygenation: A Systematic Review.

Patients on extracorporeal membrane oxygenation (ECMO) often require prolonged periods of bed rest owing to the severity of their illness. Care is also required to maintain the position and integrity of the ECMO cannula. However, they experience a range of effects due to prolonged bed rest. This systematic review examined the possible effects of the early mobilization in patients on ECMO. The database PUBMED was searched by using appropriate keywords: "rehabilitation", "mobilization", "ECMO" and "extracorporeal membrane oxygenation". The selection criteria for the article search were the following: (a) studies published in the last five years, (b) descriptive studies, (c) randomized studies, (d) published in the English language and (e) studies in adults. A total of 259 studies were found, 8 of which were finally selected. Most of the studies showed that early intensive physical rehabilitation related to a decrease in in-hospital stay and a reduction in the duration of mechanical ventilation and doses of vasopressors. In addition, improvements in the functional status and rate of mortality were observed along with a reduction in health care costs. Exercise training should be a fundamental part of the management of patients on ECMO.

Inotrope versus placebo therapy in cardiogenic shock: Rationale and study design of the CAPITAL DOREMI2 trial

Cardiogenic shock (CS) is a state of end-organ hypoperfusion related to cardiac dysfunction. Current guidelines recommend consideration of inotrope therapy in patients with CS, however no robust data support their use. The purpose of the CAPITAL DOREMI2 trial is to examine the efficacy and safety of inotrope therapy against placebo in the initial resuscitation of patients with CS. This is a multi-center, double-blind, randomized, placebo-controlled trial comparing single-agent inotrope therapy to placebo in patients with CS. A total of 346 participants with Society for Cardiovascular Angiography and Interventions class C or D CS will be randomized in a 1:1 fashion to inotrope or placebo therapy, which will be administered over a 12-hour period. After this period, participants will continue open-label therapies at the discretion of the treating team. The primary outcome is a composite of all-cause in-hospital death, and, as measured during the 12-hour intervention period, any of: sustained hypotension or high dose vasopressor requirements, lactate greater than 3.5 mmol/L at 6 hours or thereafter, need for mechanical circulatory support, arrhythmia leading to emergent electrical cardioversion, and resuscitated cardiac arrest. All participants will be followed for the duration of their hospitalization, and secondary outcomes will be assessed at the time of discharge. This trial will be the first to establish the safety and efficacy of inotrope therapy against placebo in a population of patients with CS and has the potential to alter the standard care provided to this group of patients.

EFFECT OF INTRAVENOUS ONDANSETRON PREMEDICATION ON SPINAL ANESTHESIA INDUCED HYPOTENSION IN CESAREAN SECTION - A RANDOMIZED CONTROLLED STUDY.

Background:- Spinal anesthesia is the most common anaesthesia technique for cesarean section. In this technique injection of a local anesthetic agent is injected into the subarachnoid space. The most common complication of spinal anesthesia is hypotension which is due to sympathetic blockade and activation of the Bezold Jarisch reex which leads to the utilization of higher doses of vasopressors for the maintenance of blood pressure. The present study was conducted to compare the effect of intravenous ondansetron premedication on spinal anesthesia-induced hypotension with normal saline. An observa methodology:- tional study was conducted in 180 term parturients of ASA - ІІ, scheduled for elective LSCS under spinal anesthesia. The patients were divided into two equal age groups: ondansetron 4mg (group O, n= 90) and saline group (group S, n= 90). Ondansetron 4mg (2ml) was given 10 min before the procedure in group O and group S received 2ml normal saline. Under all aseptic precautions, subarachnoid space was accessed through L3-L4 or L4-L5 intervertebral space using 25G Quincke's spinal needle. After conrmation of the free ow of CSF, a 2ml hyperbaric injection of bupivacaine 0.5% (Heavy) was administered in the subarachnoid space. Mean arterial pressure less than 65mmHg was considered as hypotension and treated with iv mephentermine 6mg bolus. The Occurrence of hypotension in Group O (22.22%) was signicantly l Result- ower than in group S(61.11%)(p&lt;0.001). The MAP was signicantly higher in Group O at 2,4,6,8,10,12,14,16,20 and 25 minutes (p&lt;0.005). 18 (20%) patients required one dose of mephentermine 6mg, and 2(2.22%) patients required two doses in group O. In group S 40 patients ((44.44%) required one dose of mephentermine 10 patients ((11.11%) ) required two doses and 5 patients (5.55%) required 3 doses. In group O 3 patients (3.33%) and in group S, 12 patients (13.33%) had nausea which was statistically signicant with a P value of 0.01. In group S 12 patients (13.33%) and 4 patients (4.44%) in group O had shivering. Which was statistically signicant with a P value of 0.03. Ondansetron is effective in Conclusion – preventing spinal-induced hypotension in elective cesarean section