Duration Of Vasopressor Use Research Articles

A prospective, randomised clinical study comparing triple therapy regimen to hydrocortisone monotherapy in reducing mortality in septic shock patients

This prospective, comparative and randomised clinical study evaluated the effectiveness of triple therapy regimen (hydrocortisone, thiamine and vitamin C) versus hydrocortisone alone in reducing the mortality rate and preventing progressive organ dysfunction in septic shock patients. A total of 94 patients were randomly assigned to one of two groups: the first group received hydrocortisone 50mg/6-h IV for 7days or till intensive care unit (ICU) discharge, if sooner, followed by tapering. The second group received hydrocortisone 50mg/6-h IV for 7days or ICU discharge followed by tapering, vitamin C 1.5g/6-h IV for 4days or till ICU discharge and thiamine 200mg/12-h IV for 4days or till ICU discharge. The triple therapy regimen showed a non-significant reduction in 28-day mortality compared to hydrocortisone alone (17 [36.2%] vs. 21 [44.7%]; P=.4005), but it was significantly lower than the control group regarding shock time and the duration of vasopressor use in days (4.000 [3.000-7.000]; 5.000 [4.000-8.000], [P=.0100]). The patients in the control group were likely to get 0.59 more in SCr level than those in the intervention group by a linear regression model which was significant (P<.05). Also, the number of patients who developed a fever after 216hours was significantly higher in the control group (P value=.0299). Vitamin C, thiamine, and hydrocortisone regimen for septic shock management showed non-significant efficacy in decreasing 28-day mortality when compared to hydrocortisone monotherapy. On the other hand, it showed significant efficacy in decreasing the shock time and duration on vasopressors.

Benefits of combination therapy of hydrocortisone, ascorbic acid and thiamine in sepsis and septic shock: A systematic review.

Sepsis and septic shock are severe medical conditions that can damage multiple organs with a higher risk of mortality. Recently, the combination of hydrocortisone, ascorbic acid and thiamine (HAT) was hypothesized to work synergistically to reverse septic shock and reduce mortality. To ascertain the efficacy of HAT therapy and compare whether HAT therapy is more beneficial compared to the standard of care in sepsis and septic shock patients. PubMed, Clinicaltrials.gov, Scopus, Web of Science, Cochrane and Embase are databases that were used to identify trials that conducted a study of the combination of HAT in sepsis or septic shock. There were 134 articles identified through a database search and 16 from other sources, which were subsequently reduced to 11 trials (six randomized trials and five non-randomized trials) that were deemed appropriate for inclusion in this review. Most of the outcomes from these studies focused on mortality, the need for renal replacement therapy, duration of vasopressor use, changes in Sequential Organ Failure Assessment score, procalcitonin clearance and lengths of intensive care unit stay. Due to inconsistent results from clinical studies, the benefits of HAT therapy cannot be confirmed at this point in sepsis and septic shock. Currently, there are at least 20 randomized controlled trials testing HAT in various combinations and dosages in patients with severe sepsis and septic shock. The results of these studies are required before definitive conclusions can be made regarding the impact of this novel treatment strategy on the morbidity and mortality of patients with sepsis.

Lipid and lipoprotein predictors of functional outcomes and long-term mortality after surgical sepsis

RationaleSepsis is a life-threatening, dysregulated response to infection. Lipid biomarkers including cholesterol are dynamically regulated during sepsis and predict short-term outcomes. In this study, we investigated the predictive ability of lipid biomarkers for physical function and long-term mortality after sepsis.MethodsProspective cohort study of sepsis patients admitted to a surgical intensive-care unit (ICU) within 24 h of sepsis bundle initiation. Samples were obtained at enrollment for lipid biomarkers. Multivariate regression models determined independent risk factors predictive of poor performance status (Zubrod score of 3/4/5) or survival at 1-year follow-up.Measurements and main resultsThe study included 104 patients with surgical sepsis. Enrollment total cholesterol and high-density lipoprotein (HDL-C) levels were lower, and myeloperoxidase (MPO) levels were higher for patients with poor performance status at 1 year. A similar trend was seen in comparisons based on 1-year mortality, with HDL-C and ApoA-I levels being lower and MPO levels being higher in non-survivors. However, multivariable logistic regression only identified baseline Zubrod and initial SOFA score as significant independent predictors of poor performance status at 1 year. Multivariable Cox regression modeling for 1-year survival identified high Charlson comorbidity score, low ApoA-I levels, and longer vasopressor duration as predictors of mortality over 1-year post-sepsis.ConclusionsIn this surgical sepsis study, lipoproteins were not found to predict poor performance status at 1 year. ApoA-I levels, Charlson comorbidity scores, and duration of vasopressor use predicted 1 year survival. These data implicate cholesterol and lipoproteins as contributors to the underlying pathobiology of sepsis.

Oral Midodrine Administration During the First 24 Hours of Sepsis to Reduce the Need of Vasoactive Agents: Placebo-Controlled Feasibility Clinical Trial.

Objectives:Our preliminary data and observational studies suggested an increasing “off label” use of oral midodrine as a vasopressor sparing agent in various groups of critically ill patients, including those with sepsis. We designed this clinical trial to evaluate the feasibility of use of midodrine hydrochloride in early sepsis to reduce the duration for IV vasopressors and decrease ICU and hospital length of stay.Design:Pilot, two-center, placebo-controlled, double blinded randomized clinical trial.Setting:Medical ICUs at Mayo Clinic Rochester and Cleveland Clinic Abu Dhabi were the study sites.Patients and Methods:Adult patients (≥ 18 yr old) were included within 24 hours of meeting the Sepsis-3 definition if the mean arterial pressure remained less than 70 mm Hg despite receiving timely antibiotics and initial IV fluid bolus of 30 cc/kg.Intervention:Three doses of 10 mg midodrine versus placebo were administered.Measurements and Main Results:Total 32 patients were randomized into midodrine (n = 17) and placebo groups (n = 15). There were no major differences in baseline variables between the groups except for higher baseline creatinine in the midodrine group (2.0 ± 0.9 mg/dL) versus placebo group (1.4 ± 0.6 mg /dL), p = 0.03. The median duration of IV vasopressor requirement was 14.5 ± 8.1 hours in midodrine group versus 18.8 ± 7.1 hours in the placebo group, p value equals to 0.19. Patients in the midodrine group needed 729 ± 963 norepinephrine equivalent compared with 983 ± 1,569 norepinephrine equivalent in the placebo group, p value equals to 0.59. ICU length of stay was 2.29 days (interquartile range, 1.65–3.9 d) in the midodrine group, compared with 2.45 days (interquartile range, 1.6–3.2 d) in the placebo group, p value equals to 0.36. No serious adverse events were observed in either group.Conclusions:Phase II clinical trial powered for clinical outcomes (duration of vasopressor use, need for central venous catheter, and ICU and hospital length of stay) is justified.

Effect of Combined Hydrocortisone, Ascorbic Acid and Thiamine for Patients with Sepsis and Septic Shock: A Systematic Review and Meta-Analysis.

This study aims to assess the effect of HAT therapy on patients with sepsis and septic shock. We searched PubMed, Embase, and Cochrane Library for studies on HAT therapy published up to November 11, 2020. The primary outcome was the duration of vasopressor use. Secondary outcomes were change of Sequential Organ Failure Assessment (SOFA) score within 72 h; death within intensive care unit (ICU), hospital, and 28 or 30 days; length of stay in ICU and hospital; rate of procalcitonin (PCT) clearance and incidence of adverse events. We also used trial sequential analysis (TSA) to assess the reliability of the available evidence. Six randomized controlled trials (RCTs) and seven observational studies enrolling 1,559 patients were included (762 were treated with HAT, and 797 were treated with hydrocortisone alone, standard care or placebo). HAT therapy was associated with significant reductions in duration of vasopressor use (mean differences [MD], -14.68, [95% CI, -24.28 to -5.08], P = 0.003) in RCTs, but not in observational studies (MD, 11.21 [95% CI, -44.93 to 67.35], P = 0.70). HAT therapy was associated with less organ dysfunction at 72 h both in RCTs (MD, -0.86 [95% CI, -1.32 to -0.40], P < 0.001) and observational studies (MD, -2.65 [95% CI, -5.29 to -0.01], P = 0.05). HAT therapy was associated with lower hospital mortality and higher PCT clearance in observational studies. Similar results for the primary outcome were found in the sensitivity analysis. TSA results suggested more trials to reach the required information size. Among patients with sepsis and septic shock, a combination therapy of hydrocortisone, ascorbic acid, and thiamine, compared with placebo, could reduce the duration of vasopressor use and SOFA scores during the first 72 h. PROSPERO registration ID for this study is CRD42020170648 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=170648).

Thiamine combined with vitamin C in sepsis or septic shock: a systematic review and meta-analysis.

Thiamine and vitamin C have been increasingly used in patients with sepsis or septic shock because of their potential for improving metabolism and reducing mortality. We aim to determine if thiamine combined vitamin C can reduce mortality in patients with sepsis or septic shock. We comprehensively searched the PubMed, Embase, Cochrane Library, and Web of Science databases from their inception dates through 1 January 2021. Literature works evaluating the efficacy of thiamine combined vitamin C in patients with sepsis or septic shock were considered. Two reviewers extracted data and assessed study quality. A meta-analysis was performed to calculate an odds ratio (OR), 95% confidence intervals (CIs), and P values for in-hospital mortality (primary outcome). Secondary outcomes included duration of ICU stay, duration of hospital stay, duration of vasopressor use, and change in sequential organ failure assessment (SOFA) scores. Seven randomized controlled trials were identified, encompassing a total of 868 patients. There was no statistical difference between groups for in-hospital mortality (OR: 1.11; 95% CI [0.79-1.56]; P = 0.55). Other than improving SOFA score during the first 72 h after enrollment and duration of vasopressor use, we found no other significant associations. Despite widespread enthusiasm for thiamine combined with vitamin C for sepsis and septic shock, we only found an association with reduced SOFA score and time of vasopressor use. There was no association with in-hospital mortality.

Low skeletal muscle mass predicts poor clinical outcomes in patients with abdominal trauma

ObjectiveThe aim of this study was to investigate whether low skeletal muscle mass is associated with clinical outcomes in patients with abdominal trauma. MethodsPatients presenting to our institution with abdominal trauma from January 2010 to April 2020 were retrospectively included. Low skeletal muscle mass was defined, using computed tomography, as skeletal muscle index (SMI) at the third lumbar vertebra below the lowest sex-specific quartile within 1 wk of admission. Clinical outcomes such as complications, hospital stay, and hospital cost were recorded, and univariate and multivariate analyses were performed. ResultsAmong 684 patients, 451 were eligible. Of these, 112 (24.8%) were classified as having low skeletal muscle mass, based on SMI diagnostic cutoff values (42.08 cm2/m2 for men and 37.35 cm2/m2 for women). Low skeletal muscle mass was significantly associated with longer hospital length of stay, longer intensive care length of stay, higher cost, higher frequency of mechanical ventilation, longer duration of vasopressor use, and higher incidence of massive transfusion and overall complications (P < 0.05). Subgroup analysis showed that pneumonia, acute gastrointestinal dysfunction, cholecystitis, digestive tract fistula, gastric fistula, and intestinal fistula were significantly associated with low skeletal muscle mass (P < 0.05). Multivariate analysis showed that low skeletal muscle mass was an independent risk factor for overall complications (odds ratio [OR], 2.44; 95% confidence interval [CI], 1.33–4.49; P = 0.004), hospital length of stay (OR, 3.49; 95% CI, 1.96–6.20; P < 0.001), and hospital cost (OR, 2.67; 95% CI, 1.48–4.80; P = 0.001). ConclusionsLow skeletal muscle mass could be an independent predictor of poor clinical outcomes in patients with abdominal trauma.

Impact of Hyperoncotic Albumin on Duration of Vasopressor Support in Septic Shock: A Propensity Score-Matched Analysis.

While albumin has not been shown to reduce mortality in sepsis and septic shock, a tertiary analysis of a large trial suggested that it may reduce the duration of vasopressor use in septic shock. We sought to test if 25% albumin administration was associated with reduced cumulative vasopressor use in septic shock in a real-world setting. This was a retrospective, propensity score-matched cohort study of septic shock in which patients receiving albumin were compared with a matched cohort of those not receiving albumin. The primary outcome was days alive and free of vasopressors. The matched cohort included 335 patients who received albumin and 335 who did not. The days alive and free of vasopressors were similar between the albumin and no albumin groups: 17.4 (0-24.8) versus 19.4 (0-25.3); P = 0.160. Similarly, in-hospital mortality was no different between groups (46.9% vs 44.8%; P = 0.587). Receipt of albumin was associated with fewer ventilator-free and intensive care unit (ICU)-free days: 0 (0-19) versus 11 (0-23), P = 0.007, and 0 (0-18) versus 10.6 (0-22.1), P = 0.002, respectively. Albumin use in septic shock was not associated with additional days alive and free of vasopressors or in-hospital mortality. The finding of fewer ventilator- and ICU-free days may reflect selection of patients who were critically ill for longer periods of time before or after albumin administration. Additional study is needed to clarify the impact that timing may have on the effectiveness of albumin in septic shock.

Association of Premorbid Blood Pressure with Vasopressor Infusion Duration in Patients with Shock.

Rationale: Guidelines for vasopressor titration suggest a universal target-mean arterial pressure (MAP) >65 mm Hg. The implications for patients with premorbid low/high blood pressure are unknown.Objectives: To investigate the relationship between premorbid blood pressure and vasopressor duration for patients with shock.Methods: We performed a retrospective cohort study of adults admitted with shock to Calgary ICUs (June 2012-December 2018). The primary exposure was premorbid blood pressure: low (systolic <100); normal (systolic 100-139 and diastolic <90); and high (systolic ≥140 or diastolic ≥90). The primary outcome was vasopressor duration; secondary outcomes included ICU/hospital length of stay and ICU/hospital mortality. We examined associations of premorbid blood pressure with vasopressor duration and length of stay using multivariable competing risk models and mortality using multivariable mixed-effects logistic regression.Measurements and Main Results: Of 3,542 admissions with shock, 177 (5.0%) had premorbid low, 2,887 (81.5%) normal, and 478 (13.5%) high blood pressure. Premorbid low admissions had lower MAPs (vs. normal or high premorbid admissions) over the duration of vasopressor use (P = 0.003) and were maintained nearest premorbid MAPs while receiving vasopressors (P < 0.001). After adjustment, premorbid low admissions had longer vasopressor use (median, 1.35 d vs. 1.04 d for normal; hazard ratio for discontinuation vs. normal, 0.78 [0.73-0.85]; P < 0.001) and premorbid high admissions had shorter use (median, 0.84 d; hazard ratio, 1.22 [1.12-1.33]; P < 0.001). Premorbid low admissions had longer adjusted length of stay and higher adjusted mortality than premorbid normal admissions.Conclusions: Premorbid blood pressure was inversely associated with vasopressor duration.

Should Vitamin C/Ascorbic Acid infusion be used in the treatment of COVID-19?

KEY FINDINGS&#x0D; There is no direct evidence available as of this point for efficacy of intravenous vitamin C as an adjunctive treatment in preventing mortality or shortening disease course among adults suspected of, or positive for COVID-19.&#x0D; • Vitamin C is currently not mentioned in the treatment guidelines for COVID.&#x0D; • Currently, there are 3 ongoing trials registered in clinicaltrials.gov studying intravenous vitamin C in COVID-19. No other ongoing or planned trials were registered in the other trial registries.&#x0D; • Most of the available data are from studies on disease populations which may be considered as COVID-19 suspects:&#x0D;  Conflicting results on mortality from indirect evidence among patients with sepsis with or without ARDS with significant reduction in mortality found in only a small subset of patients (n-40) with severe sepsis given high dose Vitamin C infusion.&#x0D;  Strong evidence supporting no mortality benefit from 5 meta-analyses on critically ill patients due to conditions other than or in combination with sepsis who were given Vit C infusion alone or in combinations with other medications. One meta-analysis showed benefit in decreasing duration of ICU stay and mechanical ventilation but sample size is small. Most showed no benefit on and other key endpoints such as acute kidney injury, duration of hospital stay/ ICU stay/ duration of vasopressor use or duration of mechanical ventilation.&#x0D; • The use of Vit C infusion is not mentioned in the treatment guidelines for COVID-19 or ARDS.&#x0D; • The risks or adverse events with short term use of Vitamin C infusion in the general population is negligible or minimal. It should be avoided in patients with G6PD insufficiency. The dose should be carefully adjusted for patients with renal insufficiency.

Combination of vitamin C, thiamine and hydrocortisone added to standard treatment in the management of sepsis: results from an open label randomised controlled clinical trial and a review of the literature

Background: Combination of vitamin C, hydrocortisone and thiamine have recently been used in sepsis but data of efficacy are conflicting and no data are available from developing countries. We sought to study the effect of addition of this combination to standard care in patients with sepsis/septic shock in a north Indian setting.Methods: In a prospective, open label, randomised fashion, 100 patients with sepsis/septic shock were recruited to receive either standard therapy alone (control group, n = 50) or a combination of vitamin C, thiamine and hydrocortisone (treatment group, n = 50) in addition. The patients were followed for various clinical and laboratory parameters, in-hospital and 30-day mortality, duration of vasopressor use, lactate clearance, duration of hospital stay, and change in serum lactate and the SOFA score over the first 4 days.Results: The 2 groups were matched for basic characteristics. The in-hospital mortality (28% in controls and 24% in treatment group, p = .82) and 30-day mortality (42% in controls and 40% in treatment group, p = 1.00) was not significantly different in the 2 groups. However, there was a significant difference in duration of vasopressor use (96.13 ± 40.50 h in control group v/s 75.72 ± 30.29 h in treatment group, p value = .010) and lactate clearance (control group: 41.81% v/s treatment group: 56.83%, p value =.031) between 2 groups.Conclusions: Addition of vitamin C, hydrocortisone, and thiamine into standard care of sepsis does not improve in-hospital or 30 day mortality. However lower vasopressor use and faster lactate clearance is observed with treatment.

The Impact of EGDT on Sepsis Mortality in a Single Tertiary Care Center in Lebanon.

Background EGDT (Early Goal Directed Therapy) or some portion of EGDT has been shown to decrease mortality secondary to sepsis and septic shock. Objective Our study aims to assess the effect of adopting this approach in the emergency department on in-hospital mortality secondary to sepsis/septic shock in Lebanon. Hypothesis Implementation of the EGDT protocol of sepsis in ED will decrease in-hospital mortality. Methods Our retrospective study included 290 adult patients presenting to the ED of a tertiary center in Lebanon with severe sepsis and/or septic shock. 145 patients between years 2013 and 2014 who received protocol care were compared to 145 patients treated by standard care between 2010 and 2012. Data from the EHR were retrieved about patients' demographics, medical comorbidities, and periresuscitation parameters. A multivariate analysis using logistic regression for the outcome in-hospital mortality after adjusting for protocol use and other confounders was done and AOR was obtained for the protocol use. 28-day mortality, ED, and hospital length of stay were compared between the two groups. Results The most common infection site in the protocol arm was the lower respiratory tract (42.1%), and controls suffered more from UTIs (33.8%). Patients on protocol care had lower in-hospital mortality than that receiving usual care, 31.7% versus 47.6% (p=0.006) with an AOR of 0.429 (p =0.018). Protocol patients received more fluids at 6 and 24 hours (3.8 ± 1.7 L and 6.1 ± 2.1 L) compared to the control group (2.7 ± 2.0 L and 4.9 ± 2.8 L p=<0.001). Time to and duration of vasopressor use, choice of appropriate antibiotics, and length of ED stay were not significantly different between the two groups. Conclusion EGDT- (Early Goal Directed Therapy-) based sepsis protocol implementation in EDs decreases in-hospital mortality in developing countries. Adopting this approach in facilities with limited resources, ICU capabilities, and prehospital systems may have a pronounced benefit.

Charge Reductions Associated With Shorter Time to Recovery in Septic Shock

Septic shock therapies that shorten the time to physiologic and clinical recovery may result in financial savings. However, the financial implications of improving these nonmortal outcomes are not well characterized. Therefore, we quantified hospital charges associated with four outcomes: ICU length of stay, duration of invasive mechanical ventilation, duration of vasopressor use, and new renal replacement therapy. This was an observational study using administrative data from a large academic hospital in the United States. The analysis included adults treated with vasopressors for septic shock in a medical ICU. Linear regression modeling with ordinary least square was used to estimate the incremental hospital charges associated with 1day of ICU length of stay, 1day of mechanical ventilation, 1day of vasopressor use, and new renal replacement therapy. The study population included 587 adults with septic shock, including 180 (30.7%) who died in the hospital. The median charge for a septic shock hospitalization was $98,583 (interquartile range [IQR], $61,177-$136,672). Decreases in ICU length of stay, mechanical ventilation duration, and vasopressor duration of 1day were associated with charge reductions of $15,670 (IQR, $15,023-$16,317), $15,284 (IQR, $13,566-$17,002), and $17,947 (IQR, $16,344-$19,549), respectively. Avoidance of new renal replacement therapy was associated with a charge reduction of $36,051 (IQR, $22,353-$49,750). Septic shock therapies that reduce the duration of organ support and ICU care have the potential to lead to substantial financial savings.

A case report on the effect of plasmapheresis in the treatment of severe calcium channel blocker toxicity

Overdose by calcium channel blocker (CCB) antihypertensive agents has been shown to be a cause of significant morbidity and can often be fatal. (1) Although overdoses of calcium-channel blockers and beta blockers are uncommon, they have a high mortality rate, and management may be complicated. (2) Amlodipine, a dihydropyridine CCB, can cause prolonged hypotension in overdose. (3) We report a case of severe Amlodipine/Atenolol overdose that was refractory to multiple therapeutic approaches but rapidly responded to plasmapheresis. We describe the case of a previously healthy 25-year-old lady presented after ingesting 30 tablets of Amlodipine 5 mg/Atenolol 50 mg in a suicide attempt. The patient was initially managed with fluid resuscitation, calcium boluses, glucagon bolus, methylene blue boluses and multiple vasoactive agents. Hyperinsulinemic euglycemic therapy was initiated when hypotension persisted despite conventional treatments but was stopped later due to life threatening hypoglycemia and hypokalemia. Refractory hypotension prompted the use of plasmapheresis in an attempt to lower serum amlodipine levels as knowing that amlodipine is highly protein bound. Plasmapheresis is a procedure used to remove pathologic substances from a patient’s blood that has proven useful in some cases of drug overdose. (1) A dramatic improvement of cardiovascular stability was already observed during plasmapheresis. The primary outcomes were to reduce mortality and improve hemodynamic parameters. The secondary outcomes included reduce length of stay in intensive care unit, duration of vasopressor use and functional outcomes. (4) Conclusion: This case demonstrates that a Plasmapheresis can be effective in restoring hemodynamic stability in severe calcium channel blocker toxicity and recommend its use in patients with calcium channel blocker toxicity that is not responsive to traditional therapies.

Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study

The global burden of sepsis is estimated as 15 to 19 million cases annually, with a mortality rate approaching 60%in low-income countries. In this retrospective before-after clinical study, we compared the outcome andclinical course of consecutive septic patients treated with intravenous vitamin C, hydrocortisone, and thiamine during a 7-month period (treatment group) with a control group treated in our ICU during the preceding 7months. The primary outcome was hospital survival. A propensity score was generated to adjust the primary outcome. There were 47 patients in both treatment and control groups, with no significant differences in baseline characteristics between the two groups. The hospital mortality was 8.5%(4 of 47) in the treatment group compared with 40.4%(19 of 47) in the control group (P< .001). The propensity adjusted odds of mortality in the patients treated with the vitamin C protocol was 0.13 (95%CI, 0.04-0.48; P= .002). The Sepsis-Related Organ Failure Assessment score decreased in all patients in the treatment group, with none developing progressive organ failure. All patients in the treatment group were weaned off vasopressors, a mean of 18.3 ± 9.8h after starting treatment with the vitamin C protocol. The mean duration of vasopressor use was 54.9 ± 28.4h in the control group (P< .001). Our results suggest that the early use of intravenous vitamin C, together with corticosteroids and thiamine, are effective in preventing progressive organ dysfunction, including acute kidney injury, and in reducing the mortality of patients with severe sepsis and septic shock. Additional studies are required to confirm these preliminary findings.

Shenfu injection for improving cellular immunity and clinical outcome in patients with sepsis or septic shock

PurposeTo assess the efficacy of Shenfu injection (SFI) for enhancing cellular immunity and improving the clinical outcomes of patients with septic shock. MethodsPatients with sepsis were randomly assigned to receive either SFI at a dose of 100mL every 24hours for 7 consecutive days or a placebo in addition to conventional therapy. The immunologic parameters were collected on days 1, 3, and 7 after the above treatments, and the clinical outcomes were updated for 28days. ResultsOf these160 patients, 3 were excluded from the analysis due to protocol violation and withdrawal of consent; thus, 157 completed the study (78 in the SFI group and 79 in the placebo group). We found that SFI increased both CD4+ and CD8+ T cells in peripheral blood and up-regulated HLA-DR expression in monocytes (P<.05). Furthermore, SFI was also found to restore ex vivo monocytic tumor necrosis factor α and interleukin 6 proinflammatory cytokine release in response to the endotoxin (P<.05). Importantly, the SFI group showed better clinical outcomes than did the placebo group in terms of the duration of vasopressor use (P=.008), Acute Physiology and Chronic Health Evaluation II score (P=.034), Marshall score (P=.01), and length of intensive care unit stay (10.5±3.2 vs 12.2±2.8days; P=.012). However, the 28-day mortality rate was not significantly different between the SFI (20.5%; 16/78) and placebo groups (27.8%; −22/79; P=.28). ConclusionThese findings suggest that SFI can enhance the cellular immunity of patients with septic shock and could be a promising adjunctive treatment for patients with septic shock.

Single induction dose of etomidate versus other induction agents for endotracheal intubation in critically ill patients.

Single induction dose of etomidate versus other induction agents for endotracheal intubation in critically ill patients.

Incidence of Adrenal Insufficiency and Impact of Corticosteroid Supplementation in Critically Ill Children with Systemic Inflammatory Syndrome and Vasopressor-Dependent Shock: Hebbar KB, Stockwell JA, Leong T, Fortenberry JD. Crit Care Med 2011;39:1145–50.

The importance of diagnosing adrenal insufficiency in pediatric patients with the Systemic Inflammatory Response Syndrome (SIRS) has not been validated, nor has the subsequent treatment with corticosteroids. This study was a retrospective review of 78 patients with a median age of 84 months, who were treated at the Atlanta Pediatric Intensive Care Unit (PICU) with a protocol for steroid supplementation in patients meeting SIRS criteria. The primary outcome was decrease in vasopressor requirements after initiation of steroid treatment. All PICU patients requiring intravenous fluids and vasopressors for treatment of shock were tested for adrenal insufficiency with a standardized corticotrophin stimulation test. Patients were then classified as having absolute adrenal insufficiency (AAI) if a basal cortisol level < 18 mg/dL was measured vs. relative adrenal insufficiency (RAI) if the corticotrophin stimulation test induced a change in measured cortisol levels. Of the initial 78 patients, 44 (56%) had AAI and 39 (50%) had RAI, for a total of 69 (88%) with some degree of adrenal dysfunction. These patients were then treated with weight-based doses of hydrocortisone, with the addition of enteral 9-alpha-fludricortisone at the discretion of the treating physician. A diagnosis of AAI was shown to be associated with increased patient age, higher incidence of Staphylococcus aureus bacteremia, increased mechanical ventilation requirements, and higher vasopressor requirements. A statistically significant decrease in duration of vasopressor use was found in those treated with steroids. Dopamine use decreased from 24 h to 8 h (p < 0.01), norepinephrine from 27.5 h to 8 h, (p = 0.0001). There was no difference found between steroids being initiated before or after 12 h of vasopressor initiation. Overall, 98% (43/44) of patients with AAI and 92% (36/39) with RAI showed a > 50% reduction in vasopressor dosage within 4 h of initiating corticosteroids. Importantly, the study found no incidence of catheter-associated bloodstream infections, ventilator-associated pneumonias, gastric bleeding, or critical illness myopathy/polyneuropathy, some of the often-reported side effects of steroids, although 14 patients (18%) had rebound hypotension after steroid discontinuation requiring additional fluid boluses. Mortality was very low in the entire cohort (5%), so comparisons could not be made between the groups.

Analysis of parameters associated with hypotension requiring vasopressor support after carotid angioplasty and stenting

Systemic hypotension has been observed for up to 36 hours in response to stimulation of the carotid baroreceptor by carotid angioplasty and stenting (CAS). The aim of this study was to identify risk factors and cardiac outcomes for postprocedural hypotension requiring vasopressor support after CAS. Between 2003 and 2005, 143 patients (87 men; mean age, 75 years) with high-grade carotid artery stenosis (mean, 87.3%) were treated with CAS and prospectively entered into a vascular registry. Data were retrospectively analyzed to determine factors predictive of hypotension requiring vasopressor support after CAS. Atropine and appropriate intravenous crystalloid solution were administered during CAS. For the first 30 patients, atropine was only used for symptomatic patients but then became routine and was used for all patients with primary carotid stenosis. Hypotension (systolic blood pressure <90 mm Hg or a mean arterial blood pressure <50 mm Hg) unresponsive to conservative measures was treated with vasopressors (phenylephrine or norepinephrine). Patients were stratified into three groups based on hypotension requiring vasopressors: (1) no vasopressors, (2) vasopressors for < or = 24 hours (short duration), and (3) vasopressors for >24 hours (prolonged duration). Risk factors for hypotension requiring vasopressors were analyzed by univariate and multivariate logistic regression analysis. Postprocedural hypotension requiring vasopressor treatment was seen in 16 (11%) of 143 of patients, with 6 (4%) requiring vasopressor support for >24 hours. Mean duration of vasopressor administration for all patients was 17 +/- 10 hours (range, 6 to 36 hours). By univariate analysis, a history of a previous myocardial infarction (P = .02) or use of the PercuSurge occlusion balloon (P = .05) were both associated with increased incidence of short duration (</=24 hours) use of vasopressors, and female sex (P = .03) and age >80 years old (P = .02) were associated with prolonged (>24 hours) vasopressor requirement. On multivariate analysis adjusted for age and sex, a history of myocardial infarction (odds ratio [OR], 4.1; 95% confidence interval [CI], 1.0 to 16.4; P = .05) remained an independent predictor of short-duration vasopressors. On multivariate analysis, female sex (OR, 10.9; 95% CI, 1.2 to 100.4; P = .04) and age >80 years old (OR, 13.8, 95% CI, 1.5 to 127.2; P = .02) remained independent predictors of prolonged vasopressor use. The incidence of periprocedural myocardial infarctions, arrhythmias, or congestive heart failure did not differ between those patients who did not receive vasopressors (5/127) and those who received vasopressors for a short (< or = 24 hours) duration (1/10, P = NS) or prolonged (>24 hours) duration (0/6, P = NS). Prolonged hypotension requiring vasopressor support occurs in a minority of patients after CAS, with higher incidences in older women. In contrast, hypotension requiring a more limited duration of vasopressor use occurs more commonly in patients who had a prior myocardial infarction, independent of age or sex. In this cohort of patients, vasopressors required for hypotension were not associated with an increased incidence of periprocedural cardiac complications. Despite the increased incidence of prolonged hypotension in older women, this study demonstrates that CAS can be performed without an increase in cardiac morbidity in older women.