Receiving Vasopressor Therapy Research Articles

Performance of Subcutaneous Continuous Glucose Monitoring in Adult Critically Ill Patients Receiving Vasopressor Therapy.

Background: Subcutaneous continuous glucose monitoring (CGM) may facilitate glucose control in the ICU. We aimed to assess the accuracy of CGM (Dexcom G6) against arterial blood glucose (ABG) in adult critically ill patients receiving intravenous insulin infusion and vasopressor therapy. We also aimed to assess feasibility and tolerability of CGM in this setting. Methods: We included ICU patients receiving mechanical ventilation, insulin, and vasopressor therapy. Numerical accuracy was assessed by the mean absolute relative difference (MARD), overall, across arterial glucose strata, over different noradrenaline equivalent infusion rates, and over time since CGM start. MARD <14% was considered acceptable. Clinical accuracy was assessed using Clarke Error Grid (CEG) analysis. Feasibility outcome included number and duration of interrupted sensor readings due to signal loss. Tolerability outcome included skin reactions related to sensor insertion or sensor adhesives. Results: We obtained 2946 paired samples from 40 patients (18 with type 2 diabetes) receiving a median (IQR) maximum noradrenaline equivalent infusion rate of 0.18 (0.08-0.33) µg/kg/min during CGM. Overall, MARD was 12.7% (95% CI 10.7-15.3), and 99.8% of CGM readings were within CEG zones A and B. MARD values ≥14% were observed when ABG was outside target range (6-10 mmol/L [108-180 mg/dL]) and with noradrenaline equivalent infusion rates above 0.10 µg/kg/min. Accuracy improved with time after CGM start, reaching MARD values <14% after 36 h. We observed four episodes of interrupted sensor readings due to signal loss, ranging from 5 to 20 min. We observed no skin reaction related to sensor insertion or sensor adhesives. Conclusions: In our ICU cohort of patients receiving vasopressor infusion, subcutaneous CGM demonstrated acceptable overall numerical and clinical accuracy. However, suboptimal accuracy may occur outside glucose ranges of 6-10 mmol/L (108-180 mg/dL), during higher dose vasopressor infusion, and during the first 36 h after CGM start.

Limb Necrosis in the Setting of Vasopressor Use.

It remains poorly understood why only some hemodynamically unstable patients who receive aggressive treatment with vasopressor medications develop limb necrosis. To determine the incidence of limb necrosis and the factors associated with it following high-dose vasopressor therapy. A retrospective case-control medical records review was performed of patients aged 18 to 89 years who received vasopressor therapy between 2012 and 2021 in a single academic medical center. The study population was stratified by the development of limb necrosis following vasopressor use. Patients who experienced necrosis were compared with age- and sex-matched controls who did not experience necrosis. Demographic information, comorbidities, and medication details were recorded. The incidence of limb necrosis following vasopressor administration was 0.25%. Neither baseline demographics nor medical comorbidities differed significantly between groups. Necrosis was present in the same limb as the arterial catheter most often for femoral catheters. The vasopressor dose administered was significantly higher in the necrosis group than in the control group for ephedrine (P = .02) but not for the other agents. The duration of therapy was significantly longer in the necrosis group than in the control group for norepinephrine (P = .001), epinephrine (P = .04), and ephedrine (P = .01). The duration of vasopressin administration did not differ significantly between groups. The findings of this study suggest that medication-specific factors, rather than patient and disease characteristics, should guide clinical management of necrosis in the setting of vasopressor administration.

Vascular Reactivity Index as an Effective Predictor of Mortality in Patients With Septic Shock: A Retrospective Study.

Sepsis is a serious complication that occurs after trauma, burns, and infections, and it is an important cause of death in intensive care unit (ICU) patients. Despite many new measures being proposed for sepsis treatment, its mortality rate remains high; sepsis has become a serious threat to human health, and there is an urgent need to carry out in-depth clinical research related to sepsis. In recent years, it has been found that septic shock-induced vasoplegia is a result of vascular hyporesponsiveness to vasopressors. Therefore, this study intended to establish an objective formula related to vasoplegia that can be used to assess the prognosis of patients and guide clinical treatment. A retrospective cohort study was conducted using data from 106 septic shock patients admitted to the ICU of Jining No. 1 People's Hospital from January 2020 to December 2022. The patients were divided into mortality and survival groups based on 28-day survival, and hemodynamics were monitored by the pulse index continuous cardiac output system. The dose and duration of vasopressors, major hemodynamic parameters, lactic acid (Lac) levels, and Sequential Organ Failure Assessment scores were recorded within 48 h of hospital admission. Multifactorial logistic regression was used to analyze the independent risk factors affecting the prognosis of patients, and the predictive value of the vascular response index (VRI) was analyzed by the receiver operating characteristic (ROC) curve. The differences between the survival and mortality groups in terms of age, sex ratio, body weight, ICU length of stay, distribution of infection sites, underlying disease conditions, baseline Lac levels, and some hemodynamic parameters were not statistically significant (P > .05). The results of multifactorial logistic regression showed that the admission Acute Physiology and Chronic Health Evaluation II score, Lac level at 24 h of treatment, maximal vasoactive inotropic score at 24 h (VISmax24), maximal vasoactive inotropic score at 48 h (VISmax48), and VRI were independent risk factors affecting 28-day mortality. Within 48 h of receiving vasopressor therapy, the VRI was lower in the mortality group than in the survival group. The area under the ROC curve for the VRI was 0.86, and the best cutoff value of the VRI for predicting 28-day mortality was 32.50 (YI = 0.80), with a sensitivity of 0.90, a specificity of 0.90, and a better prediction of mortality than the other indicators. The VRI is a good predictor of mortality in patients with septic shock, and a lower VRI indicates more severe vasoplegia, poorer prognosis, and higher mortality in patients with septic shock.

Late-onset non-obstructive mesenteric ischemia (NOMI) resulting from delayed absorption of overdosed antihypertensive drugs: An autopsy case report.

Non-obstructive mesenteric ischemia (NOMI) is caused by reduced blood flow to the intestines without physical occlusion in the mesenteric artery. Previous reports show that drug overdose occasionally induces late-onset NOMI; however, in most cases, the reason for the delayed onset is unclear. Here, we present an autopsy case of late-onset NOMI that was induced by a drug overdose. An 80-year-old man was admitted to the intensive care unit because of severe hypotension after an overdose of antihypertensive drugs. He received vasopressor therapy and continuous hemodiafiltration dialysis; however, gastrointestinal decontamination was not performed. He began to recover but developed acute mesenteric ischemia on the evening of day 4 and died on day 5. Autopsy showed discontinuous submucosal bleeding from the duodenum to the colon; there was no thrombus in the mesenteric artery, which led to a diagnosis of NOMI. In the stomach, there was 250mL of reddish-brown fluid with a muddy brown substance. Histologic examination revealed ischemic necrosis in the small intestine. Quantitative analysis of serum collected during hospitalization revealed that nifedipine and cilostazol levels had peaked on day 3 of hospitalization. The formulation of nifedipine was a controlled-release tablet, and the low water solubility of cilostazol may have caused the tablets to adhere and remain in the stomach. Therefore, the drugs had been released into the blood stream several days after hospitalization, leading to delayed-onset NOMI. In cases of overdose, it is crucial to consider the formulation and properties of the involved drugs when determining medical treatment.

Extubation of Patients Receiving Vasopressor Infusions: Results of a Survey on Statewide Practices.

Current guidelines recommend extubation only if a patient is not receiving vasopressor therapy or is receiving minimal doses of vasopressors. However, recent data indicate that extubation of patients receiving higher vasopressor doses may be safe. This study was undertaken to examine practices regarding extubation of patients receiving vasopressor therapy reported by clinician respondents to a survey by the Michigan Health and Hospital Association Keystone Center. One-third of respondents indicated that they would extubate a patient receiving vasopressors, and one-quarter indicated that it depended on the agent used, but more than half reported that their unit did not have a vasopressor use protocol or they did not know whether it did. Practices regarding extubation of patients receiving vasopressor therapy differed significantly by unit type and by role as a direct care provider. These data indicate that patient and clinician factors may drive practice patterns. Additional research to inform guidelines and local protocols is warranted.

Clinical Pearls

Extubating patients as soon as possible is recommended to prevent adverse physical and cognitive outcomes. Hemodynamic stability is often listed as a criterion for extubation; however, the evidence is conflicting regarding the safety of extubation while the patient is receiving vasopressor medications. In addition, little is known about actual bedside practice in such situations.Costa and colleagues surveyed clinicians to examine their reported practice of extubation with patients receiving vasopressor therapy. They found One-third of respondents stated that they would extubate a patient receiving a continuous infusion of vasopressors.About one-quarter reported that it would depend on the type of medication being used.Almost 58% stated that their unit did not have a protocol or that they did not know if there was a protocol for this practice.Clinicians working in a surgical intensive care unit (ICU) and those who provide direct patient care at least 50% of the time more often said they would extubate patients receiving vasopressors.Extubation of patients receiving a vasopressor varied significantly by unit type and provider role. The authors recommend further research to explore the safety of this practice and examine existing protocols in ICUs.See Article, pp 127-130Parents with children in the pediatric intensive care unit (PICU) rely on the health care team to discuss their child’s possible morbidities and risk of mortality. These are called prognostic conversations. However, very little research has addressed the impact of prognostic conversations on post–intensive care syndrome in families in the PICU.Rissman and colleagues surveyed parents and health care providers at discharge from the PICU. They found Findings support the need for prognostic conversations to occur multiple times and using multiple formats throughout the PICU hospitalization, in order to appropriately prepare families for possible post-PICU morbidities.See Article, pp 118-126Although a necessary therapy, mechanical ventilation can cause significant stress and anxiety in patients. Management of these responses continues to be via medications such as antipsychotics, analgesics, and sedatives. However, these may produce adverse effects that could increase length of stay and cost of care and could contribute to long-term adverse outcomes.Golino and colleagues evaluated the impact of live music therapy as a nonpharmacologic intervention to reduce anxiety, pain, and agitation in adult patients receiving mechanical ventilation. They found Findings show music therapy reduces pain and agitation in adults receiving mechanical ventilation. Further research is needed, but nonpharmacologic interventions such as music therapy may reduce the need for pain and anxiety medications.See Article, pp 109-115The implementation of checklists during intensive care unit (ICU) rounds helps facilitate evidence-based practice and improve patient outcomes. However, checklists are sometimes not used as intended, and customization of the checklist may affect reliability and quality of care.King and colleagues created a paper-based assessment tool that one critical care nurse could use to reliably assess ABCDEF bundle care checklist items during rounds. They evaluated the tool with 2 independent nurses during rounds on 53 patients and found that Although tool item improvements are needed, findings support having one critical care nurse serve as checklist prompter to reliably assess ABCDEF bundle care during ICU rounds.See Article, pp 92-99

Early versus delayed vasopressor administration in patients with septic shock.

This study aimed to investigate the association of early vasopressor initiation with improved septic shock outcomes. This multicenter observational study was conducted in 17 intensive care units in Japan and included adult patients with sepsis admitted to the intensive care unit from July 2019 to August 2020 and treated with vasopressor therapy. Patients were divided into the early vasopressor group (≤1 h from sepsis recognition) and the delayed vasopressor group (>1 h). The impact of early vasopressor administration on risk-adjusted in-hospital mortality was estimated using logistic regression analyses adjusted by an inverse probability of treatment weighting analysis with propensity scoring. Among the 97 patients, 67 received vasopressor therapy within 1 h from sepsis recognition and 30 received vasopressor after 1 h. In-hospital mortality was 32.8% in the early vasopressor group and 26.7% in the delayed vasopressor group (p = 0.543). The adjusted odds ratio for in-hospital mortality was 0.76 (95% confidence interval 0.17-3.29) when comparing patients in the early vasopressor with those in the delayed vasopressor group. The fit curve from the mixed-effects model showed a relatively lower trend toward an infusion volume over time in the early vasopressor group than in the delayed vasopressor group. Our study did not reach a definitive conclusion for early vasopressor administration. However, early vasopressor administration may help avoid volume overload in the long course of sepsis care.

Abrupt termination of vitamin C from ICU patients may increase mortality: secondary analysis of the LOVIT trial

BackgroundThe LOVIT trial examined the effect of vitamin C on sepsis patients, and concluded that in adults with sepsis receiving vasopressor therapy in the ICU, those who received 4-day intravenous vitamin C had a higher risk of death or persistent organ dysfunction at 28 days than those who received placebo. The aim of this study was to determine whether the abrupt termination of vitamin C administration could explain the increased mortality in the vitamin C group.MethodsWe used Cox regression with two time periods to model the distribution of deaths over the first 11 days in the LOVIT trial.ResultsCompared with a uniform difference between vitamin C and placebo groups over the 11-day follow-up period, addition of a separate vitamin C effect starting from day 5 improved the fit of the Cox model (p = 0.026). There was no difference in mortality between the groups during the 4-day vitamin C administration with RR = 0.97 (95% CI: 0.65–1.44). During the week after the sudden termination of vitamin C, there were 57 deaths in the vitamin C group, but only 32 deaths in the placebo group, with RR = 1.9 (95% CI: 1.2–2.9; p = 0.004).ConclusionThe increased mortality in the vitamin C group in the LOVIT trial is not explained by ongoing vitamin C administration, but by the abrupt termination of vitamin C. The LOVIT trial findings should not be interpreted as evidence against vitamin C therapy for critically ill patients.

Intravenous Vitamin C in Adults with Sepsis in the Intensive Care Unit

BackgroundStudies that have evaluated the use of intravenous vitamin C in adults with sepsis who were receiving vasopressor therapy in the intensive care unit (ICU) have shown mixed results with respect to the risk of death and organ dysfunction.MethodsIn this randomized, placebo-controlled trial, we assigned adults who had been in the ICU for no longer than 24 hours, who had proven or suspected infection as the main diagnosis, and who were receiving a vasopressor to receive an infusion of either vitamin C (at a dose of 50 mg per kilogram of body weight) or matched placebo administered every 6 hours for up to 96 hours. The primary outcome was a composite of death or persistent organ dysfunction (defined by the use of vasopressors, invasive mechanical ventilation, or new renal-replacement therapy) on day 28.ResultsA total of 872 patients underwent randomization (435 to the vitamin C group and 437 to the control group). The primary outcome occurred in 191 of 429 patients (44.5%) in the vitamin C group and in 167 of 434 patients (38.5%) in the control group (risk ratio, 1.21; 95% confidence interval [CI], 1.04 to 1.40; P=0.01). At 28 days, death had occurred in 152 of 429 patients (35.4%) in the vitamin C group and in 137 of 434 patients (31.6%) in the placebo group (risk ratio, 1.17; 95% CI, 0.98 to 1.40) and persistent organ dysfunction in 39 of 429 patients (9.1%) and 30 of 434 patients (6.9%), respectively (risk ratio, 1.30; 95% CI, 0.83 to 2.05). Findings were similar in the two groups regarding organ-dysfunction scores, biomarkers, 6-month survival, health-related quality of life, stage 3 acute kidney injury, and hypoglycemic episodes. In the vitamin C group, one patient had a severe hypoglycemic episode and another had a serious anaphylaxis event.ConclusionsIn adults with sepsis receiving vasopressor therapy in the ICU, those who received intravenous vitamin C had a higher risk of death or persistent organ dysfunction at 28 days than those who received placebo. (Funded by the Lotte and John Hecht Memorial Foundation; LOVIT ClinicalTrials.gov number, NCT03680274.)

A Randomized Trial of Mycobacterium w in Severe Presumed Gram-Negative Sepsis

Mycobacterium w (Mw), an immunomodulator, has been shown to resolve early organ failure in severe sepsis. Does Mw improve survival in patients with severe presumed gram-negative sepsis? This was a randomized, double-blind, placebo-controlled, parallel-group study conducted in ICUs of five tertiary care centers in India. We included consecutive patients (age≥ 18 years) with presumed gram-negative sepsis in the study within 48h of the first organ dysfunction. Patients in the treatment arm received 0.3mL/d of Mw intradermally for 3 consecutive days, whereas the control arm received matching placebo. The primary outcome was 28-day all-cause mortality. The secondary outcomes were ventilator-free days, days receiving vasopressor therapy, ICU and hospital length of stay, nosocomial infection rate, antibiotic use duration, and delta Sequential Organ Failure Assessment (SOFA) score. We included 202 patients with severe sepsis (101 Mw, 101 placebo). The use of Mw significantly reduced the mortality (9/101 vs20/101; estimate difference, 0.11 [95%CI, 0.01-0.21]; P= .04). We found no difference in ventilator-free days, days receiving vasopressor drugs, ICU length of stay, and the hospital length of stay. The time to mortality (median, 13days vs8.5days) was significantly longer in the Mw than in the placebo arm. The delta SOFA score, rate of nosocomial infections, and antibiotic use duration were similar in the two arms. We found Mw to reduce significantly the odds (OR, 0.37 [95%CI, 0.15-0.9]) of mortality after adjusting for culture-positive sepsis, baseline SOFA score, age, and sex. The use of Mw was associated with a significant reduction in mortality in patients with severe presumed gram-negative sepsis. Further studies are required to confirm our findings. ClinicalTrials.gov; No.: NCT02330432; URL: www.clinicaltrials.gov.

Acute Generalized Peritonitis in Intensive Care Unit at University Hospital of Brazzaville, Republic of Congo: Etiological, Therapeutic Aspects and Issues

Aim: To determine etiological, therapeutic aspects and issues of AGP in intensive care unit (ICU) at University Hospital of Brazzaville (UHB). Materials and Methods: It was a retrospective and descriptive study carried out from January to December 2016 in ICU at UHB. We collected completed medical records of patients admitted and operated for AGP regardless of age or sex. The parameters studied were age, sex, admission’s reasons, etiologies, management, post-operative complications, length of hospital and mortality. Data were treated in Excel 2010 and Epi info 2007. Results: Thirty-one complete medical records were identified (mean age: 40.6 ± 22.0 years). The sex ratio was 2.4. Shock was the most common reason for admission with 67.7% of the cases. The etiologies of AGP were dominated by gastroduodenal perforating ulcer (41.9%) followed by complicated appendicitis (19.4%). The management of all patients was medico-surgical. The bi antibiotic ceftriaxone-metronidazole was administered in 29 patients (93.6%). 18 patients (59.1%) received vasopressor therapy. The complications had occurred among 9 patients i.e. 29% of the cases; parietal suppurations represented 44.5% of the complications. The average length of hospitalization was 5.2 ± 4.6 days. The overall mortality was 41.9%. Conclusion: In our study, the most frequent etiologies were gastroduodenal perforating ulcer and complicated appendicitis. They affected young patients. The complications were dominated by parietal suppurations. The mortality rate was high.

Hourly Fluid Balance in Patients Receiving Continuous Renal Replacement Therapy

Introduction: Little is known about early (first 48 h) hourly and cumulative fluid balance (FB) during continuous renal replacement therapy (CRRT). Objectives: To study the characteristics and outcome associations of early hourly and cumulative FB. Methods: We studied FB in CRRT patients (2016–2018). Results: Among 350 patients, mean hourly FB became negative after 20 CRRT hours, but within 6 CRRT hours in patients with baseline fluid overload. A negative early FB was never achieved in patients receiving vasopressor therapy (p < 0.001). Mortality was 31%. The percentage of hourly negative FB was independently associated with decreased ICU mortality. A time-weighted hourly FB between 18.5 and –33 mL/h was also significantly and independently associated with decreased mortality. Conclusions: In CRRT patients, an early FB conservative approach is possible, modulated by patient characteristics, and associated with a low mortality. Moreover, avoidance of an early positive FB is associated with decreased mortality.

Outcomes of Early Enteral Nutrition in Ventilated Septic Shock Patients Receiving Vasopressor Therapy

Upon completion, participants will be able to understand the outcomes of early enteral nutrition in critically ill septic shock patients who are receiving vasopressor therapy.

Controversies of enteral nutrition in select critically-ill surgical patients: Traumatic brain injury, extracorporeal life support, and sepsis

Adequate nutritional support for critically ill pediatric patients is an essential component of optimal care in the intensive care unit. For select patient populations in this setting, the enteral delivery of nutrients can bring unique challenges and potential risks. The focus of this paper is to provide a review of existing literature concerning the safety, efficacy and benefits of enteral nutrition in select surgical patient populations for whom these discussions are most controversial: patients with traumatic brain injury, patients receiving extracorporeal life support (ECLS), and patients receiving vasopressor therapy, such as in sepsis. Recommendations in the context of consensus or a call to investigate research gaps are provided based on a review of the evidence.

THE EFFECT OF BODY REPOSITIONING ON HEMODYNAMIC STATUS IN PATIENTS WITH VASOPRESSOR THERAPY IN INTENSIVE CARE UNIT

Background: Repositioning the patients every 2 hours were often not implemented during patient care. One of the causes perceived by nurses as contraindications to repositioning in critical patients is the use of vasoactive agents. This condition increases the risk of decubitus, decreased orthostatic stability and muscle atrophy.&#x0D; Objective: The purpose of this study was to identify the effect of body reposition on hemodynamic patients receiving vasopressor therapy in Intensive Care Unit (ICU).&#x0D; Methods: The research method used Quasi Experiment with non-equivalent control group design. The subjects were ICU patients who received vasopressor therapy. The respondents recruited using consecutive sampling technique for a-four-month period and obtained 34 respondents, which was divided into control and intervention group. Data analysis used paired t-test to analyze the difference in the same group and unpaired t-test to test the difference between two groups.&#x0D; Results: Pre-post hemodynamic differences in the intervention group when patients were repositioned from supine to the right lateral and right lateral to left lateral showed p&gt; 0.05. The hemodynamic difference between the control and the intervention group also had p&gt; 0.05. The results showed there were no significant difference.&#x0D; Conclusions: In general, there is no effect of body repositioning on hemodynamic status. Critical nurses can perform body repositioning activities every two hours including in patients with vasopressor therapy to prevent complications of immobilization, still considering contraindication condition.

Hypotension in ICU Patients Receiving Vasopressor Therapy

Vasopressor infusion (VPI) is used to treat hypotension in an ICU. We studied compliance with blood pressure (BP) goals during VPI and whether a statistical model might be efficacious for advance warning of impending hypotension, compared with a basic hypotension threshold alert. Retrospective data were obtained from a public database. Studying adult ICU patients receiving VPI at submaximal dosages, we analyzed characteristics of sustained hypotension episodes (>15 min) and then developed a logistic regression model to predict hypotension episodes using input features related to BP trends. The model was then validated with prospective data. In the retrospective dataset, 102-of-215 ICU stays experienced >1 hypotension episode (median of 2.5 episodes per day in this subgroup). When trained with 75% of retrospective dataset, testing with the remaining 25% of the dataset showed that the model and the threshold alert detected 99.6% and 100% of the episodes, respectively, with median advance forecast times (AFT) of 12 and 0 min. In a second, prospective dataset, the model detected 100% of 26 episodes with a median AFT of 22 min. In conclusion, episodes of hypotension were common during VPI in the ICU. A logistic regression model using BP temporal trend features predicted the episodes before their onset.

0321 : Cardiogenic shock in acute myocardial infarction. The experience of the military hospital. About (7)0 cases

Cardiogenic shock remains the leading cause of death in the acute phase of myocardial infarction (MI); it is the result of myocardial and / or mechanical failure complication. The aim of our study was to investigate the epidemiological, clinical and support of a serie of patients hospitalized for MI complicated by cardiogenic shock as well as the immediate and late prognosis. It was a single-center retrospective study of 70 patients hospitalized in the service of cardiology of the military hospital for myocardial infarction complicated by cardiogenic shock, between 2005 and 2012. The mean age was 63 ± 10 years, 80% were men. The majority of myocardial infarction were anteriors. On admission 41% were in left ventricular failure, and 59% in shock. Thrombolysis was performed in 51% of patients. Angiography had identified a single truncal achieved in 28% of cases, bi -vessel in 44% of cases and tri- truncal in 28% of cases. The transcoronary angiolpasty was primary in 27% of cases and of rescue in 73% of cases. Revascularization was complete in 37% of cases. The success rate of TCA was 85%. The majority of bare stents were used (83%). The mean LVEF was 49 ± 14.4%. 70% of patients received vasopressor therapy with a mean duration of 3.5 days. IABP was placed in 2 patients with an average duration of 2 days. The average of hospital stay was 7 ± 8 days. Hospital mortality was 47%, occurring on average in the sixth day of hospitalization (6±9 days). We found that renal failure, late onset of shock, hyperglycemia, leukocytosis, use of vasopressors, and the anterior territory of MI were significantly predictive of hospital mortality. Despite significant advances in the treatment of myocardial infarction, particularly techniques of reperfusion, therapeutic drug, and the advent of several circulatory support techniques, mortality of cardiogenic shock in acute phase of myocardial infarction remains high. The author hereby declares no conflict of interest

Is there opportunity for automated decision-support and closed-loop control in ICU patients receiving vasopressor infusion?

Vasopressors are administered to critically ill patients suffering from a body-wide reduction in blood circulation. In theory, if the vasopressor infusion is either too high or too low, it could be harmful to the patient. In a retrospective analysis, we investigated the degree to which today's intensive care unit (ICU) patients receive appropriate vasopressor therapy, in terms of how often the mean arterial pressure (MAP) was kept within a normative range. Using the MIMIC II database, we studied patients with minute-by-minute MAP data, sourced from the bedside monitor, who were receiving vasopressor therapy. For each record, we identified MAP samples that were out-of-range, i.e., MAP <; 60 mmHg or MAP > 100 mmHg, and grouped these into out-of-range episodes. Each out-of-range episode was categorized as either transient (<; 15 min) or sustained (≥ 15 min). Out of the 224 ICU stays, we identified 152 ICU stays (68% of ICU stays) with at least one sustained MAP out-of-range episode. In that subset, MAP was frequently out-of-range (out-of-range 18.4% of the time) due to a combination of sustained episodes of hypotension and hypertension. Compared with all ICU stays, those stays with sustained out-of-range events did not demonstrate an increased MAP variability per hour. It is possible that the out-of-range events resulted from insufficient dose-adjustment. Technologies that might continuously optimize vasopressor dosing throughout the patient's stay and thereby minimize these abnormal cardiovascular states may be worthy of further study.

It is amazing what you can see if you look

It is amazing what you can see if you look

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Introduction: Enteral nutrition (EN) is recommended within the first 24-48 hours following admission to an intensive care unit (ICU) once resuscitation and hemodynamic stability have been achieved; however, hemodynamic stability is not well defined. Hypothesis: The evaluation of EN tolerance and safety in critically ill patients receiving intravenous (IV) vasopressor therapy will improve the provision of EN during critical illness. Methods: A retrospective medical record review was conducted in an urban academic medical center. Adult ICU patients from 2011 were included if they received concomitant EN and IV vasopressor therapy for? 1 hour. Tolerance was defined as an absence of gastric residuals? 300 mL, emesis, positive finding on abdominal imaging and evidence of bowel ischemia/perforation. Nominal data were compared using?2 test of independence, while a 2-sample Student’s t-test or Fisher’s exact test was utilized for continuous data. Brown-Forsythe test was used to assess for unequal variances. If the variances were heterogeneous, Welch’s ANOVA test was used for the comparison. Results: Two-hundred and fifty-nine patients were included who received 346 episodes of concomitant EN and IV vasopressor therapy. Overall EN tolerability was 74.9%. Adverse events included rising serum lactate (30.6%), elevated gastric residuals (14.5%), emesis (9%), positive finding on KUB (4.3%), and bowel ischemia/perforation (0.9%). An inverse relationship was found between maximum norepinephrine equivalent dose and EN tolerability (12.5 mcg/min for patients who tolerated EN vs.19.4 mcg/min, p=0.0009). Patients who tolerated EN were less likely to have cardiogenic shock (20.5% vs. 31.4%, p=0.023) and were less likely to have received dopamine (63.8% vs. 77.6%, p=0.018) or vasopressin (58.9% vs. 77.9%, p=0.0027). Additionally, these patients received concomitant therapy for a shorter duration of time (median 26 vs. 65 hours, p=0.0002) and received more nutrition on a daily basis (13.6 vs. 10.9 kcal/kg/day, p=0.0034). Conclusions: The majority of patients receiving vasopressor therapy tolerate EN. Tolerability was related to the specific vasopressor administered and the maximum cumulative vasopressor dose during overlap.