Use Of Metaraminol Research Articles

THE USE OF METARAMINOL AS A VASOPRESSOR IN CRITICALLY UNWELL PATIENTS: A NARRATIVE REVIEW AND A SURVEY OF UK PRACTICE

<h3>Background</h3> Major international guidelines state that norepinephrine should be used as the first-line vasopressor to achieve adequate blood pressure in patients with hypotension or shock. However, recent observational studies report that in the United Kingdom and Australia, metaraminol is often used as a first-line medication for cardiovascular support. <h3>Aim of the study</h3> The aim of this study was to carry out a systematic review of metaraminol use for the management of shock in critically unwell patients and carry out a survey evaluating whether UK critical care units use metaraminol and under which circumstances. <h3>Methods</h3> A systematic review literature search was conducted. We investigated 30 departments, representing small (< 10 beds), medium (10-20 beds), and large (> 20 beds) units, and both teaching and non-teaching hospitals, using a semi-structured narrative interview and a pre-defined list of questions. <h3>Results</h3> We received 26 responses from the 30 hospitals we contacted, representing 10% of UK adult critical care units. Of these 4 were small, 10 were medium, and 12 were large units. The surveyed units had a collective total of 34206 annual admissions, representing 17% of the UK total. The average number of admissions per small unit was 419/year, medium unit 757/year and larger unit 2080/year. In total, 88% of the units (23/26 hospitals) used metaraminol prior to critical care admission. In 70% of the hospitals, metaraminol was used on the wards or in the emergency departments. In 70% of the cases, metaraminol was used to manage hypotension due to any cause. Most hospitals (67%, 15/23) continued metaraminol infusion in the critical care unit. Almost half of the respondents explained that infusion was time-limited (usually 12–24 hours) with a subsequent change to norepinephrine. Approximately 2/3 of hospitals used metaraminol as the first-line vasopressor in critical care. The systematic literature review revealed several case reports and only two studies conducted in the last 20 years investigating the effect of metaraminol as a stand-alone vasopressor. Both studies focused on different aspects of metaraminol use, therefore it was not feasible to carry out a full systematic review. The narrative review has demonstrated the lack of robust evidence to support the use of metaraminol in critically ill patients. Even though the pharmacodynamic properties of metaraminol provide a rationale for its use but there is no evidence to evaluate its impact on important patient outcomes, such as the length of vasopressor support, complications associated with its use, morbidity, and mortality. <h3>Conclusions</h3> Metaraminol was the first-line vasopressor in a representative sample of UK critical care units. We identified no randomised trials describing clinical outcomes of metaraminol use, meaning the benefits and risks of this treatment are uncertain. Further observational studies and prospective randomised controlled trials are warranted to inform evidence-based practice for patient benefit.

The Use of Metaraminol as a Vasopressor in Critically Unwell Patients: A Narrative Review and a Survey of UK Practice.

BackgroundMajor international guidelines state that norepinephrine should be used as the first-line vasopressor to achieve adequate blood pressure in patients with hypotension or shock. However, recent observational studies report that in the United Kingdom and Australia, metaraminol is often used as second line medication for cardiovascular support.Aim of the studyThe aim of this study was to carry out a systematic review of metaraminol use for management of shock in critically unwell patients and carry out a survey evaluating whether UK critical care units use metaraminol and under which circumstances.MethodsA systematic review literature search was conducted. A short telephone survey consisting of 6 questions regarding metaraminol use was conducted across 30 UK critical care units which included a mix of tertiary and district general intensive care units.ResultsTwenty-six of thirty contacted centres responded to our survey. Metaraminol was used in 88% of them in various settings and circumstances (emergency department, theatres, medical emergencies on medical wards), with 67% reporting use of metaraminol infusions in the critical care setting. The systematic literature review revealed several case reports and only two studies conducted in the last 20 years investigating the effect of metaraminol as a stand-alone vasopressor. Both studies focused on different aspects of metaraminol use and the data was incomparable, hence we decided not to perform a meta-analysis.ConclusionsMetaraminol is widely used as a vasopressor inside and outside of the critical care setting in the UK despite limited evidence supporting its safety and efficacy for treating shock. Further service evaluation, observational studies and prospective randomised controlled trials are warranted to validate the role and safety profile of metaraminol in the treatment of the critically unwell patient.

Efficacy and safety of metaraminol in critically ill patients with shock: a systematic review

AbstractAimTo assess the efficacy and safety of metaraminol infusions in comparison to other vasopressors in critically ill patients with shock with regard to hospital mortality, effect on haemodynamics (mean arterial pressure or systolic blood pressure), duration of vasopressor use, and adverse events.Data sourcesA systematic review was conducted in eight electronic databases and nine trial registers from inception to 17 March 2021.Study selectionStudies included randomised or non‐randomised controlled trials, and retrospective or prospective observational studies of critically ill adult patients admitted to the intensive care unit or emergency department with shock of any aetiology and who received metaraminol via continuous infusion compared to patients who received other vasopressors.ResultsOut of 1387 eligible articles, three observational studies and one controlled trial were included involving a total of 54 patients. Study patients had different types of shock including septic (n = 28), cardiogenic (n = 21), hypovolemic (n = 3) and neurogenic shock (n = 2). All studies compared metaraminol to noradrenaline and were of poor quality and high risk of bias. There was no difference in hospital mortality or effect on mean arterial pressure or systolic blood pressure between metaraminol and noradrenaline in any of the studies. None of the studies reported the duration of vasopressor use or adverse drug events such as extravasation or tissue injury.ConclusionThere is limited and low‐quality efficacy and safety data to support the use of metaraminol over other vasopressors in critically ill patients with shock. Future clinical trials are needed before this agent is routinely used in this patient population.

Metaraminol use during spinal anaesthesia for caesarean section: a meta-analysis of randomised controlled trials

IntroductionDuring caesarean section, the use of a vasopressor is often required to achieve haemodynamic stability of the parturient. Metaraminol is a vasopressor used in this context in some countries. However, the differences between metaraminol and other vasopressors remain unclear. MethodsA search of the PubMed, Cochrane Library, and Embase databases was performed to identify randomised controlled trials comparing the use of metaraminol with other vasopressors during spinal anaesthesia at caesarean section. The selected studies were subjected to meta-analysis and risk-of-bias assessment. ResultsFour randomised, controlled trials met the selection criteria and 409 parturients who underwent an elective caesarean section were included in this meta-analysis. The quality of these trials was good. Metaraminol was associated with higher umbilical arterial pH (standardised mean difference [SMD] 0.82, 95% CI 0.01 to 1.62, P=0.05); a lower incidence of fetal acidosis (RR 0.08, 95% CI 0.01 to 0.63, P=0.02); and a lower incidence of nausea or vomiting (RR 0.16, 95% CI 0.04 to 0.57, P=0.0005) than was ephedrine. Metaraminol resulted in higher umbilical arterial pH (SMD 0.42, 95% CI 0.15 to 0.68, P=0.002) but a higher incidence of reactive hypertension (RR 1.80, 95% CI 1.32 to 2.46, P=0.0002) than did phenylephrine. ConclusionThe results of this study showed that for spinal anaesthesia at elective caesarean section, metaraminol may be a more suitable vasopressor than ephedrine and its effects are at least not inferior to those of phenylephrine.

Propofol for Adult Procedural Sedation in a UK Emergency Department

Abstract Background Concerns exist regarding the safe use of propofol by Emergency Physicians for procedural sedation. The World SIVA International Sedation Task Force has recently created an adverse event tool, in an effort to standardize reporting. We present a safety analysis of our use of propofol using this tool. Method Propofol was given according to a previously published guideline. We analysed our dedicated departmental sedation database between December 2006 and March 2012 and cross-examined the original sedation chart for each case recorded. We stratified the identified adverse events according to consensus agreement. Results Of the 1008 consecutive cases, we identified 11 sentinel (5 cases of hypoxia, 6 of hypotension), 34 moderate, 25 minor, and 3 minimal risk adverse events. There were no adverse outcomes. Conclusions Our large series of propofol sedations performed by emergency physicians supports the safety of this practice. The sentinel adverse event rate of 1% that we identify prompts review: we will in future emphasize adherence to the reduced 0.5 mg kg−1 propofol dose in the elderly, and reconsider our use of metaraminol. We believe that our application of the World SIVA adverse event tool sets a benchmark for further studies.

Propofol for adult procedural sedation in a UK emergency department: safety profile in 1008 cases

BackgroundConcerns exist regarding the safe use of propofol by Emergency Physicians for procedural sedation. The World SIVA International Sedation Task Force has recently created an adverse event tool, in an effort to standardize reporting. We present a safety analysis of our use of propofol using this tool. MethodPropofol was given according to a previously published guideline. We analysed our dedicated departmental sedation database between December 2006 and March 2012 and cross-examined the original sedation chart for each case recorded. We stratified the identified adverse events according to consensus agreement. ResultsOf the 1008 consecutive cases, we identified 11 sentinel (5 cases of hypoxia, 6 of hypotension), 34 moderate, 25 minor, and 3 minimal risk adverse events. There were no adverse outcomes. ConclusionsOur large series of propofol sedations performed by emergency physicians supports the safety of this practice. The sentinel adverse event rate of 1% that we identify prompts review: we will in future emphasize adherence to the reduced 0.5 mg kg−1 propofol dose in the elderly, and reconsider our use of metaraminol. We believe that our application of the World SIVA adverse event tool sets a benchmark for further studies.

Use of metaraminol in patients with Familial Mediterranean Fever

We were recently involved in the management of a 38-year-old male who was admitted to our hospital for an elective surgical procedure that mandated general anaesthesia. He was also known to suffer with Familial Mediterranean Fever (FMF). FMF is a hereditary inflammatory disease characterised by self-limited recurrent attacks of fever and serositis [1]. The recurrent attacks of fever are accompanied by severe abdominal pain, arthritis or chest pain along with a marked increase in acute phase reactants [1]. Inheritance is autosomal recessive and it affects mainly Jews, Turks, Arabs and Armenians [2]. FMF crises are characterised by an influx of polymorphonuclear leucocytes into the inflamed regions [2]. A PubMed search uncovered that attacks could be precipitated by intravenous metaraminol [3]. Indeed, the metaraminol provocative test is considered a specific diagnostic test for FMF: a 10-mg infusion of metaraminol is followed within 48 h by a typical disease-like attack [3]. As metaraminol is widely used in anaesthetic practice and cumulative doses in excess of 10 mg can be administered if hypotension is protracted, it is quite likely this could trigger a FMF crisis postoperatively. The metaraminol-induced symptoms do not occur in patients on prophylactic colchicine therapy [3]. However, colchicine treatment is often complicated by frequent gastrointestinal side-effects, reducing patient compliance [4]. We would therefore suggest anaesthetists remain vigilant to the potential risks associated with the use of metaraminol in this group of patients, especially those not taking colchicine regularly.

Metaraminol (Aramine®) in the management of a significant amlodipine overdose

To report a patient with a significant amlodipine self-poisoning who failed to clinically respond to conventional treatment and was managed with metaraminol (Aramine). A 43-year old male presenting after ingestion of 560 mg amlodipine, who failed to respond clinically to treatment with fluid resuscitation, calcium salts, glucagon and norepinephrine/epinephrine inotropic support. Following a loading bolus of 2 mg and intravenous infusion (83 microg/min) of metaraminol (Aramine) there was improvement in his blood pressure, cardiac output and urine output. This is the first case report of the beneficial use of metaraminol (aramine) in the management of significant amlodipine poisoning unresponsive to conventional therapy.

Emprego do metaraminol no bloqueio da hipotensão produzida pelo uso da levomepromazina em cães

Avaliou-se a possibilidade do uso do bitartarato de metaraminol, visando o bloqueio da hipotensão produzida pelo cloridrato de levomepromazina em cães. Foram empregados 20 cães, machos e fêmeas, adultos, com pesos compreendidos entre 8 e 12 kg. Os animais foram divididos em dois grupos iguais (GI e GII). Aos cães do GI foi administrada, por via intravenosa, levomepromazina na dose de 2 mg/kg, seguida, 15 minutos após, de 0,5 ml de solução salina 0,9%. A pressão arterial sistólica (PAS), frequências cardíaca (FC) e respiratória (FR), temperatura retal (T) e avaliação eletrocardiográfica na derivação DII foram observadas antes da aplicação da levomepromazina e após a mesma, em intervalos de 15 minutos durante 60 minutos. Aos cães do GII foi aplicada a mesma metodologia, substituindo-se, porém, a solução salina pelo metaraminol na dose de 0,1 mg/kg, pela via intravenosa. Os valores obtidos foram submetidos à avaliação estatística pelo método de Análise de Perfil. Os resultados mostraram que o metaraminol produziu um aumento da PAS e diminuição da FC, além de promover menor queda da T e melhora dos valores de FR. Não foram observadas alterações na eletrocardiografia que pudessem ser atribuídas aos fármacos empregados. Concluiu-se que o metaraminol é seguro e indicado quando se emprega a levomepromazina, em cães.

The Use of Metaraminol in the Evaluation of Mitral Insufficiency

This paper presents a simple technique which is useful in evaluating the degree of mitral insufficiency. The pulmonary capillary peak V pressures before and after the intravenous injection of 1 mg of metaraminol were studied by right and left heart catheterization in 61 patients. The presence of an increase in the V-wave over 10 mm Hg indicated mitral insufficiency in all patients if a cardiomyopathy was excluded. If the left atrium is enlarged, a small degree of insufficiency is likely to be missed, but when the insufficiency is marked, the size of the atrium and its increased compliance is not so likely to attenuate the peaked V-wave. The absence of a rise, however, may be seen in patients with all combinations of insufficiency and left atrial enlargement.

Reversal of experimental endotoxin shock with a combination of aldosterone and metaraminol.

SummaryLethal shock was established in 55 adult mongrel dogs with a standardized dose of E. coli endotoxin. The shock could not be reversed with aldosterone or metaraminol when either was used alone. However, dogs given 0.1 mg of aldosterone required approximately one-fiftieth the dose of metaraminol necessary to maintain systemic pressure, compared to the use of metaraminol alone. This action of aldosterone was about 7 times more pronounced than that obtained with hydrocortisone. The nature of the contributing effect of steroid to the pressor activity of metaraminol and to the increased survival rate is not known.

Ischemic necrosis due to administration of metaraminol. Report of a case.

The use of sympathomimetic amines, such as arterenol (Levophed) bitartrate and metaraminol (Aramine) bitartrate, as vasopressor agents in the treatment of clinical hypotension has received widespread acceptance. The occurrence of ischemic necrosis secondary to the administration of arterenol has been well documented. 1 Due to the physiological similarity of these drugs it could be expected that such a complication would arise with extensive use of metaraminol. One such case was reported recently. 2 The following is a report of a similar case. A 62-year-old man was admitted to the Latter-day Saints Hospital on April 17, 1959, with the type of electrocardiographic changes found in patients with acute, posterior myocardial infarction, a white blood cell count of 11,200 per cubic millimeter, and a serum transaminase level of 56 Todd units. At the time of admission the patient's blood pressure was 130/100 mm. Hg in both arms, and his pulse rate was