Vasoactive Therapy Research Articles

Arterial line in prehospital emergency settings – A feasibility study in four physician-staffed emergency medical systems

Background and aim of the studyArterial lines are widely used in operating rooms, critical care and emergency departments. Although invasive arterial blood pressure monitoring and arterial blood gas analysis are prehospitally available, the use of arterial lines in the field remains an exception. This study evaluates the feasibility, indications and therapeutic consequences of prehospital arterial line insertion. MethodsProspective observational study in four physician-staffed emergency medical systems (EMS), documenting patient status, indications, location of puncture, number of tries and time for puncture and therapeutic consequences. ResultsDuring the one-year observation period, arterial line placement succeeded in 115 (83.9%) of 137 patients. The median time for successful arterial cannulation was 2min (IQR 1, 3min; range: 30–600s), for preparing the invasive blood pressure monitoring 3min (IQR 2, 4min, range: 30–600s). Main indications were cardiopulmonary resuscitation (36.5%), post-resuscitation care (16.8%), respiratory insufficiency (24.1%) and unconsciousness (22.6%). Therapeutic consequences depended on whether the EMS was equipped with a blood gas analyzer or not and were, overall, reported in 51.3% of patients: fluids, vasoactive or antihypertensive therapy, correction of ventilation or acidosis. No complications occurred during the prehospital phase. ConclusionThe insertion of arterial lines is feasible under prehospital conditions, without delaying or complicating patient care. Indications originating from intrahospital use are also valid in the field. In particular when combined with arterial blood gas measurement, the use of arterial lines often leads to important therapeutic consequences.

An amputation alternative for patients with Critical Limb Ischemia

After the Prostaglandin E1 (PGE1) application, vasoactive therapy became an alternative to arterial surgery. The purpose of this study is to justify the PGE1 treatment in hopeless cases with Critical Limb Ischemia (CLI). The analysis presented covers 7 years experience with PGE1 therapy applied on 103 CLI cases. The patients were divided into 2 groups: 29 with post-operative deterioration and 74 non-operable cases with atherosclerosis, TAO or diabetes. PGE1 was applied by intravenous or intraarterial infusions, 10 days for non-responders and 4–6 weeks for responders. Patients were followed from 6 months to 7 years, mean 33 months. Satisfactory results were recorded for 9 operated patients. In the group of non-operable patients the effect was better and good results were documented in 39 cases. The limbs of 48 patients who responded to the therapy were saved and almost all became claudicants later on. In 49 (89%) of non-responders high amputations were performed. Nine cardiac deaths were observed. Side-effects were registered in 6 cases (5,8%). PGE1 treatment is an amputation alternative in 46,6% of patients with CLI, 31% after ineffective surgery and 52,7% for non-operable patients. The best results were observed for TAO-patients. Side effects were insignificant.

Sudden Bilateral Sensorineural Hearing Loss following Polysubstance Narcotic Overdose

Auditory disorders associated with substance abuse are rare. Hearing loss secondary to heroin and hydrocodone abuse has been described variously as not always responsive to steroid management, as not always reversible, and in some cases, as nonresponsive profound sensorineural hearing loss requiring cochlear implantation. We present a case of a teenager with sudden-onset moderate to severe bilateral sensorineural hearing loss after documented polysubstance "binging." The hearing loss improved substantially after high-dose steroid and vasoactive therapy. The purpose of this report is to describe the hearing disorder of a patient who had awakened with a bilateral severe hearing loss following a night of recreational drug abuse. Case report and review of the literature. The subject of this report is an 18-yr-old patient with a history of substance abuse. Data collected were magnetic resonance /computed tomography brain imaging; metabolic, infectious disease, and autoimmune evaluation; and extensive audiologic evaluation, including pure-tone and speech audiometry, immittance measures, distortion-product otoacoustic emissions, and auditory brainstem response testing. Serial audiograms were collected for 10 mo following the onset of symptoms. Two days of polysubstance abuse (heroin, benzodiazepine, alcohol, and crack [smoked cocaine]) resulted in moderately severe sensorineural hearing loss bilaterally. The loss responded to a 1 mo course of high-dose prednisone and a 10 mo course of pentoxifylline. Hearing sensitivity subsequently improved, leaving only residual high-frequency sensorineural hearing loss. This case report highlights the importance of "recreational" drug abuse in the evaluation of sudden hearing loss. Potential etiologies include altered pharmacokinetics, vascular spasm/ischemia, encephalopathy, acute intralabyrinthine hemorrhage, and genetic polymorphisms of drug-metabolizing enzymes.

Post Cardiac Arrest Syndrome

Out-of-hospital cardiac arrest (OHCA) is a common initial presentation of cardiovascular disease, affecting up to 325 000 people in the United States each year.1 In a recent meta-analysis of >140 000 patients with OHCA, survival to hospital admission was 23.8%, and survival to hospital discharge was only 7.6%.2 In patients who initially achieve return of spontaneous circulation (ROSC) after OHCA, the significant subsequent morbidity and mortality are due largely to the cerebral and cardiac dysfunction that accompanies prolonged whole-body ischemia. This syndrome, called the post cardiac arrest syndrome, comprises anoxic brain injury, post cardiac arrest myocardial dysfunction, systemic ischemia/reperfusion response, and persistent precipitating pathology3,4 (Table 1). The contribution of each of these components in an individual patient depends on various factors, including prearrest comorbidities, duration of the ischemic insult, and cause of the cardiac arrest. This review focuses on therapeutic strategies and recent developments in managing patients who are initially resuscitated from cardiac arrest. View this table: Table 1. Post Cardiac Arrest Syndrome: Pathophysiology and Potential Treatment Strategies There are 3 major aspects that require consideration in the management of the post cardiac arrest patient. After resuscitation, a decision must be made in relation to the appropriate triage of the OHCA patient. The next phase of management concerns the in-hospital treatment, which must address each component of the postarrest syndrome as appropriate for the individual patient. Finally, there are issues relating to prognostication and the deployment of various secondary prevention measures. Our recommended treatment algorithm is summarized in the Figure. This ideally follows from the implementation of basic and advanced life support measures, including effective cardiopulmonary resuscitation and defibrillation when appropriate, which are major determinants of outcome.2 Such an approach to care may be further modified according to the presence of other comorbidities and precipitating factors, which should be assessed …

Cardiac tamponade and large pericardial effusions in systemic sclerosis

Cardiac tamponade in systemic sclerosis is rare. We report four cases of SSc with hemodynamically significant pericardial effusions associated with pulmonary arterial hypertension, three of whom died, two following pericardiocentesis. Of 26 SSc cases reported in the literature with large pericardial effusions, seven were associated with PAH. Including our series, the mortality rate is 55%.The potential contributory role of PAH in the development of pericardial effusion and the management implications are explored. In SSc patients with hemodynamically significant pericardial effusions and severe pulmonary hypertension, initial stabilization of pulmonary artery pressure and right heart function with vasoactive therapy and then cautious pericardial drainage should be considered.

The effects of vasoactive drugs on pulse pressure and stroke volume variation in postoperative ventilated patients

IntroductionAlthough pulse pressure variation (PPV) and stroke volume variation (SVV) during mechanical ventilation have been shown to predict preload responsiveness, the effect of vasoactive therapy on PPV and SVV is unknown. MethodsPulse pressure variation and SVV were measured continuously in 15 cardiac surgery patients for the first 4 postoperative hours. Pulse pressure variation was directly measured from the arterial pressure waveform, and both PPV and SVV were also calculated by LiDCO Plus (LiDCO Ltd, Cambridge, United Kingdom) before and after volume challenges or changes in vasoactive drug infusions done to sustain cardiovascular stability. ResultsSeventy-one paired events were studied (38 vasodilator, 10 vasoconstrictor, 14 inotropes, and 9 volume challenges). The difference between the measured and LiDCO-calculated PPV was 1% ± 7% (1.96 SD, 95% confidence interval, r2 = 0.8). Volume challenge decreased both PPV and SVV (15% to 10%, P < .05 and 13% to 9%, P = .09, respectively). Vasodilator therapy increased PPV and SVV (13% to 17% and 9% to 15%, respectively, P < .001), whereas increasing inotropes or vasoconstrictors did not alter PPV or SVV. The PPV/SVV ratio was unaffected by treatments. ConclusionVolume loading decreased PPV and SVV; and vasodilators increased both, consistent with their known cardiovascular effects. Thus, SVV and PPV can be used to drive fluid resuscitation algorithms in the setting of changing vasoactive drug therapy.

Clinical characteristics and outcomes of patients with acute myelogenous leukemia admitted to intensive care: a case-control study

BackgroundThere is limited epidemiologic data on patients with acute myelogenous (myeloid) leukemia (AML) requiring life-sustaining therapies in the intensive care unit (ICU). Our objectives were to describe the clinical characteristics and outcomes in critically ill AML patients.MethodsThis was a retrospective case-control study. Cases were defined as adult patients with a primary diagnosis of AML admitted to ICU at the University of Alberta Hospital between January 1st 2002 and June 30th 2008. Each case was matched by age, sex, and illness severity (ICU only) to two control groups: hospitalized AML controls, and non-AML ICU controls. Data were extracted on demographics, course of hospitalization, and clinical outcomes.ResultsIn total, 45 AML patients with available data were admitted to ICU. Mean (SD) age was 54.8 (13.1) years and 28.9% were female. Primary diagnoses were sepsis (32.6%) and respiratory failure (37.3%). Mean (SD) APACHE II score was 30.3 (10.3), SOFA score 12.6 (4.0) with 62.2% receiving mechanical ventilation, 55.6% vasoactive therapy, and 26.7% renal replacement therapy. Crude in-hospital, 90-day and 1-year mortality was 44.4%, 51.1% and 71.1%, respectively. AML cases had significantly higher adjusted-hazards of death (HR 2.23; 95% CI, 1.38-3.60, p = 0.001) compared to both non-AML ICU controls (HR 1.69; 95% CI, 1.11-2.58, p = 0.02) and hospitalized AML controls (OR 1.0, reference variable). Factors associated with ICU mortality by univariate analysis included older age, AML subtype, higher baseline SOFA score, no change or an increase in early SOFA score, shock, vasoactive therapy and mechanical ventilation. Active chemotherapy in ICU was associated with lower mortality.ConclusionsAML patients may represent a minority of all critically ill admissions; however, are not uncommonly supported in ICU. These AML patients are characterized by high illness severity, multi-organ dysfunction, and high treatment intensity and have a higher risk of death when compared with matched hospitalized AML or non-AML ICU controls. The absence of early improvement in organ failure may be a useful predictor for mortality for AML patients admitted to ICU.

Early Transjugular Intrahepatic Portosystemic Shunt for Acute Variceal Bleeding Lowers Treatment Failure and Mortality

A study published in The New England Journal of Medicine finds that early rescue treatment with a transjugular intrahepatic portosystemic shunt (TIPS) for cirrhosis patients who are hospitalized for acute variceal bleeding could significantly lower treatment failure and mortality. If large varices develop in the esophagus or upper stomach, patients with cirrhosis are at risk for serious bleeding due to rupture of these varices. Once varices have bled, they tend to rebleed and the probability that a patient will die from each bleeding episode is high (30%–35%). Among current practice guidelines recommended for treating patients with acute variceal bleeding are fluid resuscitation, antibiotic prophylaxis, and vasoactive drugs such as octreotide, terlipressin, or somatostatin, followed by early endoscopy and either ligation or sclerosis of the varices. Despite these measures, failure to control index bleeding occurs in 10%–20% of patients. TIPS is indicated in patients who fail to respond to β-blockers, variceal sclerotherapy, or banding. TIPS can also be considered in treating patients with ascites that does not respond to salt and fluid restriction and diuretics. Researchers with the Early TIPS Cooperative Study Group randomized 63 patients with Child class B or C cirrhosis and acute variceal bleeding who had been treated with vasoactive drugs plus endoscopic therapy, either to treatment with a polytetrafluoroethylene (PFTE)-covered stent within 72 hours of randomization (early TIPS group, 32 patients) or to continuation of vasoactive drug therapy followed by propranolol or nadolol and long-term endoscopic band ligation (EBL), with insertion of a TIPS if needed as rescue therapy (31 patients). In this multicenter international study, patients who received early TIPS had a significantly better chance of remaining free of bleeding than did those who received the standard care (97% vs 50%). The rate of survival at 6 weeks was 97% in the TIPS group as compared with 67% in the medical therapy group, as a result of reductions in rebleeding, sepsis, and liver failure. In addition, “the number of days in the intensive care unit and percentage of time in the hospital during follow-up were significantly higher in the pharmacotherapy-EBL group,” the authors state. An editorial in the same issue of the journal notes that the study “should stimulate a reevaluation of how we approach variceal bleeding in patients with Child–Pugh class B or C disease. Instead of taking a wait-and-see approach, physicians should consider the early use of TIPS with a PFTE–covered stent as first-line therapy rather than as rescue treatment if rebleeding occurred. Additional clinical trials of adequate size should be performed to confirm these findings and to examine the effect of a rapid reduction in portal pressure on disease progression in patients with cirrhosis of various causes.” See NEJM 2010;362:2370–2379, 2421–2422. Also see Hepatology 2010:51, for AASLD TIPS practice guidelines and overview.

Early hemodynamics monitoring and nursing care after orthotopic heart transplantation

Objective To explore the experience of monitoring and the nursing care of early hemodynamics after orthotopic heart transplantation in order to improve the short-term outcome. Methods A total of 96 patients with end-stage cardiopathy underwent orthotopic heart transplantation. The hemodynamic were closely monitored and nursed care after operation in order to maintain the stability of hemodynamics of allografts. Results All recipients received vasoactive drug therapy and seven recipients died of acute allograft right ventricle dysfunction during the postoperative period. The rest survived well and had a rather good quality of life. Conclusions The hemodynamic changes often occur at the early term after orthotopic heart transplantation. The main change is the right ventrieular failure. It is important for the recovery and prognosis to monitor the hemodynamic changes and analyze the cauls in order to direct the therapy. Key words: Heart Transplantation; Hemodynamics ; Monitoring; Nursing

Urinary liver fatty acid-binding protein: another novel biomarker of acute kidney injury

Liver fatty acid-binding protein (L-FABP) binds selectively to intracellular free unsaturated fatty acids and lipid peroxidation products during hypoxic tissue injury. Urinary L-FABP is a potential biomarker for the detection and assessment of acute kidney injury (AKI). Ferguson et al. have demonstrated in a cross-sectional study that urinary L-FABP is an excellent biomarker of AKI and may be useful in predicting dialysis-free survival. This study did not assess utility for early diagnosis of AKI.

Water, taken in moderation, cannot hurt anybody (Mark Twain 1835-1910)

Water, taken in moderation, cannot hurt anybody (Mark Twain 1835-1910)

Variation in perioperative vasoactive therapy in cardiovascular surgical care: Data from the Society of Thoracic Surgeons

Variation in perioperative vasoactive therapy in cardiovascular surgical care: Data from the Society of Thoracic Surgeons

Variation in perioperative vasoactive therapy in cardiovascular surgical care: Data from the Society of Thoracic Surgeons

Variation in perioperative vasoactive therapy in cardiovascular surgical care: Data from the Society of Thoracic Surgeons

Variation in perioperative vasoactive therapy in cardiovascular surgical care: Data from the Society of Thoracic Surgeons

Variation in perioperative vasoactive therapy in cardiovascular surgical care: Data from the Society of Thoracic Surgeons

Influence of Extravascular Lung Water Determination in Fluid and Vasoactive Therapy

Preload parameters in postresuscitation phase are not sufficiently sensitive to guide fluid therapy in critically ill patients. We analyzed modifications in the fluid therapy and vasoactive drugs of critically ill patients that were produced by inclusion of extravascular lung water (EVLW) data in the treatment protocol and evaluated the short-term response. This observational and prospective study included consecutive patients with hypotension or hypoxemia, comparing the therapeutic plan for fluid and vasoactive drug treatment between before and after knowing the EVLW value. We studied 42 patients. After knowing the EVLW, 52.4% (n = 22) of initial therapeutic plans were changed, modifying fluid therapy in all of these cases and vasoactive therapy in 22% of them. EVLW value was 13.91 +/- 5.62 in patients with change of therapeutic plan versus 10 +/- 4.52 in those with no change (p < 0.05). No differences were found in preload parameters as a function of change/no change. The most frequent decision change (n = 13) was to fluid reduction plus diuretic administration, and patients with this modification had significantly (p < 0.05) higher EVLW values compared with the remaining patients with a change in fluid therapy. Out of the 22 patients with a modified therapeutic decision, the therapy proved effective in 18 patients Quantification of EVLW in patients who can be considered euvolemic induces important modifications in fluid and vasoactive therapy. These changes generally resulted in a lower volume loading and a positive outcome for the patient.

Epidemiology of Septic Acute Kidney Injury

The incidence of sepsis and acute kidney injury (AKI) are increasing in critically ill patients and both portend a higher risk of morbidity and death. Sepsis has consistently been shown to be a key contributing factor for the development of AKI. Numerous observational studies have found septic AKI to be highly common among the critically ill. Septic AKI patients are characterized by important differences in baseline demographics, acuity of illness and treatment intensity when compared with non-septic AKI. In particular, these patients are often older, have a higher prevalence of co-morbid illnesses, and are admitted for medical or emergency surgical indications. These patients show greater aberrancy in vital signs, laboratory parameters and need for vasoactive therapy and/or mechanical ventilation. Delays in initiation of appropriate antimicrobial therapy independently predict development of AKI in septic patients. Both delays to appropriate antimicrobials and initiation of renal support are also associated with higher mortality. Survival to ICU and/or hospital discharge for septic AKI patients is significantly lower when compared to patients with either non-septic AKI or sepsis alone. However, survivors of septic AKI show trends for greater rates of renal recovery and dialysis independence compared with non-septic AKI. The burden of septic AKI continues to increase and remains associated with an unacceptably high attributable morbidity and mortality. Accordingly, there is continued need to understand its epidemiology, not only to guide in management of these patients at the bedside, but also to stimulate advances in understanding its pathophysiology and in therapeutic interventions to potentially mitigate prognosis.

Early Vasoactive Drugs Improve Heart Failure Outcomes

Vasoactive therapy is often used to treat acute decompensated heart failure (ADHF). The authors sought to determine whether clinical outcomes are temporally associated with time to vasoactive therapy (vasoactive time) in ADHF. Using the Acute Decompensated Heart Failure (ADHERE) Registry, the authors examined the relationship between vasoactive time and inpatient mortality within 48 hours of hospitalization. Vasoactive agents were used early (defined as <6 hours) in 22,788 (63.8%) patients and late in 12,912 (36.2%). Median vasoactive time was 1.7 and 14.7 hours in the early and late groups, respectively. In-hospital mortality was significantly lower in the early group (odds ratio, 0.87; 95% confidence interval, 0.79-0.96; P=.006), and the adjusted odds of death increased 6.8% for every 6 hours of treatment delay (95% confidence interval, 4.2-9.6; P<.0001). Early vasoactive initiation is associated with improved outcomes in patients hospitalized for ADHF.

Interactions among donor characteristics influence post-transplant survival: A multi-institutional analysis

Quantification of donor-associated risk in a specific heart transplant recipient is often difficult. Our aim was to identify donor characteristics that affect survival in the contemporary era. Between 1990 and 2006, 7,322 patients from 32 centers in the Cardiac Transplant Research Database underwent heart transplantation. Multivariable logistic regression analysis was used to identify donor-associated risk predictors and important interactions between these donor characteristics. Recipient survival was examined using parametric regression analysis in the hazard function domain. Donor characteristics associated with post-transplant death included donor age, donor requirement for vasoactive therapy, positive donor cytomegalovirus serology, longer graft ischemic time, and lower donor body weight. Several interactions between individual donor characteristics affected survival. In male donors, history of hypertension and diabetes mellitus were risk factors for death (p = 0.006, p = 0.04, respectively), but not in female donors (p = 0.5, p = 0.8, respectively). There was a significant interaction between donor age and recipient-donor weight difference. If the donor was of younger age, increasing recipient-donor weight difference did not result in increased death. With increasing donor age, weight difference did result in compromised survival (p < 0.0003). Donor and recipient gender further modified the degree of risk: risk was higher in female donors and when recipients were male (p < 0.0003). This multi-institutional analysis identified important interactions between donor characteristics that affect post-transplant survival that explain some of the discrepancies in the results of previous studies. The results are likely to aid in efficient organ allocation.

Pulmonalvaskuläre Beteiligung bei Morbus Osler

In hereditary haemorrhagic teleangiectasia (HHT) can be accompanied by pulmonary arteriovenous vascular malformations (PAVM). Pulmonary hypertension (PH) is regarded as a rare pulmonary manifestation. We non-invasively assessed the pulmonary circulation in 20 patients with HHT using standard resting echocardiography including contrast studies. In 14 patients a mutation in the endoglin gene was present. The other 6 patients carried a mutation in the Alk-1 gene. We identified 4 patients with manifest PH, among them 2 patients (both with endoglin mutations) with concurrent thromboembolism, and 2 patients (both with Alk-1 mutations) with hepatic manifestations of HHT. Two patients required specific pulmonary vasoactive therapy with sildenafil and bosentan, respectively. Another patient received embolisation therapy for hypercirculatory PH due to hepatic arteriovenous malformations. Pulmonary arteriovenous malformations were found in 8 patients (7 with endoglin, and 1 with Alk-1 mutations), among them were 2 patients with PH. Patients with HHT should undergo echocardiographic screening for PAVM as well as PH. When PH is detected, other conditions such as hepatic or thromboembolic diseases should be considered, regardless of the underlying genetic defect.

Pulmonary hypertension in polymyositis-dermatomyositis: clinical and hemodynamic characteristics and response to vasoactive therapy

The increased incidence of pulmonary hypertension and its association with decreased survival is well-recognised in patients with systemic sclerosis. This association is not widely appreciated in patients with polymyositis-dermatomyositis. We report clinical and hemodynamic characteristics and response to vasoactive therapy in three patients with polymyositis-dermatomyositis and pulmonary hypertension and discuss them in light of the available literature.