Vasopressor Administration Research Articles

The Impact of Suprarenal Cross-Clamping on Kidney Function in Patients Undergoing Retroperitoneal Abdominal Aortic Aneurysm Repair following an Enhanced Recovery Protocol

The retroperitoneal approach (RP) is a well-established procedure for juxtarenal and infrarenal (IR) abdominal aortic aneurysm (AAA) repair when an endovascular option is not available. The aim of this study is to compare the effect of suprarenal (SR) and IR aortic clamping on postoperative renal function following an Enhanced Recovery Protocol (ERP). Since there are no defined guidelines within aortic surgery, we focused our attention on the role of fluid and vasopressor administration in the development of postoperative acute kidney injury (AKI). This is a single-center retrospective cohort study on 140 RP aortic aneurysm repair patients operated between 2009 and 2019. Patients were divided in 2 groups: 24 had SR clamping and 116 IR clamping. Since 2009, at our institution all patients have followed an Enchanced Recovery Program which has been implemented as standard care for patients undergoing open AAA repair. The 2 groups were well matched for baseline characteristics, preoperative renal function, and comorbidity. There was an increased need for intraoperative fluids (P=0.015), and vasopressors (P=0.002) in the SR group compared to the IR group. Patients in the SR group showed a higher trend of postoperative AKI as opposed to the control group (37.5% vs. 19.8%), although this event was not statistically significant (P=0.106). Acute Kidney Injury Network stage III requiring temporary dialysis occurred in only 3 patients who all belonged to the IR group. Conversely, stage I and II with a 2- or 3-fold increase in postoperative creatinine were more frequent in the SR group. However, these normalized before discharge in all cases. To the best of our knowledge, none of the above required permanent dialysis. The results from this study show that SR clamping during RP juxtarenal aortic aneurysm repair does not have an adverse effect on postoperative renal function in the short term. However, patients undergoing SR clamping require greater fluid and vasopressor usage, in contrast with the restrictive fluid therapy established by traditional protocols. This could be an important benchmark for future implementation of ERPs in vascular surgery, especially in open procedures requiring visceral clamping.

Variation in Fluid and Vasopressor Use in Shock With and Without Physiologic Assessment: A Multicenter Observational Study.

To characterize the association between the use of physiologic assessment (central venous pressure, pulmonary artery occlusion pressure, stroke volume variation, pulse pressure variation, passive leg raise test, and critical care ultrasound) with fluid and vasopressor administration 24 hours after shock onset and with in-hospital mortality. Multicenter prospective cohort study between September 2017 and February 2018. Thirty-four hospitals in the United States and Jordan. Consecutive adult patients requiring admission to the ICU with systolic blood pressure less than or equal to 90 mm Hg, mean arterial blood pressure less than or equal to 65 mm Hg, or need for vasopressor. None. Of 1,639 patients enrolled, 39% had physiologic assessments. Use of physiologic assessment was not associated with cumulative fluid administered within 24 hours of shock onset, after accounting for baseline characteristics, etiology and location of shock, ICU types, Acute Physiology and Chronic Health Evaluation III, and hospital (beta coefficient, 0.04; 95% CI, -0.07 to 0.15). In multivariate analysis, the use of physiologic assessment was associated with a higher likelihood of vasopressor use (adjusted odds ratio, 1.98; 95% CI, 1.45-2.71) and higher 24-hour cumulative vasopressor dosing as norepinephrine equivalent (beta coefficient, 0.37; 95% CI, 0.19-0.55). The use of vasopressor was associated with increased odds of in-hospital mortality (adjusted odds ratio, 1.88; 95% CI, 1.27-2.78). In-hospital mortality was not associated with the use of physiologic assessment (adjusted odds ratio, 0.86; 95% CI, 0.63-1.18). The use of physiologic assessment in the 24 hours after shock onset is associated with increased use of vasopressor but not with fluid administration.

Early vasopressor administration in pediatric blunt liver and spleen injury: An ATOMAC + study

BackgroundNo prior studies have examined the outcomes of early vasopressor use in children sustaining blunt liver or spleen injury (BLSI). MethodsA planned secondary analysis of vasopressor use from a 10-center, prospective study of 1004 children with BLSI. Inverse probability of treatment weighting (IPTW) was used to compare patients given vasopressors <48 h after injury to controls based on pretreatment factors. A logistic regression was utilized to assess survival associated with vasopressor initiation factors on mortality and nonoperative management (NOM) failure. ResultsOf 1004 patients with BLSI, 128 patients were hypotensive in the Pediatric Trauma Center Emergency Department (ED); 65 total patients received vasopressors. Hypotension treated with vasopressors was associated with a sevenfold increase in mortality (AOR = 7.6 [p < 0.01]). When excluding patients first given vasopressors for cardiac arrest, the risk of mortality increased to 11-fold (AOR = 11.4 [p = 0.01]). All deaths in patients receiving vasopressors occurred when started within the first 12 h after injury. Vasopressor administration at any time was not associated with NOM failure. ConclusionAfter propensity matching, early vasopressor use for hypotension in the ED was associated with an increased risk of death, but did not increase the risk of failure of NOM. Level of evidenceLevel III prognostic and epidemiological, prospective.

Effect of intraoperative vasopressor use on free flap outcome following major head-and-neck reconstructive surgeries

Introduction: Major head-and-neck surgeries involving wide excision of the tumor usually necessitate reconstruction with free flaps for tissue cover. Even with meticulous fluid management with crystalloids, colloids, albumin, blood, and blood products, many patients become hemodynamically unstable and require the use of vasopressors perioperatively. Objectives: The purpose of this analysis was to assess the safety, role, and present-day trends of the use of vasopressor agents in free flap surgeries and to find any relation of graft rejection or failure of flap surgeries or postoperative complications with perioperative use of such agents. Methods: Reviewing the literature regarding the usage of vasopressors in head-and-neck free flap surgeries, percentage of flap survival, thrombosis of the artery, venous edema, and need for revision surgery were analyzed. Most of the published data had shown that optimizing hemodynamic stability with vasopressors had a more beneficial effect on overall flap perfusion and minimized the complications of iatrogenic fluid overload. The common conclusion was that perioperative vasopressor administration was not detrimental to free flap survival. Conclusion: Based on available data, it is concluded that perioperative use of vasopressors does not adversely affect free flap outcome in patients undergoing head-and-neck reconstructive surgeries and could even be beneficial considering the avoidance of complications of liberal intravenous fluid administration.

Hemodynamic Safety of Continuous Infusion Labetalol Versus Esmolol Combination Therapies for Type B Aortic Dissections

Background: Medical management for type B aortic dissections (TBADs) require aggressive blood pressure and heart rate control to minimize further dissection extension and to restore perfusion to vital organs. Current guidelines recommend β-blockers (BB) as first-line therapy, however do not differentiate an ideal agent for use. Objective: This study evaluated the hemodynamic safety of continuous infusion labetalol compared to esmolol combination (EC) therapies for TBADs. Methods: This single-center, retrospective analysis identified patients with a TBAD who received high dose continuous intravenous labetalol (HD-CIVL) or EC therapies. Patients who received HD-CIVL or EC therapies for a minimum of 2 hours, during which a minimum of 4 blood-pressure readings were recorded, were included. The primary end point was the incidence of hemodynamic instability with the use of HD-CIVL versus EC therapies. Results: A total of 20 patients receiving HD-CIVL and 22 patients receiving EC therapy were included in the analysis. Ten (50%) of patients receiving HD-CIVL and 7 (32%) of patients receiving EC therapies met the clinical definition of hemodynamic instability (P = .23). Patients experiencing hemodynamic instability were all due to hypotension, with one also being due to bradycardia. Over half the patients in both groups had discontinued therapy ( P = .06) and were administered bolus fluids (P = .27). Only one patient receiving HD-CIVL required vasopressor administration while none in the EC group (P = .48). Conclusion: Our study suggests that HD-CIVL is associated with a nonstatistical significant higher incidence of hemodynamic instability compared to an EC regimen in TBADs. Further studies are warranted in this patient population.

Mitral annular plane systolic excursion and tricuspid annular plane systolic excursion for risk stratification of acute pulmonary embolism.

Risk stratification for acute pulmonary embolism (PE) incorporates metrics of right ventricle (RV) function. Significant RV dysfunction influences left ventricular (LV) function, though LV function metrics are not utilized for stratifying outcomes in patients with PE. Mitral annular plane systolic excursion (MAPSE) is a linear echocardiographic (TTE) measure that evaluates longitudinal LV function and may aid in risk stratification for acute PE. Using a single-center database of patients with PE from 2007 to 2014, MAPSE was calculated for all TTE's available with sufficient quality (n=362). A MAPSE of ≥11mm was used as a normal reference. Thirty-day adverse outcomes were defined as administration of vasopressor, fibrinolytic therapy, open embolectomy, or 30-day PE-related mortality. Odds ratios (OR) and adjusted OR (AOR) were calculated using logistic regression analysis. Tricuspid annular plane systolic excursion (TAPSE) measurements were incorporated to determine the additive benefit of MAPSE. Compared with the reference MAPSE≥11mm and LVEF>50%, patients with MAPSE<11mm and an LVEF>50% had worse outcomes (AOR 2.94 [95% CI: 1.08-7.98], P=0.035). Among patients with LVEF>50%, the presence of both a MAPSE<11mm and TAPSE<16mm was associated with greater odds of adverse outcomes compared with isolated depressed TAPSE (AOR 10.75 [95% CI: 3.06-37.8], P<0.01 vs AOR 1.68 [95% CI: 0.18-15.6], P=0.65). A depressed MAPSE, in patients with preserved LVEF, is associated with worse outcomes in patients with acute PE. The addition of MAPSE to TAPSE appears to have a greater prognostic value than either alone and may further aid in risk stratification, but for confirmation further prospective data are needed.

LekCheck: A Prospective Study to Identify Perioperative Modifiable Risk Factors for Anastomotic Leakage in Colorectal Surgery.

Objective:To assess potentially modifiable perioperative risk factors for anastomotic leakage in adult patients undergoing colorectal surgery.Summary Background Data:Colorectal anastomotic leakage (CAL) is the single most important denominator of postoperative outcome after colorectal surgery. To lower the risk of CAL, the current research focused on the association of potentially modifiable risk factors, both surgical and anesthesiological.Methods:A consecutive series of adult patients undergoing colorectal surgery with primary anastomosis was enrolled from January 2016 to December 2018. Fourteen hospitals in Europe and Australia prospectively collected perioperative data by carrying out the LekCheck, a short checklist carried out in the operating theater as a time-out procedure just prior to the creation of the anastomosis to check perioperative values on 1) general condition 2) local perfusion and oxygenation, 3) contamination, and 4) surgery related factors. Univariate and multivariate logistic regression analysis were performed to identify perioperative potentially modifiable risk factors for CAL.Results:There were 1562 patients included in this study. CAL was reported in 132 (8.5%) patients. Low preoperative hemoglobin (OR 5.40, P < 0.001), contamination of the operative field (OR 2.98, P < 0.001), hyperglycemia (OR 2.80, P = 0.003), duration of surgery of more than 3 hours (OR 1.86, P = 0.010), administration of vasopressors (OR 1.80, P = 0.010), inadequate timing of preoperative antibiotic prophylaxis (OR 1.62, P = 0.047), and application of epidural analgesia (OR, 1.81, P = 0. 014) were all associated with CAL.Conclusions:This study identified 7 perioperative potentially modifiable risk factors for CAL. The results enable the development of a multimodal and multidisciplinary strategy to create an optimal perioperative condition to finally lower CAL rates.

Effectiveness of intravenous boluses of phenylephrine, ephedrine and mephentermine as vasopressors for management of perioperative hypotension in elective lower segment caesarean section under spinal anaesthesia – A prospective comparative study

Hypotension after subarachnoid block for caesarean section is the commonest but serious complication encountered by anaesthesiologists. Various vasopressors are used to prevent/treat this complication. This study was done to compare the efficacy of three commonly used vasopressors – phenylephrine, ephedrine, mephentermine for treatment of perioperative hypotension. Sixty American Society of Anaesthesiologists (ASA) physical status class II parturients undergoing elective caesarean section under subarachnoid block were randomly allotted three groups (P, E, M) (n = 20) to receive intravenous boluses of phenylephrine 100 mcg, ephedrine 6mg &amp; mephentermine 6mg respectively, following hypotension. Maternal Haemodynamic parameters, complications &amp; neonatal APGAR scores were recorded. P-value &amp;#60; 0.05 was considered significant and P-value &amp;#60; 0.001 considered highly significant. Demographic values, baseline vital parameters and mean number of vasopressor boluses required were similar in the three groups (P &amp;#62; 0.05). The mean trends of systolic blood pressure (P = 0.06), diastolic blood pressure (P = 0.7) and mean arterial pressure (P = 0.6) were similar in the three groups. Heart rate was raised during periods of hypotension; the mean heart rate was lower in the phenylephrine group after vasopressor administration. The overall trend was similar (P = 0.1) among the three groups. There was (P = 0.003) higher incidence of bradycardia in the phenylephrine group. The neonatal APGAR scores were &amp;#62; 7 in the three groups at the 1st and 5th minute (P = 0.5). All three vasopressors effectively maintained arterial blood pressure during the subarachnoid block for caesarean section. Phenylephrine caused a significant reduction in heart rate compared to ephedrine or mephentermine.

Relationship between Early Vasopressor Administration and Spinal Cord Hemorrhage in a Porcine Model of Acute Traumatic Spinal Cord Injury.

Current practice guidelines for acute spinal cord injury (SCI) recommend augmenting mean arterial blood pressure (MAP) for the first 7 days post-injury. After SCI, the cord may be compressed by the bone/ligaments of the spinal column, limiting regional spinal cord blood flow. Following surgical decompression, blood flow may be restored, and can potentially promote a "reperfusion" injury. The effects of MAP augmentation on the injured cord during the compressed and decompressed conditions have not been previously characterized. Here, we used our porcine model of SCI to examine the impact of MAP augmentation on blood flow, oxygenation, hydrostatic pressure, metabolism, and intraparenchymal (IP) hemorrhage within the compressed and then subsequently decompressed spinal cord. Yucatan mini-pigs underwent a T10 contusion injury followed by 2 h of sustained compression. MAP augmentation of ∼20 mm Hg was achieved with norepinephrine (NE). Animals received MAP augmentation either during the period of cord compression (CP), after decompression (DCP), or during both periods (CP-DCP). Probes to monitor spinal cord blood flow (SCBF), oxygenation, pressure, and metabolic responses were inserted into the cord parenchyma adjacent to the injury site to measure these responses. The cord was harvested for histological evaluation. MAP augmentation increased SCBF and oxygenation in all groups. In the CP-DCP group, spinal cord pressure steadily increased and histological analysis showed significantly increased hemorrhage in the spinal cord at and near the injury site. MAP augmentation with vasopressors may improve blood flow and reduce ischemia in the injured cord but may also induce undesirable increases in IP pressure and hemorrhage.

Efficacy of an Alternative Oxytocin Dosing Regimen for Postpartum Hemorrhage Prevention at Cesarean Delivery [13P

INTRODUCTION: In 2013, the University of New Mexico Hospital transitioned from a 20IU oxytocin infusion to a “rule of threes” algorithm (3 IU of oxytocin titrated to uterine tone) for prevention of postpartum hemorrhage (PPH) at time of cesarean delivery. This study seeks to identify whether PPH rates have been affected by this change in oxytocin dosing. METHODS: This is a retrospective cohort study comparing PPH rates before and after an institutional shift in oxytocin administration at the time of cesarean delivery. IRB exemption was obtained for this study. Medical records were reviewed for scheduled and unscheduled cesarean section patients before and after the protocol change. 225 patients in each group were randomly selected for the analysis. Our primary outcome was the rate of PPH, determined by estimated blood loss reported by the surgeon. Secondary outcomes included administration of additional uterotonic agents, transfusion, hysterectomy, vasopressor administration, and mortality. RESULTS: There were no significant differences in age, gravidity, parity, prior number of cesarean sections, gestational age, BMI, fetal weight, or induction of labor. Women who received the 20IU oxytocin infusion had a significantly lower rate of PPH (22.2%) compared to “rule of threes” dosing (32.4%, Fishers test P=.0198). CONCLUSION: Our data show an increased rate of PPH with a rule of threes oxytocin dosing at the time of cesarean section compared with infusion dosing of oxytocin. These data indicate that rule of threes dosing may not be applicable to a wider patient population.

Selepressin, a novel selective V1A receptor agonist: Effect on mesenteric flow and gastric mucosa perfusion in the endotoxemic rabbit

Intestinal or mesenteric ischemia generally leads to inflammation and injury, potentially developing hypoxia, causing cell death and tissue necrosis. This in turn can lead to sepsis and shock. Conversely, following shock, the intestinal tract is a main organ to experience ischemic/reperfusion injury. Increased intestinal cell-membrane permeability through mesenteric ischemia provoking bacterial translocation and gut-barrier injury can lead to sepsis and multi-organ failure. Hypotension induced by systemic vasodilation and vascular leak in systemic inflammatory response syndrome and sepsis is countered by immediate fluid resuscitation and vasopressor administration, primarily norepinephrine (NE), with possible arginine vasopressin (AVP) supplementation, an agonist of vasopressin V1A and V2 receptors. Selepressin is a selective V1A-receptor agonist, avoiding potential V2 receptor-associated adverse effects. Selepressin, non-selective AVP, and NE effects on mesenteric blood flow (MBF) and gastric mucosa perfusion (GMP) were compared in control rabbits and a lipopolysaccharide-induced, fluid-resuscitated rabbit endotoxemia model. AVP induced a pronounced decrease in MBF and GMP in non-endotoxemic and endotoxemic rabbits, whereas the reduction after selepressin treatment was significantly less for both indicators in the endotoxemic animals. By contrast, NE increased the MBF and did not affect GMP in both groups. Selepressin and AVP induced a pronounced dose-dependent increase in mesenteric vascular resistance in non-endotoxemic and endotoxemic rabbits, tending to be less in endotoxemic animals, whereas a minor increase in both groups was observed with NE. Therefore, in this safety study, the risk for mesenteric ischemia on selepressin treatment was not inferior to AVP, being less in endotoxemic than in non-endotoxemic animals.

Late Vasopressor Administration in Patients in the ICU: A Retrospective Cohort Study

Little is known about the prevalence, predictors, and outcomes of late vasopressor administration which evolves after admission to the ICU. What is the epidemiology of late vasopressor administration in the ICU? We retrospectively studied a cohort of veterans admitted to the Veterans Administration ICUs for≥ 4days from 2014 to 2017. The timing of vasopressor administration was categorized as early (only within the initial 3days), late (on day 4 or later and none on day 3), and continuous (within the initial 2days through at least day 4). Regressions were performed to identify patient factors associated with late vasopressor administration and the timing of vasopressor administration with posthospitalization discharge mortality. Among the 62,206 hospitalizations with at least 4 ICU days, late vasopressor administration occurred in 5.5%(3,429 of 62,206). Patients with more comorbidities (adjusted OR [aOR], 1.02 per van Walraven point; 95%CI, 1.02-1.03) and worse severity of illness on admission (aOR, 1.01 per percentage point risk of death; 95%CI, 1.01-1.02) were more likely to receive late vasopressor therapy. Nearly 50%of patients started a new antibiotic within 24h of receiving late vasopressor therapy. One-year mortality after survival to discharge was higher for patients with continuous (adjusted hazard ratio [aHR], 1.48; 95%CI, 1.33-1.65) and late vasopressor administration (aHR, 1.26; 95%CI, 1.15-1.38) compared with only early vasopressor administration. Late vasopressor administration was modestly associated with comorbidities and admission illness severity. One-year mortality was higher among those who received late vasopressor administration compared with only early vasopressor administration. Research to understand optimization of late vasopressor therapy administration may improve long-term mortality.

Introduction of a Novel System for Quantitating Blood Loss After Vaginal Delivery: A Retrospective Interrupted Time Series Analysis With Concurrent Control Group

Postpartum hemorrhage (PPH) is a leading cause of maternal mortality worldwide. While volumetric and gravimetric blood loss measurement techniques have been shown to increase PPH detection compared to visual estimation of blood loss (vBL), a combination of these methods has not been evaluated. The primary aim of this study was to compare the change in odds of PPH detection after vaginal delivery (VD; the intervention series) versus cesarean delivery (CD; the control series) before versus after implementation of a device (Triton L&D, Gauss Surgical, Inc, Los Altos, CA) that combines gravimetric and volumetric estimation of blood loss (tBL). After institutional review board (IRB) approval, patients were identified who had a VD or CD at our institution 3 months before and 3 months after the implementation of a tBL device for VD. The levels and trends in odds of PPH detection (the primary outcome, defined as blood loss ≥500 mL for VD and ≥1000 mL for CD) were compared within and between delivery methods before and after implementation of the device. Secondary outcomes were blood loss ≥1000 mL, total blood loss, secondary uterotonic use, and a composite outcome related to PPH management (transfusion, vasopressor administration, and/or surgical procedures). A post hoc subgroup analysis compared nadir hematocrit, hematocrit reduction ≥10%, and difference between vBL or tBL and calculated blood loss (cBL) between VDs before and after introduction of the device. All outcome comparisons were performed using segmented regression with inverse probability of treatment weighting. The weighted odds ratio (wOR) of PPH detection post- versus preimplementation of the device was 2.74 (95% confidence interval [CI], 1.39-5.41; P = .004) for VDs versus 1.43 (95% CI, 0.72-2.85; P = .304) for CDs (P for interaction .190). No difference was detected in the secondary outcomes for VDs between time periods. In the subgroup of VD patients who had postdelivery hematocrits measured, the mean difference between vBL or tBL and cBL was smaller in the tBL (mean ± standard deviation [SD]: -237 ± 522 mL) versus vBL group (-600 ± 596 mL; weighted difference in means [95% CI]: 349 mL [13-684]; P = .042). In this interrupted time series analysis, the odds of PPH detection after VD increased after implementation of the tBL device. However, a statistical difference was not detected between the increase in PPH detection post- versus preimplementation of the device in VDs versus CDs.

Genesis of Antibiotic Resistance (AR) LVIII: Discordant Antibiotic Stewardship contort Early Goal Directed Fluid Resuscitation therapy (EGDT) with higher incidence of Mortality in severe Sepsis: A global melee

A retrospective analysis of EGDT trials from 2000 to 2018 registered in national clinical trials is presented here: (PRISM‐U) Study group attributed that the sepsis cohort with Mycobacterium tuberculosis (MTB) bacteremia for higher rate of in‐hospital mortality. FEAST (ISRCTN69856593) trial observed that fluid resuscitation in children with sepsis significantly increased mortality (48‐hour) possibly due to impaired perfusion. SSSP trail (NCT01449916) showed that though hypoxemic respiratory failure as contributing factor for mortality in addition to tissue hypoperfusion as inclusion criteria of patients with hypovolemia but excluding the patients with severe respiratory distress when ventilator support is not readily available could have potentially improved the survival rate. ARISE (NCT00975793) presented their report on the effectiveness of EGDT compare to that of usual sepsis care had similar (~18%) mortality rate concluding that EGDT did not reduce all‐cause mortality at 90 days. PRISM (NCT02030158) reported that, EGDT miss the mark to relieve mortality rate compare to that of usual care cohort. ProCESS (NCT00510835) reported that among 1341 patients, of whom 439 were randomly assigned to protocol‐based EGDT, 446 to protocol‐based standard therapy, and 456 to usual care in which protocol‐based resuscitation of patients in whom septic shock was diagnosed in the ER did not improve outcomes. ProMISe (ISRCTN36307479) concluded that septic shock cohort identified early and treated with intravenous antibiotics and adequate fluid resuscitation, hemodynamic management according to a strict EGDT protocol showed that no difference in mortality rate by 90 days. The IMPreSS study group found that compliance with “all of the evidence‐based bundle metrics” had a 40 % reduction in the odds of dying in hospital with the 3‐h bundle and 36 % for the 6‐h bundle. ProCESS Investigators (NCT00793442, NCT00510835 ) showed that increase in leucocyte rolling and adhering to dysfunctional endothelial surface in the cohort of septic shock compare to that of control, attributed to an increase in endothelial permeability‐hemostasis as cause for mortality. SSSP‐2 (NCT01663701) reported that cohort with sepsis and hypotension, most of whom were positive for HIV, in a resource‐limited setting, a protocol for early resuscitation with administration of intravenous fluids and vasopressors increased in‐hospital mortality compared with usual care. MOSAICS Study Group attributed the high mortality rate in severe sepsis treatment for the variation in adhering to the “all of the evidence‐based bundle metrics” for sepsis treatment. GENESIS project comparing 6‐hour resuscitation bundle (RB) for severe sepsis cohort showed decreased mortality rate compare to that of no RB bundle. Taken together it is suggested that lack coherent antibiotic stewardship practices across the globe warrant immediate review during EGDT and implementation of such guidelines would likely improve the survival rate in both low and high resource setting.Support or Funding InformationSupported by the professional development funds by SWTJC to Subburaj Kannan

Severe Calcium Channel Blocker Overdose and Successful Management: a Case Report and Literature Review

Background: Calcium channel blocker (CCB) toxicity is one of the most lethal and common drug overdoses encountered in the emergency department (ED). The toxicity of these drugs results from blockade of L-type calcium channels in smooth cells, myocardial cells, and beta cells of the pancreas. Severe toxicity can result in bradycardia, hypotension, hyperglycemia, metabolic acidosis, shock, cardiac arrest and death. According to the American Association of Poison Control Centers’ National Poison Data System’s annual report in 2015, cardiovascular medications were the fourth most common adult poisoning exposure and second most common cause of adult poisoning fatality in the USA. CCBs are responsible for a substantial portion of the mortality associated with cardiovascular medication overdose cases. Understanding the emergent management of CCB toxicity is essential. Treatment of patients with CCB overdose remains challenging especially in those with refractory hypotension and end organ dysfunction. Case Presentation: A 45-year-old male with massive amlodipine overdose presented to ED with syncope and severe hypotension. Intensive medical therapy (fluid resuscitation, inotropes, calcium gluconate, and hyperinsulinemia euglycemia therapy [HIET]) was initiated in the ED and continued in the Intensive Care Unit (ICU), and resulted in the patient’s total recovery, without any major complications. Fortunately, ECMO implantation (extracorporeal membrane oxygenation) was not required in this patient. Conclusion: Urgent administration of fluids, calcium, vasopressors, and HIET therapy seem to be the most well validated initial approaches to CCBs overdose treatment. Our successful management strategy should serve as a good learning experience as well as a recommendation for managing such patients.

High-Dose Vasopressor Therapy for Pediatric Septic Shock: When Is Too Much?

It is unknown if the requirement for high dose of vasopressor (HDV) represents a poor outcome in pediatric septic shock. This is a retrospective observational analysis with data obtained from a single center. We evaluated the association between the use of HDV and survival in these patients. A total of 62 children (38 survivors and 24 nonsurvivors) were assessed. The dose of vasopressor (hazard ratio 2.06) and oliguria (hazard ratio 3.17) was independently associated with mortality. The peak of vasopressor was the best prognostic predictor. A cutoff of 1.3 μg/kg/min was associated with mortality with a sensitivity of 75% and specificity of 89%. Vasopressor administration higher than 1.3 μg/kg/min was associated with increased mortality in children with septic shock.

Delayed vasopressor initiation is associated with increased mortality in patients with septic shock

Despite significant advancements in the management of septic shock, mortality rates remain high. Systemic vasodilation leading to inadequate tissue perfusion and in turn multi-organ failure leads to death. Strategic sepsis bundles were introduced by the 2016 Surviving Sepsis Campaign (SSC) and recommend antibiotics within 1 hour of onset and early and aggressive fluid resuscitation, as well as three and six-hour bundles to allow for re-evaluation. Vasopressor initiation to correct hemodynamic instability that is unresponsive to fluid resuscitation can occur at any number of points during resuscitation per the SSC recommendations. Despite the crucial role of vasopressors in maintaining hemodynamic stability, there is limited data to show how the timing of vasopressor initiation affects outcomes, though some studies have shown mortality benefit with early administration of vasopressors in septic shock.

Clinical utility of midodrine and methylene blue as catecholamine-sparing agents in intensive care unit patients with shock

Shock is common in the intensive care unit, affecting up to one third of patients. Treatment of shock is centered upon managing hypotension and ensuring adequate perfusion via administration of fluids and catecholamine vasopressors. Due to the risks associated with catecholamine vasopressors, interest has grown in using catecholamine-sparing agents such as midodrine and methylene blue. Midodrine is an orally administered alpha-1 adrenergic agonist while methylene blue is an intravenously administered blue dye used to restore vascular tone and increase blood pressure. Separate MEDLINE, Scopus, and Embase database searches were conducted to assess literature revolving around these agents. Examples of search terms included "midodrine", "methylene blue", "critically ill", "shock", and "catecholamine-sparing." Several studies have evaluated their use in patients with shock and found potential benefits in terms of causing significant elevations in blood pressure and hastening catecholamine vasopressor discontinuation with few adverse effects; however, robust evidence is lacking for these off-label indications. Because of the variety of dosing strategies used and the incongruences between patient populations, it is also challenging to define finite recommendations. This review aims to summarize current evidence for the use of midodrine and methylene blue as catecholamine-sparing agents in critically ill patients with resolving or refractory shock.

The Australasian Resuscitation In Sepsis Evaluation: Fluids or vasopressors in emergency department sepsis (ARISE FLUIDS), a multi‐centre observational study describing current practice in Australia and New Zealand

ObjectivesTo describe haemodynamic resuscitation practices in ED patients with suspected sepsis and hypotension.MethodsThis was a prospective, multicentre, observational study conducted in 70 hospitals in Australia and New Zealand between September 2018 and January 2019. Consecutive adults presenting to the ED during a 30‐day period at each site, with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation, were eligible. Data included baseline demographics, clinical and laboratory variables and intravenous fluid volume administered, vasopressor administration at baseline and 6‐ and 24‐h post‐enrolment, time to antimicrobial administration, intensive care admission, organ support and in‐hospital mortality.ResultsA total of 4477 patients were screened and 591 were included with a mean (standard deviation) age of 62 (19) years, Acute Physiology and Chronic Health Evaluation II score 15.2 (6.6) and a median (interquartile range) systolic blood pressure of 94 mmHg (87–100). Median time to first intravenous antimicrobials was 77 min (42–148). A vasopressor infusion was commenced within 24 h in 177 (30.2%) patients, with noradrenaline the most frequently used (n = 138, 78%). A median of 2000 mL (1500–3000) of intravenous fluids was administered prior to commencing vasopressors. The total volume of fluid administered from pre‐enrolment to 24 h was 4200 mL (3000–5661), with a range from 1000 to 12 200 mL. Two hundred and eighteen patients (37.1%) were admitted to an intensive care unit. Overall in‐hospital mortality was 6.2% (95% confidence interval 4.4–8.5%).ConclusionCurrent resuscitation practice in patients with sepsis and hypotension varies widely and occupies the spectrum between a restricted volume/earlier vasopressor and liberal fluid/later vasopressor strategy.

Blood and fluid management during scoliosis surgery: a single-center retrospective analysis.

In the present retrospective study in scoliosis surgery, we hypothesized that application of a protocol for blood and fluid management, based on goal-directed fluid therapy, cell salvage and tranexamic acid, could lead to reduced allogeneic red blood cells transfusion. Thirty-five patients, with American Society of Anesthesiologists physical status I/III, between 14 and 18years scheduled for elective orthopedic surgery of scoliosis, with a planned intensive care unit admission, were enrolled in a retrospective observational study. Patients were divided in two groups. Patients in no-protocol group (Group noPro, n = 18) received a liberal intraoperative fluid therapy and patients in protocol group (Group Pro, n = 17) received fluid therapy managed according to a stroke volume variation-based protocol. The protocol included fluid therapy according to SVV monitor, permissive hypotension, tranexamic acid infusion, restrictive RBC trigger and use of perioperative cell savage. Student's t test (2-tailed), Mann-Whitney test, Chi square test were used for statistical analysis of the data. There were no significant differences between the two groups in demographic data and clinical characteristics. Infused crystalloids (p = .003) and transfused allogeneic red blood cells (p = .015) were lesser in Group Pro compared to Group noPro. On the other hand, diuresis (p < .001) and vasopressors administration (p = .042) were higher in Group Pro than in Group noPro. The application of a protocol for blood and fluid management, based on goal-directed fluid therapy, cell salvage and tranexamic acid, was associated with less crystalloid fluid administration, less perioperative RBC transfusions and significantly better diuresis than patients in the no-protocol group in scoliosis surgery. ClinicalTrials.gov Identifier: NCT03814239.