Vasopressor Agents Research Articles

The characteristics and outcomes of oncology patients in intensive care unit in a tertiary care hospital in Saudi Arabia

Background: Many cancer patients need admission to intensive care unit (ICU). It is important to identify patients who will benefit most from ICU care. Objective: The current study aimed to identify the clinical features associated with outcomes and factors predicting ICU mortality of cancer patients at a tertiary care hospital in Riyadh, Saudi Arabia. Materials and Methods: This was a single-center, retrospective study of all adult patients with either hematological or solid cancer admitted to ICU between January 2017 and June 2018 at King Fahad Medical City, Riyadh, Saudi Arabia. Collected data included: patients' demographics, type of cancer, diagnosis, stage of disease, number of organs failure, reason for ICU admission, severity scores (Acute Physiology and Chronic Health Evaluation [APACHE] II, and Sepsis-related Organ Failure Assessment [SOFA] score), code status, interventions in the ICU, and outcomes. Results: A total of 108 cancer patients were admitted 128 times to ICU during the specified study period. Overall, mortality rate was 57% with standardized mortality rate according to the APACHE II of 0.75. Associative mortality included: vasopressor agents odds ratio (OR) = 3.44, cardiopulmonary resuscitation (CPR) before ICU admission OR = 3.35, presence of sepsis OR = 2.64, and need for invasive ventilatory support OR = 2.16. A total of 46 patients (43%) had hematological malignancies, whereas 62 (57%) had solid organ malignancies. Septic shock ranked first (44%) as the main reason for ICU admission. The mortality rate among hematological and solid organ cancer patients were 52% and 61%, respectively. The code status was do not resuscitate (DNR) in 55 patients (51%), 22% of the DNR patients were survivors. Twelve patients (22%) were DNR before ICU admission, whereas 43 (78%) were made DNR during their ICU stay. Most of ICU mortalities for both groups occurred within the first 20 days of ICU admission. Conclusion: Cancer patients admitted to ICU has high mortality rates; however, this does not preclude aggressive treatment for some. Factors associated with mortality include vasopressors, CPR, sepsis, and mechanical ventilation. Change of code status to DNR during ICU stay is common.

Current management of Gram-negative septic shock.

Sepsis is a common condition in critically ill patients and associated with high morbidity and mortality. Sepsis is the result of infection by many potential pathogens, including Gram-negative bacteria. There are no specific antisepsis therapies and management relies largely on infection control and organ support, including hemodynamic stabilization. We discuss these key aspects and briefly mention potential immunomodulatory strategies. New aspects of sepsis management include the realization that early treatment is important and that fluids and vasopressor agents should be administered simultaneously to insure rapid restoration of an adequate perfusion pressure to limit development and worsening of organ dysfunction. New immunomodulatory therapies, both suppressive and stimulatory, are being tested. Early diagnosis enabling rapid treatment can optimize outcomes. The multiple components of adequate sepsis management necessitate a team approach.

Review article: the pharmacological causes of colon ischaemia.

Colon ischaemia is the most common ischaemic disorder of the gastrointestinal system, can affect any segment of the colon, and may present with a range of symptoms. Diagnosis can be challenging due to symptom overlap with other conditions, varied aetiology, and often rapid and self-resolving course. To review comprehensively the literature regarding the pharmacological aetiologies of colonic ischaemia to enhance the understanding of the various mechanisms of disease, presentations, distribution, and outcomes. A PubMed search for "colon ischaemia" and "ischaemic colitis" alone as well as in combination with various known pharmacologic causes was performed. Only the highest quality and relevant literature was included in this review. The quality of the literature for each association was rated by the authors and a consensus was made when discrepancies were encountered. Only associations that were deemed "moderate" or "strong" were included. The literature considering pharmacologically associated colonic ischaemia is diverse, lacks codification and is characterised by numerous case reports and case series. Constipation-inducing drugs, digoxin, hormonal therapies, illicit drugs, immunomodulators, laxatives, and NSAIDs were strongly associated with colonic ischaemia. Antimicrobials, appetite suppressants, chemotherapies, decongestants, diuretics, ergot alkaloids, serotonin agents, statins, and vasopressor agents were moderately associated. Patients presenting with abdominal pain, diarrhoea, or bloody stool need to be evaluated for the possibility of this condition and treated accordingly. Timely diagnosis is necessary to improve patient outcomes. This review aims to increase awareness among clinicians regarding the presentation of pharmacologically induced colonic ischaemia.

Evaluation of Vasopressin for Vasoplegic Shock in Patients With Preoperative Left Ventricular Dysfunction After Cardiac Surgery: A Propensity-Score Analysis.

Postoperative vasoplegic shock after cardiac surgery seems to be a frequent complication with poor outcomes. We hypothesized that vasopressin may increase the risk of poor outcomes in patients with preoperative Left Ventricular Dysfunction (pLVD) rather than norepinephrine. The aim of this study was to assess whether vasopressin is superior to norepinephrine to improve outcomes in patients with pLVD after cardiac surgery. This retrospective cohort study included 1,156 patients with postoperative vasoplegic shock (mean arterial pressure <65 mmHg resistant to fluid challenge and cardiac index >2.20 L/min m) and pLVD (left ventricular ejection fraction ≤35%, left ventricular end-diastolic diameter ≥60 mm, New York Heart Association ≥III) from 2007 to 2017. To address any indicated biases, we derived a propensity score predicting the functions of vasopressin (0.02-0.07 U/min) and norepinephrine (10-60 μg/min) on postoperative vasoplegic shock. The primary outcomes were 30-day mortality, mechanical ventilation more than 48 h, cardiac reoperation, extracorporeal membrane oxygenation, stroke, and acute kidney injury, whereas the secondary outcomes included infection, septic shock, atrial fibrillation and ventricular arrhythmias. There were 338 patients (169 vasopressin and169 norepinephrine) with a similar risk profile in propensity score-matched cohort. In propensity-matched patients, the primary outcomes of vasopressin and norepinephrine showed no significant difference (50.89% vs. 58.58%, P = 0.155). However, compared with norepinephrine, secondary outcomes of vasopressin were increased due to the high rate of atrial fibrillation (11.83% vs. 20.12%, P = 0.038) and ventricular arrhythmias (14.20% vs. 24.85%, P = 0.014). Compared with norepinephrine, vasopressin could not improve the postoperative outcomes in patients with pLVD after cardiac surgery. Vasopressin should be cautious to be used as a first-line vasopressor agent in postcardiac vasoplegic shock.

Rapidly Improving ARDS in Therapeutic Randomized Controlled Trials

Observational studies suggest that some patients meeting criteria for ARDS no longer fulfill the oxygenation criterion early in the course of their illness. This subphenotype of rapidly improving ARDS has not been well characterized. We attempted to assess the prevalence, characteristics, and outcomes of rapidly improving ARDS and to identify which variables are useful to predict it. A secondary analysis was performed of patient level data from six ARDS Networkrandomized controlled trials. We defined rapidly improving ARDS, contrasted with ARDS > 1day, as extubation or a Pao2 to Fio2 ratio (Pao2:Fio2) > 300 on the first study day following enrollment. The prevalence of rapidly improving ARDS was 10.5%(458 of 4,361 patients) and increased over time. Of the 1,909 patients enrolled in the three most recently published trials, 197 (10.3%) were extubated on the first study day, and 265 (13.9%) in total had rapidly improving ARDS. Patients with rapidly improving ARDS had lower baseline severity ofillness and lower 60-day mortality (10.2%vs26.3%; P< .0001) than ARDS >1day. Pao2:Fio2 at screening, change in Pao2:Fio2 from screening to enrollment, use of vasopressor agents, Fio2 at enrollment, and serum bilirubin levels were useful predictive variables. Rapidly improving ARDS, mostly defined by early extubation, is an increasingly prevalent and distinct subphenotype, associated with better outcomes than ARDS > 1day. Enrollment of patients with rapidly improving ARDS may negatively affect the prognostic enrichment and contribute to the failure of therapeutic trials.

Risk factors for death in patients with sepsis in an intensive care unit

Objective: to determine the main risk factors for death in patients with sepsis in an intensive care unit. Methods: it is a retrospective cohort study, wich included 126 patient chorts lhat had clinical and clinical and laboratory diagnosis of sepsis were considered eligible. The conditional probability of death was calculated through the Kaplan-Meier method and the risk of death was estimated by the hazard ratio, using a Cox regression model with p<0.050. Results: a total of 124 patients were included in the study. The main focus of infection was the respiratory system. Regarding the outcome, 40.3% patients with sepsis, 73.9% with severe sepsis and 69.2% with septic shock died. Patients with abdominal sepsis and using vasopressors were at higher risk of death. Conclusion: septic patients with abdominal source of infection and using vasopressor agents had a higher risk of dying, while patients who were tracheostomized had a better chance of living.

Renal autoregulation in experimental septic shock and its response to vasopressin and norepinephrine administration.

Evidence suggests that septic shock patients with chronic arterial hypertension may benefit from resuscitation targeted to achieve higher blood pressure values than other patients, possibly as a result of altered renal autoregulation. The effects of different vasopressor agents on renal autoregulation may be important in this context. We investigated the effects of arginine vasopressin (AVP) and norepinephrine (NE) on renal autoregulation in ovine septic shock. Sepsis was induced by fecal peritonitis. When shock developed (decrease in mean arterial pressure to <65 mmHg and no fluid responsiveness), animals were randomized to receive NE or AVP in a crossover design. Before the switch to the second vasopressor, the first vasopressor was discontinued for 30 min to ensure complete washout of the first vasopressor. Renal autoregulation was evaluated by recording the change in renal blood flow (RBF) in response to manual, stepwise reductions in renal inflow pressure. In this model, the lower limit of renal autoregulation was not significantly altered 6 h after sepsis induction (59 ± 9 vs. 64 ± 7 mmHg at baseline, P = 0.096). After development of shock, the autoregulatory threshold was lower with AVP than with NE (59 ± 5 vs. 65 ± 7 mmHg, P = 0.010). However, RBF was higher with NE both at the start of autoregulatory measurements (206 ± 58 vs. 170 ± 52 ml/min; P = 0.049) and at the autoregulatory threshold (191 ± 53 vs. 150 ± 47 ml/min; P = 0.008). As vasopressors may have different effects on renal autoregulation, blood pressure management in patients with septic shock should be individualized and take into account drug-specific effects.NEW & NOTEWORTHY Septic shock patients with chronic arterial hypertension may benefit from higher blood pressure targets due to underlying deficits in renal autoregulatory efficiency. The current study is the first to show that the choice of vasopressor agent can differentially affect renal autoregulation. These findings may contribute to more personalized blood pressure management in patients with septic shock.

Effect of increasing mean arterial blood pressure on microcirculation in patients with cardiogenic shock supported by extracorporeal membrane oxygenation.

Little is known about the effect of mean arterial blood pressure (MAP) augmentation on the microcirculation in cardiogenic-shock patients with peripheral veno-arterial extracorporeal membrane oxygenation (ECMO) support. We investigated the effect of increasing MAP on the microcirculation in cardiogenic-shock patients with ECMO support. A single-center prospective observational study under taken in ICU patients undergoing ECMO support for post-cardiotomy cardiogenic shock was carried out. Patients with MAP <60 mmHg treated with ECMO support were the study cohort. Inotropic and vasopressor agents (dopamine, dobutamine, norepinephrine or epinephrine) were administered to maintain the MAP at 60-90 mmHg. Hemodynamic and microcirculatory data were obtained at a baseline MAP of <60 mmHg and 1 h after target MAP was reached. As parameters of microcirculation, we measured thenar eminence tissue oxygenation (StO2) and its change during the vessel obstruction test and cerebral tissue oxygenation (rSO2) with near-infrared spectroscopy. Seventeen patients were enrolled in the study. MAP of all patients increased and reached predefined therapeutic targets (52 [50-54.5] vs.74 [70-78.5] mmHg; p < 0.001). To obtain these targets, doses of inotropic agents were increased (inotrope score increased from 14 [15.5-28] μg/kg/min; p < 0.001). No obvious changes were observed in thenarmuscleStO2 and cerebral rSO2. Thenar muscle StO2 desaturation slope and resaturation slopes during the vessel obstruction test were also unchanged. Increasing MAP from <60 mmHg to 60-90 mmHg did not affect microcirculation variables in cardiogenic-shock patients with ECMO support.

Relationships Between Intraoperative Hemodynamic Parameters and Delayed Hemodynamic Recovery After Valve Deployment in Transcatheter Aortic Valve Replacement

To determine the relationships between intraoperative hemodynamic parameters and delayed hemodynamic recovery after valve deployment and identify the predictive factors of delayed hemodynamic recovery by focusing on intraoperative hemodynamics in patients with transcatheter aortic valve replacement (TAVR). A retrospective study. A single university hospital. Sixty-four patients who underwent elective TAVR between 2015 and 2017. No intervention. The 64 patients were divided into the following 2 groups according to the time for recovery: systolic arterial pressure exceeded 90 mmHg and central venous oxygen saturation (ScvO2) exceeded 65%-delayed recovery (DR) (n = 36) group, and early recovery (ER) (n = 28) group. ScvO2 in the DR group was not lower than that in the ER group after induction of anesthesia. However, ScvO2 in the DR group gradually decreased and was lower than that in the ER group before valve deployment, despite improvement in blood pressure through the administration of vasopressor agents. ScvO2 monitoring during TAVR is useful to predict delayed recovery greater than 60 seconds after valve deployment in TAVR.

Ultrasound-guided superficial cervical plexus block under dexmedetomidine sedation versus general anesthesia for carotid endarterectomy: a retrospective pilot study.

BackgroundCarotid endarterectomy (CEA) has been performed under regional and general anesthesia (GA). The general anesthesia versus local anesthesia for carotid surgery study compared the two techniques and concluded that there was no difference in perioperative outcomes. However, since this trial, new sedative agents have been introduced and devices that improve the delivery of regional anesthesia (RA) have been developed. The primary purpose of this pilot study was to compare intraoperative hemodynamic stability and postoperative outcomes between GA and ultrasound-guided superficial cervical plexus block (UGSCPB) under dexmedetomidine sedation for CEA.MethodsMedical records from 43 adult patients who underwent CEA were retrospectively reviewed, including 16 in the GA group and 27 in the RA group. GA was induced with propofol and maintained with sevoflurane. The UGSCPB was performed with ropivacaine under dexmedetomidine sedation. We compared the intraoperative requirement for vasoactive drugs, postoperative complications, pain scores using the numerical rating scale, and the duration of hospital stay.ResultsThere was no difference between groups in the use of intraoperative antihypertensive drugs. However, intraoperative inotropic and vasopressor agents were more frequently required in the GA group (p<0.0001). In the GA group, pain scores were significantly higher during the first 24 h after surgery (p<0.0001 between 0-6 h, p<0.004 between 6-12 h, and p<0.001 between 12-24 h). The duration of hospital stay was significantly more in the GA group (13.3±4.6 days in the GA group vs. 8.5±2.4 days in the RA group, p<0.001).ConclusionIn this pilot study, intraoperative hemodynamic stability and postoperative outcomes were better in the RA compared to the GA group.

Anthony Fairclough Lever

Anthony Fairclough Lever (“Tony”), who was the director and driving force of the Medical Research Council blood pressure unit in Glasgow, Scotland, between 1967 and 1994, and, latterly, professor emeritus...

Evaluation of Risk of Injury by Extravasation of Hyperosmolar and Vasopressor Agents in a Rat Model

Inadvertent leakage of noncytotoxic agents causes severe tissue injury. In this study, we macroscopically and histopathologically evaluated the extent of skin injury caused by extravasation of hyperosmolar or vasopressor agents in rats. Rats were intradermally administered saline (100 µL), the hyperosmolar agents mannitol (5-20 mg/100 µL) and glucose (5-50 mg/100 µL), or the vasopressors dopamine (2 mg/100 µL), adrenaline (0.1 mg/100 µL), and noradrenaline (0.1 mg/100 µL). Lesion size (erythema, induration, ulceration, and necrosis) was monitored after agent injection. Skin tissue biopsies were evaluated at 24 h after agent injection. Mannitol and glucose induced severe lesions in a concentration (and osmolarity)-dependent manner. Mannitol and glucose at 10-20% (w/v) induced inflammation, and lesions healed within 3-6 d. In contrast, ≥25% (w/v) glucose elicited severe skin lesions with ulceration and necrosis within 24 h, which healed gradually 16-22 d after injection. The severity of extravasation injury caused by vasopressors varied. Adrenaline and noradrenaline induced severe injury with ulceration and necrosis, which healed over 23.3 and 18.3 d, respectively. In contrast, dopamine induced erythema and induration, and damage duration was only 5.7 d. In conclusion, mannitol and glucose at osmolarities of 549-1098 and 833-1110 mOsm/L, respectively, can be classified as "irritants," while ≥1388 mOsm/L glucose can be classified as a "vesicant." As for vasopressors, adrenaline and noradrenaline can be classified as "vesicants" whereas dopamine can be classified as an "irritant."

Left Lateral Table Tilt for Elective Cesarean Delivery Under Spinal Anesthesia Has No Effect on Neonatal Acid-Base Status

(Anesthesiology. 2017;127(2):241–249) Cesarean delivery in the supine position may result in maternal hypotension, aortocaval compression, and fetal complications. Uterine displacement by left lateral tilt is currently recommended to prevent these outcomes. Tilting was associated with superior neonatal acid-base status in studies during the 1970s. The current use of vasopressor agents to effectively prevent maternal spinal hypotension calls into question the necessity of tilting, particularly since the target tilt of 15 degrees is rarely achieved. This study hypothesized that, using a fluid coload with spinal anesthesia and a phenylephrine infusion to maintain baseline systolic blood pressure, neonatal acid base status would not be affected by maternal position (supine vs. tilted) in women delivering via elective cesarean delivery.

Vasopressor support vs. liberal fluid administration in deep inferior epigastric perforator (DIEP) free flap breast reconstruction - a randomized controlled trial.

Perioperatively, patients' hemodynamics are modulated predominantly by intravenous fluid administration and vasoactive pharmacological support. Vasopressor agents are suspected to be detrimental on free flap survival by the cause of vasoconstriction of the pedicle with consecutive reduced overall flap perfusion and by aggravation of flap dissection. A novel, standardized fluid restrictive perioperative hemodynamic management was assessed for its feasibility in clinical practice in free flap patients undergoing breast reconstruction. Patients were randomized to two perioperative regimens with different fluid and vasopressor limits. The primary endpoint regarded flap survival. Secondary endpoints included surgery times, time of patient ambulation and length of hospital stay. There was one total flap failure with liberal fluid administration (LFA). No total or partial flap failure was noted in the fluid restrictive regimen with norepinephrine administration up to 0.04μg/kg/min (FRV). No delay regarding operation time (p = 0.217), patient mobilization (p = 0.550) or hospital discharge (p = 0.662) was registered in the FRV study subpopulation compared to LFA. The results of this prospective interventional trial could not detect any negative impact of vasopressors, neither for the primary endpoint of flap survival nor for the overall patient outcome. The fear of vasopressor associated flap complications has led to a traditional liberal fluid administration, which failed to demonstrate any benefits when compared to a fluid restrictive vasopressor strategy.

F24. Evaluation of cardiovascular parameters during intravenous loading dose of lacosamide

Several recent reports have described the efficacy of intravenous (IV) lacosamide (LCS) in the management of acute seizures and status epilepticus (SE). Based on data from 3 randomized control trials LCS appeared to be well tolerated. However, previous studies of patients on maintenance LCS therapy have reported Electrocardiographic (ECG) changes including conduction disturbances and sinus node dysfunction. A study of IV LCS boluses of 200, 300, and 400 mg administered over 15 min to outpatient subjects with epilepsy showed no changes in ECG during the infusions. We performed a retrospective review of adult patients who received IV LCS of 400–1400 mg and evaluated for changes in cardiovascular parameters during and immediately after the loading dose. With IRB approval, patients were identified that received IV LCS in the ICU for acute treatment of seizures during the years 2013–2016. Data elements collected were age, gender, weight, duration of infusion, change or termination of infusion because of immediate side effects, heart rate changes, blood pressure changes, oxygen saturation changes, and use of vasopressor agents one hour before, during and up to one hour after the infusion completed. All loading doses were administered over 30–60 min. No concurrent other anti-epileptic medication was given during loading dose of LCS. Three hundred and fifty-four adult patients were identified that were treated with LCS for seizures and SE in the ICU. 318/354 patients had IV loading dose of 400–1400 mg. Demographics were male/female (130/188), average weight 83.7 kg (range 40.8–219.5), and average age was 60 yrs (18–97). Ranges of the bolus doses included 400–600 mg (210 pts), 601–800 mg (78 pts) and 801–1400 mg (30 pts). No patients required a change or discontinuation of the infusion due to acute side effects. No patients required vasopressors from blood pressure changes during the bolus. The systolic blood pressure (mm Hg) 1 h prior, during, and 1 h post bolus were 137.56 ± 25.3, 133.4 ± 24.87, and 131.6 ± 25.89 (measured with 1 standard deviation). Similarly, the diastolic measurements were 72.3.9 ± 12.87, 72.7 ± 13.78, and 69.94 ± 13.46. Similarly, the heart rate measurements were 86.98 ± 19.73, 85.92 ± 18.85, and 85.22 ± 18.25. Patients with refractory SE who require anesthetic agents or repeated doses of benzodiazepines are most vulnerable to severe hypotension which complicates the management and increases risk for organ hypo-perfusion and mortality. The choice of IV antiepileptic medications is limited since IV fosphenytoin has been associated with substantial hypotension. In our study IV bolus doses of LCS appears to have no deleterious cardiovascular effects thus favoring its use in the management of acute seizures and SE. Furthermore, we did not identify any malignant changes in heart rate related to the bolus dose ranging from 400 to 1400 mg.

Effects of bacterial translocation on hemodynamic and coagulation parameters during living-donor liver transplant

BackgroundBacterial translocation (BT) has been proposed as a trigger for stimulation of the immune system with consequent hemodynamic alteration in patients with liver cirrhosis. However, no information is available regarding its hemodynamic and coagulation consequences during liver transplantation.MethodsWe screened 30 consecutive adult patients undergoing living-donor liver transplant for the presence of BT. Bacterial DNA, Anti factor Xa (aFXa), thromboelastometry, tumor necrosis factor-α TNF-α, and interleukin-17 (IL-17) values were measured in sera before induction of anesthesia. Systemic hemodynamic data were recorded throughout the procedures.ResultsBacterial DNA was detected in 10 patients (33%) (bactDNA(+)). Demographic, clinical, and hemodynamic data were similar in patients with presence or absence of bacterial DNA. BactDNA(+) patients showed significantly higher circulating values of TNF-α and IL-17, and had significantly higher clotting times and clot formation times as well as significantly lower alpha angle and maximal clot firmness than bactDNA(−) patients, P < 0.05. We found no statistically significant difference in aFXa between the groups, P = 0.4. Additionally, 4 patients in each group needed vasopressor agents, P = 0.2. And, the amount of transfused blood and blood products used were similar between both groups.ConclusionBacterial translocation was found in one-third of patients at the time of transplantation and was largely associated with increased markers of inflammation along with decreased activity of coagulation factors.Trial registrationTrial Registration Number: NCT03230214. (Retrospective registered). Initial registration date was 20/7/2017.

Acute Kidney Injury in Critically Ill Patients with Sepsis: Clinical Characteristics and Outcomes

ABSTRACTObjective: The objectives of this study were to examine the clinical profile of critically ill patients with septic acute kidney injury (AKI) and to investigate clinical characteristics associated with the outcome of patients. Methods: Data from 582 critically ill patients were collected and retrospectively reviewed. Patients were divided into two groups: without AKI development and with AKI development. Baseline characteristics, laboratory, and other clinical data were compared between these two groups, and correlations between the characteristics and AKI development were examined. Patients with AKI development were further divided into two groups according to the survival outcome, and variables associated with the outcome were determined. Results: AKI was developed in 54.12% (n = 315) of patients, and these patients had blood pressure, SOFA score, APACHE II score, GCS, and various blood chemistry and hematology characteristics significantly different from the patients without AKI. Demographic characteristics (e.g. age and weight) were comparable between the two groups of patients. Among the 315 patients with AKI, 136 of them died during the study period. Multivariate logistic regression analysis revealed that the outcome of patients was associated with lung infection, coagulation system dysfunction, staphylococcus aureus infection, and use of various treatments (epinephrine, norepinephrine, and the use of mechanical ventilation) after AKI development. Conclusion: AKI occurred in approximately half of the critically ill patients admitted to ICU. The site and type of infections, as well as the use of vasopressor agents, were associated with the outcome.

Fatores de risco para morte em pacientes com sepse em uma unidade de terapia intensiva

Objetivo: determinar os principais fatores de risco para a morte em pacientes com sepse em uma unidade de terapia intensiva. Métodos: trata-se de uma coorte retrospectiva, onde foram incluídos 124 prontuários de pacientes que tiveram diagnóstico clínico e laboratorial de sepse. A probabilidade condicional de morte foi calculada através do método de Kaplan-Meier; o risco de morte foi estimado pela razão de risco, utilizando modelo de regressão de Cox com p&lt;0,050. Resultados: o foco principal da infecção foi o sistema respiratório. Em relação ao desfecho, morreram 40,3% pacientes com sepse, 73,9% com sepse grave e 69,2% com choque séptico. Os pacientes com sepse abdominal e que utilizaram vasopressores apresentaram maior risco de morte. Conclusão: pacientes sépticos com fonte abdominal de infecção e fazendo uso de agentes vasopressores apresentaram maior risco de morte, enquanto que pacientes traqueostomizados tiveram melhores chances de sobreviver.

Vasopressin in Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials

To summarize the results of randomized controlled trials on the use of vasopressin as a vasopressor agent in cardiac surgery. Meta-analysis. Six-hundred-twenty-five adult patients undergoing elective or emergency cardiac surgery. Arginine vasopressin infusion (n = 313) or control/standard therapy (n = 312). The rates of perioperative complications and postoperative mortality were used as primary and secondary endpoints, respectively. Fixed and/or random effects models were used to compare pooled odds ratios. Arginine vasopressin reduced the pooled odds ratio (OR) of perioperative complications (OR, 0.33; 95% confidence interval [CI], 0.2-0.54; p < 0.0001). A sensitivity analysis excluding the largest trial showed an unchanged reduction in perioperative complications (OR, 0.35; 95% CI, 0.18-0.69; p = 0.002). When analyzing each perioperative complication separately, vasopressin reduced the pooled OR of vasodilatory shock (OR, 0.4; 95% CI, 0.16-0.97; p = 0.04) and new-onset atrial fibrillation (OR, 0.42; 95% CI, 0.21-0.82; p = 0.01). The pooled OR of postoperative death was not different between patients treated with arginine vasopressin and those receiving standard therapy or placebo (OR, 0.83; 95% CI, 0.45-1.53; p = 0.55). The funnel plot for the primary endpoint suggested a relevant publication bias. All included trials suffered from a high risk of bias. Our meta-analysis suggests that arginine vasopressin may reduce the rate of perioperative complications in patients undergoing elective or emergency cardiac surgery. No difference in postoperative mortality was observed. An adequately powered multicenter trial is required for reliable estimation of the effects of arginine vasopressin on perioperative complication rates and mortality in cardiac surgical patients.

Dihydromyricetin improves vascular hyporesponsiveness in experimental sepsis via attenuating the over-excited MaxiK and KATP channels

Context: Dihydromyricetin (DMY) has oxidation resistance, anti-inflammatory and free radical scavenging capabilities. The preventive effects of DMY for vascular hyporeactivity remain unclear.Objective: This study investigates the preventive effects of DMY in vascular hyporeactivity.Materials and methods: The experimental sepsis was induced by transvenous administration of lipopolysaccharide (LPS) to Sprague–Dawley (SD) rats. DMY-treated rats received daily administration of DMY, 5 μg/kg dissolved in DMSO through the tail vein for 7 days. The invasive mean arterial pressure (MAP) of the caudal ventral artery was measured. Dose-response curves for norepinephrine (NE, doses from 10−9 to 10−6 M) were obtained in isolated thoracic aorta in a cumulative manner. The function of MaxiK and KATP channels were investigated using whole-cell patch clamp recording. The Elisa was adopted to measure the serum concentration of NO, MDA, 3-NT, IL-1β and TNF-α.Results: The increased MAP in septic rats induced by vasopressor agents was smaller than that in control rats. However, the % of increased MAP induced by vasopressor agents was raised by DMY injection (NE: 20.4 ± 8.495 vs. 15.16 ± 5.195%; AVP: 14.05 ± 2.459 vs. 9.583 ± 2.982%, p < 0.05). The vascular hyporesponsiveness to NE (10−6 M) in vitro. was increased by 51% in LPS + DMY group compared with that in LPS + Con group (2.74 ± 0.81 vs. 1.82 ± 0.92 g, p < 0.05). Charybdotoxin (a potent MaxiK channel blocker) and glibenclamide (a KATP channel blocker) pretreatment, instead of 4-aminopyridine (4-AP) and BaCl2, could diminish the DMY-induced improvement of vasoconstrictor hyporeactivity (ChTX: 73.2 ± 11.8 vs. 71.8 ± 13.5%; Glib: 63.1 ± 12.5 vs. 58.1 ± 13.7%, p > 0.05). DMY blunted the highly sensitized MaxiK and KATP channels of arterial smooth muscle cells isolated from the thoracic aorta of LPS rats. DMY decreased the serum level of NO, MDA, IL-1β and TNF-α, which had increased in LPS rats.Discussion and conclusions: Our results indicate that DMY administration ameliorated the impaired contractility of the rat aorta in experimental sepsis. Such an effect is mediated by normalization of the over-excited MaxiK and KATP, channels possibly via oxidative stress inhibition.