Vasopressor Infusion Research Articles

Evaluation of high-dose insulin/euglycemia therapy for suspected β-blocker or calcium channel blocker overdose following guideline implementation.

High-dose insulin/euglycemia (HDIE) is targeted therapy for β-blocker and calcium channel blocker overdose. A guideline using concentrated insulin infusions (20 units/mL), aggressive monitoring, and supportive recommendations was implemented. We sought to evaluate safety before and after HDIE guideline implementation and describe the patient population, insulin doses, supplemental dextrose, vasopressor use, hospital and intensive care unit (ICU) lengths of stay, and mortality. Retrospective review was performed of patients receiving HDIE before and after guideline implementation at an academic medical center and community hospital from March 2011 through December 2019. Information on patient and overdose demographics, ingestion data, vital signs, interventions, adverse events, and disposition was collected. Data are presented descriptively with comparisons using Mann-Whitney U analysis and Fisher's exact tests. During the study period, 27 patients were treated with HDIE, 10 before guideline implementation (37%; mean [SD] initial insulin dose, 0.49 [0.35] units/kg/h; mean [SD] maximum insulin dose, 2.25 [3.29] units/kg/h; median [interquartile range] duration, 10 [5.5-18.75] hours) and 17 after guideline implementation (63%; mean [SD] initial insulin dose, 1.01 [0.34] units/kg/h; mean [SD] maximum insulin dose, 2.99 [5.05] unit/kg/h; median [interquartile range] duration, 16 [11.5-37] hours). Hypoglycemia, hypokalemia, and volume overload occurred in 80% vs 29% (P = 0.018), 40% vs 53% (P = 0.69), and 50% vs 65% (P = 0.69) of patients in the preguideline vs postguideline group, respectively. Most patients received an initial insulin bolus (85%; mean [SD], 70.3 [21.8] units, 0.9 [0.26] units/kg) and vasopressor infusion (85%). More postguideline patients received a dextrose infusion with a concentration of 20% or higher (93% vs 50%, P = 0.015). There were no differences in cardiac arrest, in-hospital mortality, or hospital or ICU length of stay between the groups. Hypoglycemia was reduced using an HDIE guideline and concentrated insulin.

Abstract 9321: Cardiac Work and End-Organ Perfusion During Biventricular Compared to Left Ventricular Impella and Norepinephrine Support in a Porcine Model of Severe Cardiogenic Shock

Background: Vasopressors are often combined with left ventricular (LV) mechanical support in severe cardiogenic shock to increase end-organ perfusion. Biventricular mechanical support might improve end-organ perfusion at lower cardiac workload compared to LV mechanical support and vasopressor infusion in severe cardiogenic shock. Aim: To compare LV and right ventricular (RV) total cardiac work (pressure-volume area x heart rate x 10 3 ) and organ-specific venous oxygen saturations from the pulmonary artery (SvO 2 ), kidney- and cerebral- veins in pigs with cardiogenic shock treated with biventricular (Bipella) versus ImpellaCP + norepinephrine 0.10 μg/kg/min (Imp+NE). Methods: Cardiogenic shock was induced by injections of microspheres into the left main coronary artery in eight pigs (approx. 70 kg). From conductance catheters in both ventricles, cardiac workload was calculated, and oxygen saturations were attained from the pulmonary artery, internal jugular- and kidney vein. Pigs were allocated in a crossover model to Bipella for 60 minutes (n=4) or Imp+NE for 30 minutes (n=4) and after completion shifted to the opposite treatment. Results are presented as median(Q1;Q3). Results: Bipella effectively unloaded the LV with reduction in LV work compared to Imp+NE (569[410-685] vs 357[206-509] 10 3 ml x mmHg/min, p=0.0078) while RV work was comparable (p=0.74). A significant increase in SvO 2 (66[63-73] vs 49[44-58]%, p=0.01) and cerebral venous oxygen saturations (71[63-77] vs 62[48-66]%, p=0.016) was observed during Imp+NE compared to Bipella, whereas no difference in kidney oxygen saturations was demonstrated (p=0.31). Conclusion: In this porcine study of cardiogenic shock due to left main coronary ischemia, Bipella decreased LV workload, but systemic oxygen delivery was not optimal (Figure). Imp+NE provided a higher LV workload balanced by an improvement in cerebral- and mixed venous oxygen saturation.

Acute Kidney Injury After Liver Transplant: Incidence, Risk Factors, and Impact on Patient Outcomes.

Acute kidney injury is a frequent complication of liver transplant. Here, we assessed the rate and contributing factors of acute kidney injury and need for renal replacement therapy in patients undergoing liver transplant at a transplant center in Tehran, Iran. We identified all patients who underwent liver transplant at the Imam Khomeini Hospital Complex from March 2018 to March 2019 and who were followed for 3 months after transplant. Acute kidney injury was defined based on the Acute Kidney Injury Network criteria. We collected demographic and pretransplant, intraoperative, and posttransplant data. Univariable and multivariable models were applied to explore independent risk factors for acute kidney injury incidence and need for renal replacement therapy. Our study included 173 deceased donor liver transplant recipients. Rates of incidence of acute kidney injury and need for renal replacement therapy were 68.2% and 14.5%, respectively. The 3-month mortality rate among those with severe and mild or moderate acute kidney injury was 44.0% (14/25) and 9.7% (9/ 93), respectively (P < .001). Multivariable analyses indicated that serum albumin (relative risk of 0.55; 95% confidence interval, 0.34-0.87; P = .021), baseline serum creatinine (relative risk of 2.11; 95% confidence interval, 1.56-2.90; P = .037), and intraoperative mean arterial pressure (relative risk of 0.76; 95% confidence interval, 0.63-0.82; P = .008) were independent factors for predicting posttransplant acute kidney injury. Independent risk factors for requiring renal replacement therapy were pretransplant serum creatinine (relative risk of 1.99; 95% confidence interval, 1.89-4.47; P = .044) and intraoperative vasopressor infusion (relative risk of 1.41; 95% confidence interval, 1.38-2.00; P = .021). We found a high incidence of acute kidney injury among liver transplant recipients in our center. There was a significant association between severity of acute kidney injury and 3-month and in-hospital mortality.

Effects of acute kidney injury on acute pancreatitis patients' survival rate in intensive care unit: A retrospective study.

BACKGROUNDAcute kidney injury (AKI) is one of the most common acute pancreatitis (AP)-associated complications that has a significant effect on AP, but the factors affecting the AP patients’ survival rate remains unclear.AIMTo assess the influences of AKI on the survival rate in AP patients. METHODSA total of 139 AP patients were included in this retrospective study. Patients were divided into AKI group (n = 72) and non-AKI group (n = 67) according to the occurrence of AKI. Data were collected from medical records of hospitalized patients. Then, these data were compared between the two groups and further analysis was performed.RESULTSAKI is more likely to occur in male AP patients (P = 0.009). AP patients in AKI group exhibited a significantly higher acute physiologic assessment and chronic health evaluation II score, higher Sequential Organ Failure Assessment score, lower Glasgow Coma Scale score, and higher demand for mechanical ventilation, infusion of vasopressors, and renal replacement therapy than AP patients in non-AKI group (P < 0.01, P < 0.01, P = 0.01, P = 0.001, P < 0.01, P < 0.01, respectively). Significant differences were noted in dose of norepinephrine and adrenaline, duration of mechanical ventilation, maximum and mean values of intra-peritoneal pressure (IPP), maximum and mean values of procalcitonin, maximum and mean serum levels of creatinine, minimum platelet count, and length of hospitalization. Among AP patients with AKI, the survival rate of surgical intensive care unit and in-hospital were only 23% and 21% of the corresponding rates in AP patients without AKI, respectively. The factors that influenced the AP patients’ survival rate included body mass index (BMI), mean values of IPP, minimum platelet count, and hospital day, of which mean values of IPP showed the greatest impact.CONCLUSIONAP patients with AKI had a lower survival rate and worse relevant clinical outcomes than AP patients without AKI, which necessitates further attention to AP patients with AKI in surgical intensive care unit.

Risk Factors Associated With Pressure Ulcers in Patients With Traumatic Brain Injury Admitted to the Intensive Care Unit.

Pressure injuries (PIs) are one of the most important and frequent complications in patients admitted to the intensive care unit (ICU) or those with traumatic brain injury (TBI). The purpose of this study was to determine the incidence and risk factors of PIs in patients with TBI admitted to the ICU. In this retrospective study, the medical records of 237 patients with TBI admitted to the trauma ICU of a university hospital were examined. Demographic, trauma-related, and treatment-related characteristics of all the patients were evaluated from their records. The incidence of PIs was 13.9%, while the main risk factors were a higher injury severity score, use of mechanical ventilation, vasopressor infusion, lower Braden Scale score, fever, and period of enteral feeding. This study advances the nursing practice in the ICU by predicting the development of PIs and their characteristics in patients with TBI.

Safety and efficacy of peripheral versus centrally administered vasopressor infusion: A single-centre retrospective observational study

BackgroundShock affects one-third of patients admitted to intensive care and is associated with increased mortality. Vasopressor medications are used to maintain blood pressure in shock. Central venous catheters are associated with serious complications and pose logistical difficulties for insertion. Delivery of vasopressors via peripheral intravenous cannula may be a safe alternative. MethodsThis is a retrospective cohort study comparing safety profile and outcomes of vasopressor delivery via peripheral and central routes in critically ill patients over a 12-month period in a mixed medical-surgical intensive care unit. Demographics, clinical characteristics, treatments, and safety outcome data were extracted from medical records. Patients were classified into three groups: vasopressor infusions via peripheral intravenous cannula, combined peripheral intravenous cannula followed by central venous catheter, and central venous catheter only. Groups were compared using the Kruskal–Wallis test for continuous variables and Fisher's exact test for categorical variables. The impact of duration of vasopressor infusion on complication rates was assessed using logistic regression. ResultsWe identified 212 patients who received vasopressor infusion, 39 received via peripheral only (Group 1), 155 via peripheral followed by central (Group 2), and 18 via central only (Group 3). There were some baseline differences between groups. Group 1 had the lowest median Acute Physiology and Chronic Health Evaluation III score (64, interquartile range = 44–77), and Group 3, the highest (86, interquartile range = 57–101). Duration of vasopressor infusion was shortest in Group 1 and longer in Groups 2 and 3. There were no major complications; however, minor complications such as leakage, extravasation, and erythema occurred in 41% of Group 1 and 28% of Group 2 patients. Duration of peripheral vasopressor infusion was not associated with an increased risk of complications. ConclusionsAdministration of vasopressor infusions for short duration in critically ill patients via a peripheral venous cannula may be feasible, with low rates of complications, and offers a safe alternative to central venous access.

Association of Continuous Intraoperative Vasopressor Use With Reoperation Rates in Head and Neck Free-Flap Reconstruction

Continuous vasopressor use in free-flap reconstruction is a point of contention among microvascular surgeons despite data demonstrating safety. To investigate the association between continuous vasopressor use and the incidence of reoperation in the early postoperative period. In this cohort study, a retrospective medical record review was conducted of patients who underwent head and neck free-flap reconstructions between May 1, 2014, and October 31, 2019, in an academic tertiary care center. All patients undergoing free-flap reconstruction for head and neck defects were included. Continuous intraoperative vasopressors. Patient medical records were queried for demographic variables; intraoperative use of vasopressors; vasopressor type, duration, and infusion rate; reoperation within the first 5 postoperative days; and reason for reoperation. Four hundred forty-nine consecutive free-flap reconstructions were performed on 426 patients. The mean age was 62 years (IQR, 55.7-71.1); 293 patients were men (65.3%), 380 were White (84.6%), 55 were Black (12.2%), and 14 were of other race or ethnicity (3.1%). A total of 174 patients received a continuous vasopressor during their reconstruction. Twenty-three reoperations occurred within 5 days postoperatively, 8 of which included vasopressors during initial intervention. Vasopressor type had no association with reoperation (4.5% vs 5.5% [8/174 vs 15/275, respectively] for patients who received vasopressors vs those who did not) (dobutamine odds ratio [OR], 1.02 [95% CI, 0.21-2.91]; dopamine OR, 1.48 [95% CI, 0.33-4.26]). No difference was seen in the duration (dobutamine OR, 1.50 [95% CI, 0.78-2.90]; dopamine OR, 0.87 [95% CI, 0.59-1.28]) or infusion rate (dobutamine OR, 1.50 [95% CI, 0.99-1.02]; dopamine OR, 1.00 [95% CI, 0.99-1.01]) of vasopressors between patients who underwent reoperation and those who did not. Analysis after the exclusion of reasons for reoperation that did not represent possible microvascular anastomosis failure (eg, Doppler malfunction, donor site complications) showed no increased propensity for reoperation (OR, 1.18; 95% CI, 0.27-3.9). In this cohort study, use of vasopressors for extensive periods intraoperatively during free-tissue transfer appeared to have no association with the rate of reoperation within 5 days of intervention, regardless of agent used, simultaneous use of agents, type of free-flap operation performed, or reason for reoperation. This study adds to the body of literature supporting the judicious use of vasopressors in patients requiring intraoperative pharmacological pressure support during free-flap reconstruction.

Comparing Risk Profiles in Critical Care Patients With Stage 2 and Deep Tissue Pressure Injuries: Exploratory Retrospective Cohort Study.

Understanding hospital-acquired pressure injury (HAPrI) etiology is essential for developing effective preventive interventions. Pressure injuries are classified based on the degree of visible tissue damage; the two most commonly identified HAPrI stages in critical care patients are stage 2 and deep tissue injury (DTI). Some experts speculate that stage 2 and DTI have different etiologies, with stage 2 injuries formed from the "outside in" as a result of tissue deformation, decreased perfusion, and subsequent ischemia caused by external pressure and/or shear forces, whereas DTI emerges from the "inside out" due to inadequate perfusion to the deeper tissues causing tissue ischemia. The purpose of this study was to compare risk profiles of intensive care unit (ICU) patients who developed stage 2 injuries versus DTIs. This was a retrospective cohort study to compare the risk profiles of patients in the ICU with stage 2 injuries and DTIs using electronic health record data. Eligible patients were admitted to the surgical or cardiovascular ICU at an academic medical center in the United States between 2014 and 2018. Anatomic locations were examined, and differences in anatomic patterns were compared using the χ2 test. Risk profile variables included demographic characteristics, Braden Scale scores, vasopressor infusions, hypotension, surgical factors, length of stay, BMI, laboratory values, diabetes, Charlson Comorbidity Index, and the levels of sedation or agitation. The distributions of potential risk variables between patients with stage 2 injuries and DTIs were summarized and compared. A logistic regression model with the least absolute shrinkage and selection operator method was developed to identify the critical risk factors for distinguishing stage 2 and DTI patients. A total of 244 patients developed a stage 2 injury or DTI during the study period. Of those, 38 patients with medical device-related pressure injury were excluded. The final study sample consisted of 206 patients (n=146 stage 2 and n=60 DTI). Compared with DTIs, stage 2 HAPrIs were more likely to be located on a bony prominence (n=206, χ21=8.43, P=.03). The multivariate model showed that patients who developed stage 2 HAPrIs had a longer length of stay in the ICU than those with DTIs (odds ratio [OR] 1.001, 95% CI 1-1.002, P=.03) but were less likely than patients with DTIs to experience a diastolic blood pressure <50 mmHg (OR 0.179, 95% CI 0.072-0.416, P<.001) or receive an epinephrine infusion (OR 0.316, 95% CI 0.079-0.525, P=.008). Stage 2 injuries and DTIs have different risk factors and different anatomic patterns. Patients who developed DTIs were more likely to experience low diastolic blood pressure and receive epinephrine, a potent vasopressor. Stage 2 injuries were more likely to occur on the bony prominences, whereas DTIs commonly occurred on the fleshy parts of the body such as the buttock.

Dexmedetomidine in critically ill adults requiring noninvasive ventilation.

Dexmedetomidine in critically ill adults requiring noninvasive ventilation.

Early vs. Late Vassopressor therapy in the Management of Patients with Sepsis and Hypotension, A Multicenter Observational Study

To describe and compare early with late vasopressor commencement in emergency department (ED) patients with sepsis and hypotension. This is a sub-study of the ARISE FLUIDS observational study conducted in 70 EDs in Australia and New Zealand. Adults with suspected sepsis and hypotension who received a vasopressor infusion in the first 24 h after ED presentation were included. 'Early' was defined as vasopressor commenced within 2 h from a) sepsis recognition, or b) triage. 177 patients (mean age 68 years) received vasopressors and had a lactate of 3.0 (IQR 2.0-4.9) mmol/L and APACHE II score of 17.8 (SD 6.3). 110 (62%) received a single agent vasopressor with noradrenaline being the most common (n = 74) and 67 (38%) received multiple vasopressors, most commonly metaraminol then noradrenaline (20.3%, n = 36). One-third (34.7%, n = 62) had vasopressors started via a peripheral line. Vasopressors were started within 2 h of sepsis recognition in 74 patients and within 2 h of triage in 24 patients. Both early groups had a higher lactate (3.5 vs. 2.9mmol/L and 5.0 vs. 2.9mmol/L, both p <0.05) and received lower fluid volumes prior to vasopressor commencement (2.0 vs. 2.85 L and 1.55 vs. 2.4 L, both p <0.001), compared to patients receiving vasopressors later. No differences in duration of vasopressor infusion, need for organ support or in-hospital mortality were found. Early vasopressor commencement was associated with the administration of lower intravenous fluid volumes but not with duration of vasopressor use, organ support or mortality. Large prospective studies addressing this question are required.

Perioperative Normal Saline Administration and Delayed Graft Function in Patients Undergoing Kidney Transplantation: A Retrospective Cohort Study.

Perioperative normal saline administration remains common practice during kidney transplantation. The authors hypothesized that the proportion of balanced crystalloids versus normal saline administered during the perioperative period would be associated with the likelihood of delayed graft function. The authors linked outcome data from a national transplant registry with institutional anesthesia records from 2005 to 2015. The cohort included adult living and deceased donor transplants, and recipients with or without need for dialysis before transplant. The primary exposure was the percent normal saline of the total amount of crystalloids administered perioperatively, categorized into a low (less than or equal to 30%), intermediate (greater than 30% but less than 80%), and high normal saline group (greater than or equal to 80%). The primary outcome was the incidence of delayed graft function, defined as the need for dialysis within 1 week of transplant. The authors adjusted for the following potential confounders and covariates: transplant year, total crystalloid volume, surgical duration, vasopressor infusions, and erythrocyte transfusions; recipient sex, age, body mass index, race, number of human leukocyte antigen mismatches, and dialysis vintage; and donor type, age, and sex. The authors analyzed 2,515 records. The incidence of delayed graft function in the low, intermediate, and high normal saline group was 15.8% (61/385), 17.5% (113/646), and 21% (311/1,484), respectively. The adjusted odds ratio (95% CI) for delayed graft function was 1.24 (0.85 to 1.81) for the intermediate and 1.55 (1.09 to 2.19) for the high normal saline group compared with the low normal saline group. For deceased donor transplants, delayed graft function in the low, intermediate, and high normal saline group was 24% (54/225 [reference]), 28.6% (99/346; adjusted odds ratio, 1.28 [0.85 to 1.93]), and 30.8% (277/901; adjusted odds ratio, 1.52 [1.05 to 2.21]); and for living donor transplants, 4.4% (7/160 [reference]), 4.7% (14/300; adjusted odds ratio, 1.15 [0.42 to 3.10]), and 5.8% (34/583; adjusted odds ratio, 1.66 [0.65 to 4.25]), respectively. High percent normal saline administration is associated with delayed graft function in kidney transplant recipients.

Subsequent Pressure Injury Development in Mechanically Ventilated Critical Care Patients with Hospital-Acquired Pressure Injury: A Retrospective Cohort Study.

To identify factors associated with subsequent hospital-acquired pressure injury (HAPrI) formation among patients in surgical and cardiovascular surgical ICUs with an initial HAPrI. Patients admitted to a level 1 trauma center and academic medical center in the Western US between 2014 and 2018 were eligible for this retrospective cohort study. Inclusion criteria were development of an HAPrI stage 2 or above, age older than 18 years, the use of mechanical ventilation for at least 24 hours, and documentation of a risk-based HAPrI-prevention plan including repositioning at least every 2 hours. The primary outcome measure was development of a second, subsequent HAPrI stage 2 or higher. Potential predictor variables included demographic factors, shock, Charleston comorbidity score, blood gas and laboratory values, surgical factors, vasopressor infusions, levels of sedation or agitation, Braden Scale scores, and nursing skin assessment data. The final sample consisted of 226 patients. Among those, 77 (34%) developed a second HAPrI. Independent risk factors for subsequent HAPrI formation were decreased hemoglobin (odds ratio, 0.71; 95% confidence interval [CI], 0.53-0.92; P < .000), vasopressin infusion (odds ratio, 2.20; 95% CI, 1.17-4.26; P = .02), and longer length of stay in the ICU (odds ratio, 1.01; 95% CI, 1.00-1.02; P = .009). Patients with an HAPrI are at high risk of subsequent HAPrI development. Anemia, vasopressin infusion, and longer ICU stays are independent risk factors for repeat HAPrI formation.

Practice Patterns in the Initiation of Secondary Vasopressors and Adjunctive Corticosteroids during Septic Shock in the United States

Rationale: A central component of septic shock treatment is the infusion of vasopressors, most commonly starting with norepinephrine. However, the optimal approach and practice patterns for initiating adjunctive vasopressors and corticosteroids are unknown. Objectives: To characterize practice pattern variation in the norepinephrine dose at which secondary vasopressors and adjunctive corticosteroids are initiated and to identify factors associated with a treatment strategy favoring secondary vasopressors compared with factors associated with a treatment strategy favoring adjunctive corticosteroids among patients with septic shock on norepinephrine. Methods: We used a multicenter intensive care unit (ICU) database to identify patients with septic shock who were started on norepinephrine followed by an additional vasopressor or corticosteroids. We used multilevel models to determine the hospital risk-adjusted norepinephrine dose at which additional vasopressors and corticosteroids were started, the percentage of variation in the norepinephrine dose at the time of adjunctive treatment associated with the hospital of admission, and the factors associated with choosing an "additional-vasopressor-first" strategy versus a "corticosteroid-first" strategy. Results: Among 4,401 patients with septic shock on norepinephrine, 1,940 (44.0%) were started on adjuncts (1,357 received an additional-vasopressor-first strategy, and 583 received a corticosteroid-first strategy). The hospital risk-adjusted norepinephrine dose at which vasopressors were initiated ranged from 6.4 μg/min (95% confidence interval [CI], 5.9-7.0 μg/min) to 92.6 μg/min (95% CI, 72.8-113.0 μg/min). The hospital risk-adjusted norepinephrine dose at which corticosteroids were initiated ranged from 3.0 μg/min (95% CI, 2.4-3.8 μg/min) to 32.7 μg/min (95% CI, 24.9-43.0 μg/min). Of the variation in the norepinephrine dose at which additional vasopressors were initiated, 25.1% (intraclass correlation coefficient 95% CI, 24.8-25.5%) was explained by the hospital site after adjusting for all hospital- and patient-level covariates. The hospital of admission was strongly associated with receiving an additional-vasopressor-first strategy over a corticosteroid-first strategy (median odds ratio, 3.28 [95% CI, 2.81-3.83]). Conclusions: Practice patterns for adjunctive therapies to norepinephrine during septic shock are variable and are determined in large part by the hospital of admission. These results inform several future studies seeking to improve septic shock management.

Propofol Versus Remifentanil Sedation for Transcatheter Aortic Valve Replacement: A Single Academic Center Experience

Comparison of remifentanil versus propofol for sedation during transcatheter aortic valve replacement (TAVR) procedures to analyze the risk of sedation-related hypoxemia and hypotension. Secondary outcomes included the rate of conversion to general anesthesia, procedure length, rate of intensive care unit (ICU) admission, ICU and hospital lengths of stay, and 30-day mortality. Retrospective cohort study. A single tertiary teaching hospital. Two hundred fifty-nine patients who had propofol or remifentanil sedation for TAVR between March 2017 and March 2020. None. There were 130 patients (50.2%) in the propofol cohort and 129 patients (49.8%) in the remifentanil cohort. The primary outcomes were oxygen saturation nadir values and vasopressor infusion use. Remifentanil was associated with a lower oxygen saturation nadir, as compared to propofol (91.3% v . 95.4%, p < 0.001). Risk factors associated with hypoxemia (defined as <92%) were body mass index (p = 0.0004), obstructive sleep apnea (p = 0.004), and remifentanil maintenance (p < 0.001). Vasopressor infusion use was significantly higher with propofol (64.9% v . 8.5%, p < 0.001). Propofol maintenance and angiotensin-converting enzyme inhibitor/angiotensin II receptor-blocker use were the only variables identified as risk factors for vasopressor use (p < 0.001 and p = 0.009). For patients undergoing TAVR with conscious sedation, remifentanil was associated with more hypoxemia while propofol was associated with a higher rate of vasopressor use.

Risk Factors for Patients Using Intraoperative Vasopressor Infusions During Carotid Body Tumor Excision

Objective To investigate the risk factors for patients using intraoperative vasopressor infusions during carotid body tumor(CBT)excision.Patients' mean arterial pressure(MAP)and heart rate(HR)fluctuations as well as their requirements for vasoactive agents during surgery were assessed. Methods The patients receiving CBT excision in Peking Union Medical College Hospital from May 1,2013 to July 31,2017 were included for a retrospective cohort study.The potential factors of intraoperative requirement for vasopressor infusions were investigated using univariate analysis and Logistic multivariate analysis.Furthermore,the relationships of Shamblin types of CBT with intraoperative MAP/HR fluctuations and requirements for vasoactive agents were analyzed. Results A total of 108 patients with 116 CBTs were included.Univariate analysis revealed that maximum tumor diameter >4 cm,intraoperative internal carotid artery injury,internal carotid artery reconstruction,malignant pathology,advanced Shamblin types(type Ⅱ and Ⅲ),estimated blood loss ≥400 ml,and operation duration >4 hours were associated with intraoperative requirements for vasopressor infusions.Logistic analysis showed that Shamblin type Ⅲ(OR=2.286,95% CI=1.324-14.926,P=0.016)and operation duration >4 hours(OR=3.874,95% CI=1.020-14.623,P=0.046)were risk factors for intraoperative requirements for vasopressor infusions during CBT surgery.In addition,Shamblin type Ⅲ was associated with intraoperative abnormal HR elevation and requirements for vasopressors.Conclusions Shamblin type Ⅲ and operation duration>4 hours are risk factors for intraoperative requirements of patients for using vasopressor infusions during CBT surgery.Shamblin type Ⅲ is associated with intraoperative abnormal HR elevation and requirements for vasopressors.

STS INTERMACS Database: The Key to Conduct Single-Arm Trials in Advanced Heart Failure Patients

BackgroundSafe introduction of novel mechanical circulatory support (MCS) devices into clinical practice is a challenging process. Single-arm trials using a control arm from existing database is an effective alternative that could be applied for regulatory approval. This study analyzes the capability of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database to establish objective performance criteria and select patient population that could be used for future single-arm MCS trials. MethodsPatients with INTERMACS profiles IM1-2 and IM3-5, who underwent implantation of isolated left ventricular assist devices between 2014 and 2017, were included. Both cohorts were further stratified into shock and nonshock groups using surrogate markers of shock (extracorporeal membrane oxygenation, temporary ventricular assist device, vasopressor infusions). Survival, transplantation rates, adverse events, 6-minute walk test, and quality-of-life measures were obtained for all 4 groups at 6 and 12 months. ResultsTotal of 7907 patients were divided into IM1-2 (n = 3909), IM3-5 (n = 3998), shock (n = 3469), and nonshock (n = 3040) groups. Recategorization occurred in 11% of patients from the IM3-5 group into the shock group. Overall, patients in the shock group had similar outcomes to the IM1-2 group (1-year survival: 86% vs 85%; P = .74). Patients in the nonshock group also had similar outcomes to the IM3-5 (1-year survival: 90% vs 90%; P = .43). ConclusionsThe INTERMACS database can successfully establish objective performance criteria and concurrent control group for single-arm trials that could be used to support regulatory approval of new, less invasive MCS. INTERMACS data allow reliable comparisons of outcomes and adverse events.

Is Greater Than 0.5 MAC Inhalational Agent Use Post-Bypass Related to Need for Inotropic and/or Vasoconstrictor Support?

Background and Aims: We hypothesized that maintaining a patient on moderate–high doses of potent inhalational agent for greater than 30 min during the post-bypass period would be an independent predictor of initiation and usage of either inotropic and/or vasopressor infusions. Setting and Design: This study is a retrospective design and approved by the institutional review board. The setting was a single-center, academic tertiary care hospital in Detroit, Michigan. Materials and Methods: Three-hundred, ninety-seven elective cardiac surgery patients were identified for chart review. Electronic medical records were reviewed to collect demographics and perioperative data. Statistics used include a propensity score regression adjusted analysis utilizing logistic regression models and a multivariable model. Results: A propensity score regression adjusted analysis was performed and then applied in both univariate and multivariate logistic regression models with a p value of &lt;0.05 reaching statistical significance. Fifty-six percent of the participants had an exposure of greater than 30 min of a minimum alveolar concentration of isoflurane greater than 0.5 (ETISO ≥ 0.5MAC, 30 min) in the post-bypass period. After adjusting for propensity score, this was found to be a significant predictor of inotrope and/or vasoconstrictor use post-bypass (OR 2.49, 95% CI 1.15–5.38, p = 0.021). In the multivariate model, pulmonary hypertension (OR 5.9; 95% CI 1.33–26.28; p = 0.02), Euroscore II (2.73; 95% CI 1.35–5.5; p = 0.005), and cardiopulmonary bypass hours (OR 1.86; 95% CI 1.02–3.4; p = 0.042) emerged as significant. Conclusions: This study showed that an ETISO ≥ 0.5MAC, 30 min exposure during the immediate post-bypass period during elective cardiac surgery was an independent predictor of a patient being started on inotrope or vasoconstrictor infusions. Further research should consider a prospective design and examine depth of anesthesia during the post-bypass period.

The perioperative management of simultaneous bilateral nephrectomy with renal transplantation: a case series.

PurposeBilateral nephrectomy is performed at times with renal transplantation. Though surgical indications and timing of these two procedures have been described, there are no large case series describing the anesthetic management of these cases. We sought to describe our experience.MethodsWe performed a historical cohort study on 54 consecutive cases of simultaneous bilateral nephrectomy with renal transplantation at a single, tertiary-care medical centre. Descriptive statistics were used.ResultsThe most common etiology of kidney disease involved was autosomal dominant polycystic kidney disease at 52/54 (96%) cases. All patients received grafts from living donors. An arterial line was placed in 44 (81%) and a central venous catheter in 16 (30%) subjects. At least one vasopressor infusion was used in 44 (81%) cases and 37 (69%) patients required admission to the intensive care unit (ICU). Of this subset, 30 (81%) were admitted for ongoing vasopressor support and six (16%) for hemodynamic monitoring. All patients were extubated in the operating room upon completion of the procedure. Median [interquartile range (IQR)] ICU length of stay (LOS) was 0.9 [0.7–1.4] days and total hospital LOS was 4.4 [4.3–5.4] days. There were no cases of mortality at 30 days or of postoperative dialysis.ConclusionsAdult patients undergoing simultaneous bilateral nephrectomy with renal transplantation often developed perioperative hypotension requiring vasopressor infusions and postoperative transfer to the ICU. This is possibly due to a temporary loss of the renin-angiotensin system. Despite this, patients most commonly were transferred to the floor on postoperative day 1 and had successful outcomes with no mortality at 30 days.

Impact of Goal Directed Therapy in Head and Neck Oncological Surgery with Microsurgical Reconstruction: Free Flap Viability and Complications.

Simple SummaryBased on the proven benefits of goal directed therapy (GDT) in the perioperative management of different surgical procedures and in high-risk patients, we hypothesised that this approach would also be beneficial in microvascular free flap reconstruction in head and neck cancer. In this study, we investigated whether GDT would directly benefit flap viability in addition to improving morbidity and mortality. As this reconstructive technique is gradually being introduced in more specialist fields, particularly radical oncological surgery, the benefits of GDT in this context could be extended to numerous procedures.(1) Background: Surgical outcomes in free flap reconstruction of head and neck defects in cancer patients have improved steadily in recent years; however, correct anaesthesia management is also important. The aim of this study has been to show whether goal directed therapy can improve flap viability and morbidity and mortality in surgical patients. (2) Methods: we performed an observational case control study to analyse the impact of introducing a semi invasive device (Flo Trac®) during anaesthesia management to optimize fluid management. Patients were divided into two groups: one received goal directed therapy (GDT group) and the other conventional fluid management (CFM group). Our objective was to compare surgical outcomes, complications, fluid management, and length of stay between groups. (3) Results: We recruited 140 patients. There were no differences between groups in terms of demographic data. Statistically significant differences were observed in colloid infusion (GDT 53.1% vs. CFM 74.1%, p = 0.023) and also in intraoperative and postoperative infusion of crystalloids (CFM 5.72 (4.2, 6.98) vs. GDT 3.04 (2.29, 4.11), p < 0.001), which reached statistical significance. Vasopressor infusion in the operating room (CFM 25.5% vs. GDT 74.5%, p < 0.001) and during the first postoperative 24h (CFM 40.6% vs. GDT 75%, p > 0.001) also differed. Differences were also found in length of stay in the intensive care unit (hours: CFM 58.5 (40, 110) vs. GDT 40.5 (36, 64.5), p = 0.005) and in the hospital (days: CFM 15.5 (12, 26) vs. GDT 12 (10, 19), p = 0.009). We found differences in free flap necrosis rate (CMF 37.1% vs. GDT 13.6%, p = 0.003). One-year survival did not differ between groups (CFM 95.6% vs. GDT 86.8%, p = 0.08). (4) Conclusions: Goal directed therapy in oncological head and neck surgery improves outcomes in free flap reconstruction and also reduces length of stay in the hospital and intensive care unit, with their corresponding costs. It also appears to reduce morbidity, although these differences were not significant. Our results have shown that optimizing intraoperative fluid therapy improves postoperative morbidity and mortality.

Vasopressor Responsiveness Beyond Arterial Pressure: A Conceptual Systematic Review Using Venous Return Physiology.

We performed a systematic review to investigate the effects of vasopressor-induced hemodynamic changes in adults with shock. We applied a physiological approach using the interacting domains of intravascular volume, heart pump performance, and vascular resistance to structure the interpretation of responses to vasopressors. We hypothesized that incorporating changes in determinants of cardiac output and vascular resistance better reflect the vasopressor responsiveness beyond mean arterial pressure alone.We identified 28 studies including 678 subjects in Pubmed, EMBASE, and CENTRAL databases.All studies demonstrated significant increases in mean arterial pressure (MAP) and systemic vascular resistance during vasopressor infusion. The calculated mean systemic filling pressure analogue increased (16 ± 3.3 mmHg to 18 ± 3.4 mmHg; P = 0.02) by vasopressors with variable effects on central venous pressure and the pump efficiency of the heart leading to heterogenous changes in cardiac output. Changes in the pressure gradient for venous return and cardiac output, scaled by the change in MAP, were positively correlated (r2 = 0.88, P < 0.001). Changes in the mean systemic filling pressure analogue and heart pump efficiency were negatively correlated (r2 = 0.57, P < 0.001) while no correlation was found between changes in MAP and heart pump efficiency.We conclude that hemodynamic changes induced by vasopressor therapy are inadequately represented by the change in MAP alone despite its common use as a clinical endpoint. The more comprehensive analysis applied in this review illustrates how vasopressor administration may be optimized.