Need For Vasopressors Research Articles

The effect of hydroxocobalamin and methylene blue for vasoplegic syndromes: A systematic review

<b>Background: </b>The role of methylene blue (MB) and hydroxocobalamin (B12) in treating patients with vasoplegic syndromes remains uncertain.<br /> <b>Objective:</b> This systematic review aimed to assess the effects of MB and hydroxocobalamin on patients with vasoplegic syndromes following surgery.<br /> <b>Methods:</b> A systematic search was conducted for articles reporting the use of MB and hydroxocobalamin in vasoplegic syndromes. The databases PubMed, ScienceDirect, Cochrane Library, Springer, Scopus, and medRxiv were systematically searched up to 9 June 2024. Clinical outcomes, hemodynamic outcomes, length of stay (LOS), mortality, and adverse events were extracted from each study.<br /> <b>Results:</b> This review included five studies. The findings from these studies suggested that hydroxocobalamin, with or without MB, effectively reduced vasopressor requirements and improved MAP mainly at 1-hour post-administration. The LOS and mortality did not differ between the two groups. The most common reported side effects for MB include serotonin syndrome. Meanwhile, chromaturia affects the hydroxocobalamin group.<br /> <b>Conclusion: </b>Hydroxocobalamin could lower the need for vasopressors and increase MAP better than MB only. Hydroxocobalamin can also cause temporary chromaturia, which resolves itself. Given the side effects, the choice between MB or hydroxocobalamin for treating vasoplegic syndrome should be based on the patient’s condition. Further studies are required to confirm its findings.

Decoding Inflammation: Predicting Sepsis in the ICU.

Sepsis is a life-threatening condition arising from a dysregulated host response to infection leading to organ dysfunction. Traditional clinical signs are often unreliable for detecting sepsis, necessitating the exploration of more accurate biomarkers. Furthermore, currently, recommended screening scores perform poorly, necessitating more effective biomarkers to identify sepsis. Therefore, in this study, we evaluated the predictive capabilities of six inflammatory biomarkers - C-reactive protein (CRP), red cell distribution width (RDW), neutrophil-lymphocyte ratio (NLR), monocyte distribution width (MDW), mean neutrophil volume (MNV), and mean monocyte volume (MMV) - measured from samples taken for complete blood count (CBC) for the development of sepsis in ICU patients. We conducted a prospective observational study involving ICU patients at a tertiary-care hospital in Hyderabad, India, over a one-year period to primarily assess the predictability of these six biomarkers for sepsis. As a secondary outcome, we also analyzed the predictiveness of the biomarkers with respect to mortality, the need for vasopressors, invasive mechanical ventilation or renal replacement therapy (RRT), the presence of organ failure, and hospital length of stay. Blood samples were collected for CRP and CBC on the first day of admission, from which RDW, NLR, MDW, MNV, and MMV were measured. Demographic data, including Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores, clinical progression (recovery or mortality), requirement for vasopressors, invasive mechanical ventilation, RRT, presence of organ failure, and overall length of hospital stay, were documented. We analyzed data from 84 patients after one patient withdrew consent. The study sample had a mean age of 65.83 years, with 60 (71.4%) patients >60 years of age and a male predominance (n = 50; 59.5%). About 57 (67.85%) patients had three or more comorbidities. About 71 (84.5%) patients met the sepsis-3 criteria. Mean APACHE II and SOFA scores were 18.73 and 5.36, respectively. Primary outcome analysis showed that CRP and MDW were the most sensitive, with sensitivities of 81.75% and 81.7%, respectively, whereas MDW, MNV, and MMV had the highest specificity at 100% each. Correlation analysis revealed that MDW had the best area under the curve (AUC) of 0.932 in predicting sepsis. Multivariate logistic regression identified both MDW and MMV to have a significant positive correlation in the prediction of sepsis. The overall mortality rate was 9.5%. About 82 (97.6%) patients had organ failure, 35 (41.7%) required vasopressors, 20 (23.8%) required invasive mechanical ventilation, 16 (19%) required RRT, and 59 (70.2%) had a hospital stay exceeding five days, with an average length of hospital stay of eight days. No biomarkers showed strong AUC or specificity compared to the SOFA score (0.710, 94.74% specificity in predicting mortality). However, among the six biomarkers, MDW was the most specific (86.84%). A CRP of >65 mg/L was the best indicator for prolonged hospital stay, vasopressor use, and RRT. An MMV of >179 and MDW of >21.86 U were the most sensitive markers for vasopressor requirements. Our findings suggest that easily accessible biomarkers derived from routine CBC tests, particularly MDW and MMV, may serve as valuable tools for early sepsis diagnosis in resource-limited settings.

Relationships between adrenal insufficiency and cardiovascular outcomes in patients with congestive heart failure.

Patients with adrenal insufficiency (AI) face elevated risks during various hospitalizations including cardiovascular related admissions. Despite this, limited data exist specifically regarding congestive heart failure (CHF) in the context of AI. This investigation leveraged a comprehensive national database to examine the association between AI and cardiovascular outcomes among patients admitted with CHF. Admissions for CHF were identified in the 2016-2019 National Inpatient Sample. In-hospital outcomes were compared between patients with and without AI. The primary outcome was in-hospital mortality. Secondary outcomes included cardiogenic shock, ventricular tachycardia (VT), acute kidney injury (AKI), vasopressor use, mechanical circulatory support (MCS) use, mechanical ventilation use, hospital length of stay (LOS), and total charges. Multivariable regression models were used to adjust for potential confounders. Among 1,270,784 CHF hospitalizations, 3812 (0.3%) had a diagnosis of AI. AI was associated with higher odds of in-hospital mortality (aOR 2.6, 95% CI 2.1-3.7), VT (aOR 1.40, 95% CI 1.1-1.8), AKI (aOR 1.29, 95% CI 1.10-1.52), the need for vasopressors (aOR 3.3, 95% CI 1.9-5.63), mechanical ventilation use (aOR 3.8, 95% CI 2.9-4.99), cardiogenic shock (aOR 3.08, 95% CI 2.38-3.98), and MCS (aOR 2.12, 95% CI 1.14-3.95). Patients with AI also had a longer LOS (8.62 days vs. 5.25 days, p<0.001) and higher total charges ($103,248 vs. $50,280, p<0.001). Patients with AI admitted for CHF had higher in-hospital mortality, non-fatal adverse outcomes, and incurred higher hospital charges compared to patients without AI.

Efficacy and safety of a generic remifentanil formulation versus fentanyl and Ultiva during general anaesthesia: A phase III, prospective, multi-centric, observer-blind, randomised controlled trial.

Remifentanil and fentanyl are potent opioid analgesics commonly used during surgery due to their distinct pharmacological profiles. This study aimed to compare the efficacy and safety of a generic remifentanil (test drug) with fentanyl and Ultiva (innovator formulation) during general anaesthesia in the Indian population. This phase III, multi-centre (n = 13), randomised, three-arm, comparative study was conducted from 24 November 2021 to 31 March 2022. Eligible subjects scheduled for elective therapeutic and diagnostic surgical procedures (n = 314) were randomised into generic remifentanil, Ultiva, and fentanyl groups. An independent anaesthetist blinded to treatment allocation assessed efficacy and safety parameters. The primary efficacy endpoint was haemodynamic response during specific activities (endotracheal intubation, skin incision, skin closure, and extubation). The study groups exhibited no significant differences in demographic and baseline characteristics. Heart rate was similar between the remifentanil and Ultiva groups measured during laryngeal intubation, skin incision, skin closure, and extubation (P > 0.05 in all four procedures). Heart rate was significantly higher in the fentanyl group in comparison to the remifentanil group during laryngeal intubation (P = 0.035), skin incision (P = 0.017), skin closure (P = 0.001), and extubation (P = 0.026). The need for vasopressor and anti-cholinergic drugs was similar between groups, and no subject required naloxone administration. Our study's findings demonstrated that generic remifentanil is non-inferior to fentanyl and equivalent to Ultiva for general anaesthesia in Indian patients undergoing various surgical and diagnostic procedures. Remifentanil offers advantages in terms of optimum haemodynamic stability, fast equilibrating analgesia, and rapid emergence from sedation, making it a suitable alternative to fentanyl.

The association of obesity and in-hospital outcomes among patients undergoing ablation for atrial fibrillation: a propensity-score matched analysis

Abstract Background Obesity is a strong risk factor for atrial fibrillation (AF), and it can affect the prognosis of AF. However, the impact of obesity (BMI≥30 kg/m²) on postoperative complications after AF ablation has not been extensively studied. We aimed to evaluate the association of obesity with in-hospital outcomes among patients with AF who ablation procedures. Methods The study utilized the National Inpatient Sample (NIS) database 2016-2020. Patients were divided into obese and non-obese groups and matched with propensity score matching (1:1). This matching involved adjusting for baseline variables (including age, gender, primary expected payer, race, and median household income) and comorbidities (including diabetes, hypertension, hyperlipidemia, history of coronary artery bypass grafting (CABG), chronic kidney disease, hyperthyroidism, cardiomyopathy, prior stroke or transient ischemic attack, heart failure with preserved ejection fraction (HFpEF), heart failure with reduced ejection fraction (HFrEF), heart valve disease, coronary artery disease, chronic obstructive pulmonary disease (COPD), alcohol misuse, anemia, and smoking). Furthermore, a weighted analysis was conducted utilizing weights provided by the NIS, and multivariate logistic regression was used to calculate the odds ratio. Results A total of 29,440 patient with AF who underwent ablation were included. After propensity matching, (8,110 in obese and 8,110 in non-obese group) the baseline characteristics were not significantly different between the two groups. Obesity was independently associated with higher risk of pseudoaneurysm, hematoma, postoperative anemia, acute kidney injury, vasopressor need, mechanical ventilation, pulmonary embolism, and ischemic stroke in patients who underwent ablation for AF (Figure 1). In addition, obese group had significantly higher length of stay (median and IQR 2 [1-3] vs 2 [1-4]) and total charges (median and IQR: 131,248$ [95,303-197,784] vs 143,693$ [102,720-206728]) compared to non-obese group (p&amp;lt;0.001). However, in-hospital mortality was not significantly different between the two groups. Conclusion In patients who underwent AF ablation, obesity is associated with significantly higher risk of post-operative complications, as well as increased LOS and total hospital charges.

Outcomes of ST-Segment Elevation Myocardial Infarction in Patients With Adrenal Insufficiency.

Patients with adrenal insufficiency (AI) have both increased risk of cardiovascular disease and adverse outcomes with many medical emergencies. However, limited data exist specifically regarding ST-segment elevation myocardial infarction (STEMI) in the context of AI. To evaluate associations between AI and in-hospital outcomes of patients with STEMI. Admissions for STEMI were identified in the 2016-2019 National Inpatient Sample. In-hospital outcomes were compared between patients with and without AI. The primary outcome was in-hospital mortality. Secondary outcomes included percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), intervention, acute kidney injury (AKI), vasopressor use, mechanical circulatory support (MCS), mechanical ventilation, ventricular tachycardia (VT), hospital length of stay (LOS), and total charges. Multivariable regression models were used to adjust for potential confounders. Among 690 430 STEMI hospitalizations, 1382 (0.2%) had a diagnosis of AI. AI was associated with higher odds of in-hospital mortality (adjusted OR [aOR] 1.51, 95% CI 1.03-2.2), lower odds of PCI (aOR 0.73, 95% CI 0.55-0.98), higher odds of CABG (aOR 2.8, 95% CI 1.89-4.2) and, AKI (aOR 2.38, 95% CI 1.72-3.3), VT (aOR 1.55, 95% CI 1.1-2.2), need for vasopressors (aOR 2.34, 95% CI 1.33-4.1), mechanical ventilation (aOR 2.11, 95% CI 1.54-2.89), and MCS (aOR 2.18, 95% CI 1.57-3.03). Patients with AI also had a longer LOS (10 days vs 4.2 days, P < .001) and higher charges ($258 475 vs $115 505, P < .001). Patients with AI admitted for STEMI had higher in-hospital mortality, nonfatal adverse outcomes, and resource utilization than patients without AI.

Evaluation of a Physiologic-Driven Closed-Loop Resuscitation Algorithm in an Animal Model of Hemorrhagic Shock.

Appropriate resuscitation from hemorrhagic shock is critical to restore tissue perfusion and to avoid over-resuscitation. The objective of this study was to test the ability of a closed-loop diagnosis and resuscitation algorithm called resuscitation from shock using functional hemodynamic monitoring using invasive monitoring (ReFit1) and minimally invasive monitoring (ReFit2) to identify, treat, and stabilize a porcine model of severe hemorrhagic shock. We created a ReFit algorithm using dynamic hemodynamic parameters of pulse pressure variation (PPV), stroke volume variation (SVV), dynamic arterial elastance (Ea dyn = PPV/SVV), driven by mean arterial pressure (MAP), mixed venous oxygen saturation, and heart rate targets to define the need for fluids, vasopressors, and inotropes. University-based animal laboratory. Twenty-seven female pigs. Anesthetized, intubated, and ventilated (8 mL/kg) pigs were bled at 10 mL/min until a MAP of less than 40 mm Hg, held for 30 minutes, then resuscitated. The ReFit algorithm used the above dynamic parameters to drive computer-controlled infusion pumps to deliver blood, lactated Ringer's solution, norepinephrine, and in ReFit1 dobutamine. In four animals, after initial resuscitation from hemorrhagic shock, the ability of the ReFit1 algorithm to treat acute air embolism-induced pulmonary hypertension and right heart failure was also tested. In 10 ReFit1 and 17 ReFit2 animals, the time to stabilization from shock was not dissimilar to open controlled resuscitation performed by an expert physician (52 ± 12, 50 ± 13, and 60 ± 15 min, respectively) with similar amounts of fluids and norepinephrine needed. In four ReFit1 animals after initial stabilization, the algorithm successfully resuscitated the animals after inducing an acute air embolism right heart failure, with all animals recovering stability within 30 minutes. Our physiologically based functional hemodynamic monitoring-centered closed-loop resuscitation system can effectively diagnose and treat cardiovascular shock due to hemorrhage and air embolism.

Exploration of the optimal programmed intermittent epidural bolus volume with the dural puncture epidural technique for labour analgesia: a biased-coin up-and-down sequential allocation study.

To determine the optimal programmed intermittent epidural bolus (PIEB) volume for providing effective analgesia in 90% of patients (EV90) during the first stage of labour using the dural puncture epidural (DPE) technique to initiate labour analgesia. We conducted a biased-coin up-and-down sequential allocation study. We included 40 nulliparous women requiring epidural labour analgesia. We used a 25G Whitacre spinal needle to puncture the dural mater and then administered a loading dose of 12mL of ropivacaine 0.1% and sufentanil 0.3μg·mL-1. Subsequently, the PIEB pump delivered boluses with an identical solution at a fixed 40-min interval, starting 1hr after epidural initiation. The bolus volume for the first patient was 7mL and was adjusted for subsequent patients according to the study protocol (bolus volume, 7-12mL). The primary endpoint was effective analgesia, indicated by no need for patient-controlled or manual boluses within 6hr after analgesia initiation or until complete cervical dilation, whichever came first. Outcome evaluators assessed the patients' pain ratings, Bromage scores, sensory blockade level, and maternal blood pressure hourly. Using the truncated Dixon and Mood method, the estimated EV90 was 9.2mL (95% confidence interval [CI], 8.5 to 9.9) whereas the isotonic regression method yielded a value of 8.8mL (95% CI, 8.6 to 9.8). None of the patients experienced a motor block. Two patients experienced hypotension without the need for vasopressors. The estimated PIEB EV90 for ropivacaine 0.1% and sufentanil 0.3μg·mL-1 approached 9mL when DPE was combined with a fixed 40-min interval. ChiCTR.org.cn ( ChiCTR2300067281 ); first submitted 3 January 2023.

Neutrophil-platelet ratio as a predictor of acute kidney injury in severe COVID-19.

Acute kidney injury (AKI) is one of the most seen complications of coronavirus-2019 (COVID-19) infection. Patients with AKI caused by COVID-19 likely have higher neutrophil counts and lower platelet and lymphocyte levels. Therefore, the predictive value of many inflammation indexes calculated from the total blood count has been investigated to predict the AKI in COVID-19. According to our clinical experience, we thought that neutrophilia and thrombocytopenia may be more common in the development of AKI. For this reason, this study aimed to evaluate the predictive value of the neutrophil-to-platelet ratio (NPR) for AKI in severe COVID-19 patients. This retrospective study included 334 severe COVID-19 patients followed up in the intensive care unit (ICU). Predictive factors for AKI were analyzed. ROC curve analysis was performed to determine the inflammation indexes' cutoff values for the AKI prediction. Multivariate analyses were performed to determine correlations between the inflammation indexes and AKI. In this study, AKI was determined at the rate of 43% (n:145). Independent risk factors affecting AKI were determined to be age (HR = 1.047, 95% confidence interval [CI]: 1.021-1.072, P < .001), the need for invasive mechanical ventilation (HR = 3.003, 95% CI: 1.645-5.481, P = .001) and the need for vasopressor (HR = 8.111, 95% CI: 3.786-17.375, P < .001). The optimal cutoff values predicting AKI were determined to be 3.9 for the NPR (AUC = 0.679, 95% CI: 0.622-0.737, P < .001) with 71.7% sensitivity and 61.9% specificity, 16.1 for the neutrophil-to-lymphocyte ratio (NLR) (AUC = 0.634, 95% CI: 0.575-0.694, P < .001) with 65.5% sensitivity and 56.1% specificity, and 3872.5 × 109L for the systemic inflammatory index (SII) (AUC = 0.566, 95% CI: 0.504-0.629, P = .038) with 60% sensitivity and 55.6% specificity. In the regression model, only NPR values above the cutoff were related to AKI (HR = 3.817, 95% CI: 1.782-8.177, P = .001). The NPR has more predictive value than the NLPR, NLR, and SII in developing AKI in severe COVID-19 patients in the ICU. NPR is a new helpful index that can help clinicians predict early AKI in critical COVID-19.

A pilot randomized controlled trial comparing noradrenaline and adrenaline as a first-line vasopressor for fluid-refractory septic shock in neonates.

Limited data exists on noradrenaline therapy in neonatal septic shock. We compared the efficacy of noradrenaline with adrenaline in neonatal septic shock. This single center, open label, pilot randomized controlled trial included neonates with clinical evidence of sepsis and shock. Primary outcomes were: 1) resolution of shock one hour after treatment, and 2) mortality during hospital stay. Secondary outcomes included: need for additional vasopressors; hemodynamic stability without further administration of vasopressors for ≥2 h; changes in blood pressure and heart rate after 1 h of vasopressor treatment; and morbidities during the hospital stay. Of 65 eligible neonates, 42 were randomized (21 each in adrenaline and noradrenaline treatment arms) between August 2020 and January 2022, at level III neonatal intensive care unit (NICU) of Bharati Vidyapeeth Deemed University Medical College and Hospital (BVDUMCH). The mean (SD) gestational age and mean (SD) birth weight were 36.1(4.2) weeks and 1.8 (0.2) kilograms birth weight for noradrenaline and 36.9 (4.1) weeks and 1.7 (0.7) kilograms for adrenaline. Shock resolved within 1 h of vasopressor therapy in 76.2% neonates in the noradrenaline arm and 61.9% in adrenaline arm (p value-0.53). Mortality during hospital stay was 28.6% (6/21) in noradrenaline group and 33.3% (7/21) in adrenaline group (p value- 0.58). Additional vasopressors were required in 23.8% neonates of the noradrenaline group compared to 38.1% neonates in adrenaline arm (p value-0.53). Median (SD) duration of intensive care stay was 6 (SD) days in the noradrenaline group and 10 (SD) days in the adrenaline group (p value-0.045). Among neonates with septic shock, the efficacy of noradrenaline was comparable to adrenaline in resolving septic shock after one hour of infusion and on the mortality during hospital stay. https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=NDI2NTc=&Enc=&userName=noradrenaline, Clinical Trials Registry - India with identifier CTRI/2020/08/027185 (17/08/2020).

Comparison Of Prophylactic Effects Of Gargling Different Doses Of Ketamine On Attenuating PostOperative Sore Throat.

Aims and objectives: The aim of the study is to evaluate effectiveness of two doses of ketamine gargle in preventing post-operative sore throat (POST). Materials &amp; Method: Sixty-nine patients scheduled for elective surgery under general anaesthesia were randomized into three groups: Group C, saline 30 ml; Group A, ketamine 100 mg in Saline 30 ml and Group, ketamine 120 mg in saline 30ml. Patients were asked to gargle this mixture for 30 seconds, 5 minutes before induction of anaesthesia. POST was graded at 4, 8 and 24 hours after operation on a four-point scale (0-3). The primary outcome of incidence and grading of POST along with secondary outcomes of drug-related adverse effects were observed and recorded. Results: In the Control group POST occurred more frequently, when compared with patients belonging to both the Ketamine groups at 4, 8, and 24 hours (74%, 70%, and 52%). The greatest difference in the severity of POST was observed at the 4-hour and 8-hour intervals in both the 100 mg and 120 mg ketamine groups. However, these groups exhibited similar outcomes at the 24-hour mark (p&lt;0.05). Conclusion: Prophylactic intravenous Glycopyrrolate in spinal anesthesia for cesarean section reduces the incidence and severity of hypotension and the need for Vasopressor.

Development of Acute Kidney Injury Predictor Score in Intensive Care Unit Patients in Padang, Indonesia.

This study aims to develop and create a specialized acute kidney injury (AKI) predictor score for the intensive care unit (ICU) patients in Padang, Indonesia. This study was a prospective observational study on 352 ICU patients at three specialized hospitals in Padang City; Dr. M. Djamil General Hospital, Dr. Rasidin General Hospital, and Siti Rahmah Islamic Hospital. Data regarding demographics, clinical characteristics, laboratory results, and outcomes related to AKI were gathered. The factors that predict AKI were identified using multivariate logistic regression analysis to determine independent factors. The predictor scores were created using regression coefficients and then internally confirmed. Out of a total of 352 patients, 128 individuals (36.4%) suffered from AKI. Factors that independently predict the occurrence of AKI include age over 60 years old, having a history of chronic kidney disease, having sepsis, need for vasopressors, and having creatinine level 1.3 mg/dL (IQR 1.0-1.8) upon admission to ICU. An area under the curve (AUC) of 0.85 (95% CI 0.80-0.90) indicated the strong performance of the constructed predictor score. The constructed AKI predictor score a scale factor of 10, resulting in a range of 0-10 for the AKI predictor score. It demonstrates a good level of accuracy in predicting AKI in ICU patients in Padang. This score can be used by healthcare professionals to quickly identify and categorize individuals based on their risk level, facilitating timely intervention and personalized treatment.

National Trends and In-Hospital Outcomes for Immediate Implant-Based Versus Autologous-Based Breast Reconstruction: A Propensity Score-Matched Analysis.

Breast reconstruction consists primarily of two methods: autologous breast reconstruction (ABR) and implant-based breast reconstruction (IBR). Each of these methods has its advantages and disadvantages. The current study used the National Inpatient Sample (NIS), the largest inpatient database in the United States, to explore the trends, complications, and disparities in the use of IBR and ABR. The current study used the NIS database from 2016 to 2020, including the International Classification of Diseases, 10th version (ICD-10) codes. A propensity score-matching (1:1) analysis was used to match the IBR and ABR groups. The percentage of breast reconstruction increased from 58.8% in 2016 to 63.4% by 2020. The trend of ABR was upward, and the trend of IBR was downward. In addition, the ABR group had significantly higher rates of cardiovascular complications (odds ratio [OR], 1.29), respiratory complications (OR, 4.26), vascular complications requiring surgery (OR, 7.82), blood transfusions (OR, 3.44), vasopressor need (OR, 1.409), and acute kidney injury (OR, 1.68). However, the ABR group had significantly lower rates of wound infection (OR, 0.430), wound dehiscence (OR, 0.213), wound seroma (OR, 0.602), and sepsis (OR, 0.252). A significant disparity was found in using ABR for different subgroups based on age, hospital teaching status, racial background, socioeconomic status, and hospital bed size. The current study showed an upward trend in the utilization of ABR and a downward trend for IBR. Although ABR had a higher rate of pulmonary, cardiovascular, vascular, and bleeding complications, it had a lower rate of wound-related complications.

The polymyxin-B direct hemoperfusion OPTimal Initiation timing with Catecholamine PMX-OPTIC study: A multicenter retrospective observational study.

Polymyxin-B direct hemoperfusion (PMX-DHP) is an endotoxin adsorption column-based blood purification therapy. Since one of the most potent effects of PMX-DHP is blood pressure elevations, it may be the most effective when it is introduced at the time when the need for vasopressors is the greatest, which, in turn, may reduce mortality. A multicenter retrospective study was conducted at 24 ICUs in Japan. In each ICU, the 20 most recent consecutive cases of septic shock treated with PMX-DHP were analyzed. The duration between the time of the peak vasopressive agent dose, expressed as the noradrenaline equivalent dose (NEq), and the time of PMX initiation was evaluated. The primary outcome was 28-day mortality, and a multivariable analysis was performed to investigate factors associated with mortality. A total of 480 septic shock patients were included in the analysis. Among all patients, the 28-day mortality group was older, more severely ill, and had a higher body mass index. The NEq peak and NEq on PMX-DHP initiation were both higher in deceased patients. Regarding the timing of PMX-DHP initiation from the NEq peak, -4 << 4 h had more survivors (229/304, 75.3%) than ≤-4 h (50/75, 66.7%) and ≥4 h (66/101, 65.4%) (p = 0.085). When -4 << 4 h was assigned as a reference, the timing of PMX-DHP initiation from the NEq peak of ≤-4 h had an odds ratio of 1.96 (1.07-3.58), p = 0.029, while ≥4 h had an odds ratio of 1.64 (0.94-2.87), p = 0.082 for 28-day mortality, in the multivariable regression analysis. A spline curve of the relationship between the probability of death and the timing of PMX-DHP initiation from the NEq peak showed a downward convex curve with a nadir at timing = 0. The odds ratios of the timing of PMX-DHP initiation other than -4 << 4 h were significantly higher in an older age, male sex, lower BMI, more severe illness, and higher oxygenation. The induction of PMX-DHP at the time of the peak vasopressor dose correlated with lower mortality. PMX-DHP is one of the options available for elevating blood pressure in septic shock, and its initiation either too early or late for shock peak may not improve the outcome.

Minimal invasive extracorporeal circulation: A bibliometric network analysis of the global scientific output.

Minimal Invasive Extracorporeal Circulation (MiECC) has recently emerged as a more 'physiologic' alternative to conventional extracorporeal circulation. However, its adoption is still limited due to lack of robust scientific evidence and ongoing debate about its potential benefits. This bibliometric analysis aims to analyze the scientific articles on MiECC and identify current research domains and existing gaps to be addressed in future studies. Pertinent articles were retrieved from the Web of Science (WOS) database. The search string included 'minimal invasive extracorporeal circulation' and its synonyms. The VOSviewer (version 1.6.17) software was used to conduct comprehensive analyses. Semantic and research networks, bibliographic coupling and journal analysis were performed. Of the 1777 articles identified in WOS, 292 were retrieved. The trend in publications increased from 1991 to date. Most articles focused on transfusion requirements, acute kidney injury, inflammatory markers and cytokines, inflammation and delirium, though the impact of intraoperative optimal fluid and hemodynamic management as far as the occurrence of postoperative complications were poorly addressed. The semantic network analysis found inter-connections between the terms "cardiopulmonary bypass", "inflammatory response", and "cardiac surgery". Perfusion contributed the highest number of published documents. The most extensive research partnerships were between Germany, Greece, Italy, and England. Notwithstanding the scientific community's growing interest in MiECC, crucial topics (i.e., the best anesthetic management and intraoperative need for inotropes, vasopressors and fluids) still require more comprehensive exploration. This investigation may prove to be a useful tool for clinicians, scientists, and students concerning global publication output and for the use of MiECC in cardiac surgery.

Comparison of 24 vs 72-hr octreotide infusion in acute esophageal variceal hemorrhage - A multi-center, randomized clinical trial

BackgroundCurrent guidelines lack clarity about the optimal duration of octreotide therapy for patients with esophageal variceal hemorrhage (EVH). To address this lack of evidence, we conducted a randomized clinical trial (RCT) of 24-hr versus 72-hr continuous infusion of octreotide for patients with EVH. MethodsThis multi-center, prospective RCT (NCT03624517), randomized patients with EVH to 24-hr versus 72-hr infusion of octreotide. Patients were required to undergo esophageal variceal band ligation prior to enrollment. The primary endpoint was rebleeding rate at 72 hr. The study was terminated early due to an inability to recruit during and after the COVID-19 epidemic. ResultsFor patients randomized to 72-hr (n = 19) of octreotide vs 24-hr (n = 15), there were no differences in the need for transfusion, average pRBC units transfused per patient (3 units vs 2 units), infection (5 % vs 0 %), mechanical ventilation (11 % vs 7 %), or the need for vasopressors (5 % vs 3 %), respectively (none of these differences were statistically significantly different). There were 2 re-bleeding events in the 72-hr group (11 %), and no re-bleeding events in the 24-hr group (p = 0.49). 8/15 of patients receiving 24 hr of octreotide were discharged at or before hospital day 3 while none in the 72-hr group was discharged before day 3 (p < 0.001). There was one death (in the 72-hr group) within 30 days. ConclusionsA 24-hr infusion is non-inferior to a 72-hr infusion of octreotide for prevention of re-bleeding in patients with EVH. We propose that shortened octreotide duration may help reduce hospital stay and related costs in these patients.

Epidemiology of cardiogenic shock using the Shock Academic Research Consortium (SHARC) consensus definitions.

The Shock Academic Research Consortium (SHARC) recently proposed pragmatic consensus definitions to standardize classification of cardiogenic shock (CS) in registries and clinical trials. We aimed to describe contemporary CS epidemiology using the SHARC definitions in a cardiac intensive care unit (CICU) population. The Critical Care Cardiology Trials Network (CCCTN) is a multinational research network of advanced CICUs coordinated by the TIMI Study Group (Boston, MA). Cardiogenic shock was defined as a cardiac disorder resulting in SBP < 90 mmHg for ≥30 min [or the need for vasopressors, inotropes, or mechanical circulatory support (MCS) to maintain SBP ≥ 90 mmHg] with evidence of hypoperfusion. Primary aetiologic categories included acute myocardial infarction-related CS (AMI-CS), heart failure-related CS (HF-CS), and non-myocardial (secondary) CS. Post-cardiotomy CS was not included. Heart failure-related CS was further subcategorized as de novo vs. acute-on-chronic HF-CS. Patients with both cardiogenic and non-cardiogenic components of shock were classified separately as mixed CS. Of 8974 patients meeting shock criteria (2017-23), 65% had isolated CS and 17% had mixed shock. Among patients with CS (n = 5869), 27% had AMI-CS (65% STEMI), 59% HF-CS (72% acute-on-chronic, 28% de novo), and 14% secondary CS. Patients with AMI-CS and de novo HF-CS were most likely to have had concomitant cardiac arrest (P < 0.001). Patients with AMI-CS and mixed CS were most likely to present in more severe shock stages (SCAI D or E; P < 0.001). Temporary MCS use was highest in AMI-CS (59%). In-hospital mortality was highest in mixed CS (48%), followed by AMI-CS (41%), similar in de novo HF-CS (31%) and secondary CS (31%), and lowest in acute-on-chronic HF-CS (25%; P < 0.001). SHARC consensus definitions for CS classification can be pragmatically applied in contemporary registries and reveal discrete subpopulations of CS with distinct phenotypes and outcomes that may be relevant to clinical practice and future research.

Intercambio de plasma y enfermedades autoinmunes críticas

Introduction: Renal replacement therapy (RRT) has evolved significantly since its introduction; initially used to treat acute renal failure, it is applied in various clinical scenarios due to improved membranes and equipment. Other techniques have emerged, such as therapeutic apheresis and hemoadsorption, which allow specific components to be removed from the blood. These therapies have shown promise in the treatment of various diseases. Important points: Sepsis and septic shock are the most common causes of admission to intensive care units (ICU), and extracorporeal therapies (ECT) have shown promise in their management. Sepsis is characterized by a dysregulated inflammatory response, which can lead to multiorgan damage. ECT can help modulate this response, eliminating inflammatory mediators and restoring immune balance. Although clinical evidence is inconclusive for all indications, studies have shown improvements in clinical parameters, such as decreased need for vasopressors and improved oxygenation. The response to ECT may be variable between patients due to genetic, epigenetic, and sociodemographic factors. Conclusion: extracorporeal therapies are presented as a promising tool in the management of critically ill patients, and their use is expanding beyond sepsis. As more scientific evidence accumulates, it is expected that these techniques will become consolidated as part of the standard treatment in various pathologies.

Prognostic value of PGI score compared to poison severity score (PSS) and simplified acute physiology score (SAPS) II as predictors of mortality and other adverse outcomes in acute poisoning with aluminum phosphide

Aluminum phosphide (AlP) poisoning is a life-threatening emergency prevalent in the Middle East region including Egypt. Early prediction of prognosis is critical for initiating the utmost intensive interventions. Though many scoring systems were studied for predicting the prognosis of AlP poisoning, these scores received wide criticism. Complexity and reliability were the main concerns. Therefore, this retrospective cross-sectional study aimed to evaluate the performance of the recently introduced PGI score as a predictor of case fatality, the need for mechanical ventilation and vasopressor therapy in acute AlP poisoning. Moreover, it compares the performance of PGI with the known poison severity score (PSS), and the simplified acute physiology score (SAPS) II. Among 144 exposed patients, we reported a mortality rate of 61.1%. Non-survivors exhibited significantly higher PGI, PSS, and SAPS II than survivors. Though the PGI, PSS, and SAPS II proved their significance as predictors of mortality and, the need for MV and vasopressors, the PGI score showed a significantly higher area under the curve (AUC) as a predictor of MV (AUC = 0.848) compared to PSS (AUC = 0.731) and SAPS II (AUC = 0.749). Additively, PGI of 2 or more was a significant predictor of mortality (AUC = 0.831, sensitivity = 65.9%, and specificity = 89.3 %) and MV (p < 0.001), while PGI of 1 or more was another predictor of vasopressor need (AUC = 0.881, sensitivity = 89.0% and specificity = 79.4%). Given the PGI score's high AUCs across all outcomes, coupled with its balanced sensitivity and specificity, the PGI score could be a simple, and robust tool replacing the PSS and SAPS II for predicting mortality, clinical decision-making including the need for MV and vasopressor therapy in acute AlP exposure. Adopting the PGI score seems substantially useful in managing acute AlP poisoning, notably in resource-restricted countries.

Prediction of vasopressor needs in hypotensive emergency department patients using serial arterial blood pressure data with deep learning

AbstractBackgroundShock is a life‐threatening condition that is associated with high mortality and morbidity. Therefore, the timely identification and management of this condition are important. We aimed to develop a prediction model for vasopressor use based on concise serial arterial blood pressure data.MethodsWe collected continuous arterial blood pressure from patients admitted to the emergency department (ED) resuscitation room. Patients with an initial systolic blood pressure lower than 90 mmHg were included in the study. We developed prediction models using convolutional neural networks (CNNs) and long short‐term memory (LSTM) networks. Discrimination performance was assessed using the area under the receiver operating characteristic curve (AUROC) and the area under the precision–recall curve (AUPRC).ResultsA total of 120 patients were enrolled in the study. The CNN and LSTM models yielded AUROCs ranging from 0.731 to 0.834 for predicting the need for vasopressor infusion within different time frames (30 min, 1 h, and 6 h). LSTM outperformed the CNN in terms of predicting vasopressor infusion within 30 min and 1 h (p value &lt; 0.05). The AUPRC values ranged from 0.200 to 0.252, and sensitivity–specificity analyses indicated that the models have potential for clinical applications.ConclusionThis study used serial arterial blood pressure data to construct a promising prediction model for the need for vasopressors in hypotensive ED patients. The simplicity and accuracy of the model provide valuable insights for developing a clinical decision support tool for resuscitation in emergency settings.