Vasopressor Requirements In Patients Research Articles

Continuous Infusion of Ketamine in Mechanically Ventilated Patients with SARS-CoV-2.

Widespread drug shortages led to higher utilization of ketamine in our intensive care unit, especially among patients with SARS-CoV-2. To evaluate the impact of continuous infusion of ketamine on vasopressor requirements in patients with SARS-CoV-2. This was a single-center, retrospective, cohort study comparing mechanically ventilated (MV), adult patients with SARS-CoV-2 receiving either propofol or ketamine for at least 72 hours. 84 patients (mean age of 61-year-old, 68% male) were analyzed. 31 patients received ketamine, and 53 patients received propofol. Mean vasopressor doses were not significantly different between ketamine and propofol groups at prespecified timepoints. However, mean arterial pressures (MAP) were higher in the ketamine group at 24 h, 48 h, and 96 h postsedative initiation. The median opioid infusion requirements were 3 vs. 12.5 mg/hr (p < 0.0001) for ketamine and propofol groups, respectively. Comparing to propofol, C-reactive protein (CRP) values were significantly lower in the ketamine group at 24 h (7.53 vs. 15.9 mg/dL, p=0.03), 48 h (5.23 vs. 14.1 mg/dL, p=0.0083), and 72 h (6.4 vs. 12.1 mg/dL, p=0.0085). In patients with SARS-CoV-2 on MV, there was no difference in the vasopressor requirement in patients receiving ketamine compared to propofol. Nevertheless, the use of ketamine was associated with higher MAP, reductions in CRP in select timepoints, and overall lower opioid requirements.

Intravenous vitamin C for vasoplegia: A double-blinded randomised clinical trial (VALENCIA trial)

PurposeTo determine whether intravenous vitamin C compared with placebo, reduces vasopressor requirements in patients with vasoplegic shock. MethodsDouble-blinded, randomised clinical trial (RCT) conducted in two intensive care units in Perth, Australia. Vasopressor requirements at enrolment needed to be >10 μg/min noradrenaline after hypovolaemia was clinically excluded. Patients received either intravenous 1.5 g sodium ascorbate in 100 ml normal saline every 6 h for 5 days, or placebo (100 ml normal saline). The primary outcome was duration of vasopressor usage in hours. Secondary outcomes were ICU and hospital length of stay, and 28-day, ICU and hospital mortality. ResultsOf the 71 patients randomised (35 vitamin C, 36 placebo group), the median vasopressor duration was 44 h [95% CI, 37–54 h] and 55 h [95% CI, 33–66 h]) in the vitamin C and placebo groups (p = 0.057). ICU and hospital length of stay, mortality outcomes were similar between groups. ConclusionsIn this RCT of patients with vasoplegic shock of at least moderate severity, the use of IV vitamin C compared with placebo did not significantly reduce the duration of vasopressors. Trial registrationProspective registration – trial number ACTRN12617001392358.

Hypotension duration and vasopressor requirements following intrathecal oxytocin for Total hip arthroplasty: Secondary analysis of a randomized controlled trial

IntroductionA recent publication investigating intrathecal oxytocin, 100 μg, administered immediately prior to a spinal anesthetic in patients undergoing primary total hip arthroplasty surgery demonstrated a reduction in disability for 3-weeks, increased walking distance at 8-weeks, and earlier opioid cessation. This secondary analysis study was undertaken to assess the acute cardiovascular safety and analgesic efficacy of intrathecal oxytocin in this study population. Methods90 patients were included in the analysis (44 randomized to spinal oxytocin and 46 to placebo [saline]). Data collected prospectively during the previously published study were supplemented with additional retrospectively collected data. The primary outcomes were comparisons of the duration of hypotension (minutes with mean arterial pressure < 65 mmHg) and cumulative vasopressor requirements during the initial 60 min following spinal placement. Secondary outcomes included hypotension durations and vasopressor requirements at later time points, perioperative fluid administration, physical therapy metrics, time to first opioid administration, cumulative opioid consumption through 24 h, and verbal pain scores through 24 h. ResultsThe duration of hypotension during the first 60 min following spinal placement did not differ between intrathecal oxytocin and placebo groups (12.2 ± 10.7 vs 14.0 ± 13.0 min, respectively; p = 0.476). There was also no difference in cumulative vasopressor requirements (1303 ± 883 vs 1156 ± 818 μg [phenylephrine equivalents]; p = 0.413) during that time period. No group differences were found for any of the investigated secondary outcomes. ConclusionThe administration of 100 μg of intrathecal oxytocin does not significantly impact the duration of hypotension or the need for vasopressor agents when given as a component of a spinal anesthetic. The oxytocin and placebo groups also did not differ in regards to physical therapy related metrics, time to first opioid administration, cumulative opioids at 24-h, or pain scores through 24-h.What is already known on this topic: Rapid intravenous oxytocin causes hypotension after cesarean delivery, but intrathecal oxytocin does not cause hypotension in healthy volunteers.What this study adds: Compared to saline control, intrathecal oxytocin, 100 μg did not increase the duration of hypotension or vasopressor requirements in patients during total hip arthroplasty.How this study might affect research, practice, or policy: Lack of hypotension from intrathecal oxytocin in this study supports future investigations to further explore its potential benefits, in terms of both analgesia and functional recovery following surgery.

O068 Magnesium, the anaesthetists’ friend during carotid endarterectomy (CEA)

Abstract Introduction Magnesium can be used as an antihypertensive for CEA patients, with the added benefit of anti-arrhythmic and anti-convulsive effects without the negative chronotropic effect of classic antihypertensives. It however causes vasodilation and increased diuresis, possibly increasing post-operative vasopressor requirements. This study determines the postoperative haemodynamic impact of magnesium therapy on CEA patients. Methods A retrospective review of CEA patients’ medical records between April 2020 and December 2021 was undertaken. In our unit, the postoperative trigger for commencing vasopressors (metaraminol or noradrenaline) is a systolic blood pressure &amp;lt;110 mmHg. A comparison of the postoperative vasopressor requirements in patients given intraoperative magnesium {5g IV infusion over 20 min if SBP &amp;gt;170mmHg} with those not given magnesium therapy was made (using Chi-square test). A secondary outcome was to assess the development of new acute postoperative kidney injury (AKI) (eGFR &amp;lt;60 ml/min/1.73m2). Results Of the 89 CEA patients; 8 had incomplete data and 65% were over 70 years old. The Surgical Outcome Risk Tool (SORT) score identified 44 (53%) patients as high risk (&amp;gt;5% risk of perioperative mortality). There was no difference between the magnesium vs non-magnesium therapy groups postoperatively in vasopressor requirement. (p=0.38, X2=0.74) or AKI rates (n=14, 16.8%). Conclusion Organ perfusion and cardiac stability can be achieved perioperatively in CEA patients with magnesium therapy without increasing vasopressors requirement or renal impairment; making it a good first-line therapy for intraoperative hypertension.

Single-Center Experience With the Seraph-100® Microbind® Affinity Blood Filter in Patients With SARS-CoV-2 Infection and Septic Shock at a Military Treatment Facility.

Coronavirus disease 2019 (COVID-19) infection is characterized by a dysregulated inflammatory response, which may result in severe hemodynamic instability and septic shock. The Seraph-100® Microbind® Affinity Blood Filter is a commercially available extracorporeal pathogen absorbent device with the ability to bind pathogens and cytokines present within the blood. Our study aimed to evaluate the efficacy of the Seraph-100® for patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and septic shock. A retrospective review was performed to evaluate the use of the Seraph-100® blood filter at a Single Center tertiary-care facility at Brooke Army Medical Center from 2020 to 2021. Nine patients (11 treatments) were completed with the Seraph-100® blood filter in patients with SARS-CoV-2 infection and septic shock. The Seraph-100® blood filter was used in combination with continuous renal replacement therapy and slow low-efficiency dialysis or directly in parallel with the extracorporeal membrane oxygenation circuit. Within this cohort, there was a statistically significant improvement in the following clinical parameters comparing values to before and after treatment with the Seraph-100® blood filter: Mean arterial pressure (mmHg) (64.2 ± 2.36 vs. 76.2 ± 2.68; P < .001), heart rate (beats per minute) (128 ± 6.6 vs. 100.3 ± 6.07; P < .001), administered fraction of oxygen (%) (74.4 ± 10.58 vs. 60.3 ± 10.35; P < .001), serum lactate (mmol/L) (6.14 ± 1.25 vs. 2.8 ± 1.14; P = .0095), and pH (7.29 ± 0.03 vs. 7.39 ± 0.04; P = .0203). There were statistically significant improvements in vasopressor requirements: norepinephrine (mcg/min) (36.3 ± 4.74 vs. 8.3 ± 3.92; P < .001), vasopressin (units/min) (0.04 ± 0.004 vs. 0.02 ± 0.003; P < .001), dobutamine (mcg/kg/min) (2.3 ± 1.00 vs. 0.2 ± 0.75; P = .006) and angiotensin II (ng/kg/min) (34.5 ± 6.4 vs. 3.3 ± 5.26; P < .001). The use of the Seraph-100® blood filter was associated with statistically and clinically significant improvements in hemodynamic parameters and decreased vasopressor requirements in patients with septic shock and SARS-CoV-2 infection.

Association between dexmedetomidine administration and outcomes in critically ill patients with sepsis-associated acute kidney injury

Study objectiveTo investigate the association between dexmedetomidine administration and outcomes in critically ill patients with sepsis-associated acute kidney injury (SA-AKI). DesignA single-center, retrospective, cohort study. SettingIntensive care unit (ICU). PatientsA total of 2192 critically ill patients with SA-AKI were included in the analysis, which identified from the Medical Information Mart for Intensive Care (MIMIC-IV) database between 2008 and 2019. InterventionsIntravenous infusion of dexmedetomidine. MeasurementsThe primary outcome was recovery of renal function. In-hospital mortality, vasopressor requirements, length of ICU and hospital stay were considered secondary outcomes. The Cox proportional hazards, logistic regression, and linear regression models were used to assess the association between dexmedetomidine and outcomes. Propensity score matching (PSM) analysis was used to match patients receiving dexmedetomidine to those without treatment. Main resultsAfter PSM, 719 matched patient pairs were derived from patients who received dexmedetomidine and those who did not. The administration of dexmedetomidine was associated with a higher rate of renal recovery [61.8% vs. 55.8%, hazard ratio (HR) 1.35; P = 0.01], reduced in-hospital mortality [28.3% vs. 41.3%, HR 0.56; P < 0.001], and prolonged intensive care unit (ICU) stay [15.8d vs 12.6d, HR 2.34; P < 0.001] and hospital stay [23.7d vs 19.7d, HR 4.47; P < 0.001]. No significant difference was found in vasopressor requirements in patients with SA-AKI. Nevertheless, results illustrated that dose receiving between 0.30 and 1.00 μg/kg/h and duration using under 48 h of dexmedetomidine was associated with improvements in renal function recovery in SA-AKI patients. ConclusionDexmedetomidine administration was associated with improvements in renal function recovery and in-hospital survival in critically ill patients with SA-AKI. The results need to be verified in further randomized controlled trials.

Effect of Ketamine on Vasopressor Needs in Mechanically Ventilated Patients: A Retrospective Study

Background: Ketamine has many recognized effects that may be beneficial in patients undergoing mechanical ventilation. While ketamine provides sedation and analgesia, it has additional sympathomimetic properties that may help support critically ill patients in shock. We hypothesized patients undergoing mechanical ventilation with continuous ketamine infusion as an adjunct to sedation agents would be associated with a lower vasopressor requirement. Methods: We performed a retrospective cohort study on 200 mechanically-ventilated patients (205 hospital encounters) in two academic hospitals between 2015 to 2019. Patients on ketamine as an adjunct (K-G) to another sedative were utilized as the intervention group. Patients on both propofol and fentanyl (PF-G), a common sedation regimen, were used as the control group. The primary outcome was vasopressor requirements before and after initiation of ketamine or propofol and fentanyl. Secondary outcomes included all-cause mortality, 30-day mortality, ICU length-of-stay (LOS), hospital LOS, and ventilator-free days. Results: The overall proportion of males was 63.4% (p-value =0.5016). The norepinephrine average dose (up to 48 hours after initiating sedatives) was lower in K-G (8.7 mcg/kg/min) when compared with PF-G (14.2 mcg/kg/min), p-value&lt;0.0001. The ICU, 30-day or any time all-cause mortality was similar in both groups (22.0, 21.5 and 32.2%, p-value=0.8952, 0.9709, 0.8019, respectively). The average ICU and hospital stay overall were 8.8 (p-value=0.5174) and 16.6 (p-value=0.9280) days, respectively. The average ventilator-free days for K-G was 22.8 days compared to 23.2 days in PF-G (p-value=0.5567). Conclusions: In our study, ketamine as an adjunct sedation agent was associated with decreased vasopressor requirements in patients on mechanical ventilation when compared to the standard use of propofol and fentanyl. Further prospective research is necessary before ketamine can be broadly recommended as an adjunct to sedation in critically ill patients with shock.

Antihypertensive Medications Prior to Shock Onset Do Not Impact Initial Vasopressor Requirements in Patients With Shock

Purpose: The effect of the use of antihypertensive agents in patients prior to the development of shock is unclear. The purpose of this study was to determine the impact of antihypertensive agents on vasopressor dose and duration in shock. Materials and Methods: This retrospective, single-center study included patients with shock who received at least one vasopressor for at least 24 hours after shock onset from January 1 to June 30, 2017. Patients taking an antihypertensive agent(s) were compared to those who were not. The primary outcome was the number of vasopressor-free hours at 72 hours. Secondary outcomes included maximum and cumulative vasopressor doses, intensive care unit length of stay, and 30-day mortality. Results: One hundred and sixty-eight patients were included and 99 (59%) were on antihypertensives. Distributive shock was the most common type of shock (75.5%) and more patients taking antihypertensives had hypertension, coronary artery disease, and dyslipidemia at baseline. There was no difference in the number of vasopressor-free hours at 72 hours between patients taking an antihypertensive medication(s) and the control group (2 hours vs 1 hour; P = .11). No difference was found between any of the secondary outcomes. Conclusion: Patients taking antihypertensive agents prior to shock onset did not require increased vasopressor doses or duration.

Effects of thiamine on vasopressor requirements in patients with septic shock: a prospective randomized controlled trial

BackgroundThiamine, an essential vitamin for aerobic metabolism and glutathione cycling, may decrease the effects of critical illnesses. The objective of this study was to determine whether intravenous thiamine administration can reduce vasopressor requirements in patients with septic shock.MethodsThis study was a prospective randomized double-blind placebo-controlled trial. We included adult patients with septic shock who required a vasopressor within 1–24 h after admission between March 2018 and January 2019 at a tertiary hospital in Thailand. Patients were divided into two groups: those who received 200 mg thiamine or those receiving a placebo every 12 h for 7 days or until hospital discharge. The primary outcome was the number of vasopressor-free days over 7 days. The pre-defined sample size was 31 patients per group, and the study was terminated early due to difficult recruitment.ResultsSixty-two patients were screened and 50 patients were finally enrolled in the study, 25 in each group. There was no difference in the primary outcome of vasopressor-free days within the 7-day period between the thiamine and placebo groups (mean: 4.9 days (1.9) vs. 4.0 days (2.7), p = 0.197, mean difference − 0.9, 95% CI (− 2.9 to 0.5)). However, the reductions in lactate (p = 0.024) and in the vasopressor dependency index (p = 0.02) at 24 h were greater among subjects who received thiamine repletion vs. the placebo. No statistically significant difference was observed in SOFA scores within 7 days, vasopressor dependency index within 4 days and 7 days, or 28-day mortality.ConclusionsThiamine was not associated to a significant reduction in vasopressor-free days over 7-days in comparison to placebo in patients with septic shock. Administration of thiamine could be associated with a reduction in vasopressor dependency index and lactate level within 24 h. The study is limited by early stopping and low sample size.Trial registrationTCTR, TCTR20180310001. Registered 8 March 2018, http://www.clinicaltrials.in.th/index.php?tp=regtrials&menu=trialsearch&smenu=fulltext&task=search&task2=view1&id=3330.

The effect of dexmedetomidine on vasopressor requirements in patients with septic shock: a subgroup analysis of the Sedation Practice in Intensive Care Evaluation [SPICE\xa0III] Trial

BackgroundSeptic shock is associated with decreased vasopressor responsiveness. Experimental data suggest that central alpha2-agonists like dexmedetomidine (DEX) increase vasopressor responsiveness and reduce catecholamine requirements in septic shock. However, DEX may also cause hypotension and bradycardia. Thus, it remains unclear whether DEX is hemodynamically safe or helpful in this setting.MethodsIn this post hoc subgroup analysis of the Sedation Practice in Intensive Care Evaluation (SPICE III) trial, an international randomized trial comparing early sedation with dexmedetomidine to usual care in critically patients receiving mechanical ventilation, we studied patients with septic shock admitted to two tertiary ICUs in Australia and Switzerland. The primary outcome was vasopressor requirements in the first 48 h after randomization, expressed as noradrenaline equivalent dose (NEq [μg/kg/min] = noradrenaline + adrenaline + vasopressin/0.4).ResultsBetween November 2013 and February 2018, 417 patients were recruited into the SPICE III trial at both sites. Eighty-three patients with septic shock were included in this subgroup analysis. Of these, 44 (53%) received DEX and 39 (47%) usual care. Vasopressor requirements in the first 48 h were similar between the two groups. Median NEq dose was 0.03 [0.01, 0.07] μg/kg/min in the DEX group and 0.04 [0.01, 0.16] μg/kg/min in the usual care group (p = 0.17). However, patients in the DEX group had a lower NEq/MAP ratio, indicating lower vasopressor requirements to maintain the target MAP. Moreover, on adjusted multivariable analysis, higher dexmedetomidine dose was associated with a lower NEq/MAP ratio.ConclusionsIn critically ill patients with septic shock, patients in the DEX group received similar vasopressor doses in the first 48 h compared to the usual care group. On multivariable adjusted analysis, dexmedetomidine appeared to be associated with lower vasopressor requirements to maintain the target MAP.Trial registrationThe SPICE III trial was registered at ClinicalTrials.gov (NCT01728558).

Effect of Vitamin C, Hydrocortisone, and Thiamine vs Hydrocortisone Alone on Time Alive and Free of Vasopressor Support Among Patients With Septic Shock

Sepsis is associated with up to half of all in-hospital deaths. The administration of intravenous (IV) hydrocortisone, thiamine, and vitamin C has been suggested to improve mortality rates in patients with septic shock compared to those who received hydrocortisone alone, but the number of patients studied and the methods of previous studies have been scrutinized. The authors of this multi-center, randomized control trial aimed to determine if there is a significant difference in mortality and vasopressor requirements in patients with septic shock between hydrocortisone monotherapy and hydrocortisone therapy plus the addition of intravenous vitamin C and thiamine.

Vasopressor Requirement in Patients Undergoing Ventricular Assist Device Explant and Heart Transplant

Vasoplegia post ventricular assist device (VAD) explant and heart transplantation is a well recognised phenomenon. One potential reason for this is the continuous flow nature of current generation VADs. We were interested in exploring the quantity of vasopressor requirement in patients undergoing heart transplantation between three groups - VAD explant (VE), Non-VAD implant previous sternotomy (PS) and no previous sternotomy (NPS). We included 15 patients in each group for a total of 45 patients. Patients were retrospectively identified from our transplant database. We aimed to include our most recent transplants with 30-day outcome data available. Demographic, operative, and post-operative data was obtained from the medical records, operation reports and ICU charts. Statistical analysis was conducted using SPSS v25. There was no significant difference between the three groups in terms of Gender, Age, BMI, Pre-operative eGFR, Donor Ischaemic time, Donor Gender, Donor age or Donor BMI. Intraop blood transfusions were higher in the PS and VE groups compared to the NPS groups, p<0.01. There was no significant difference amongst the groups in terms of blood products. Median Cardiopulmonary bypass time was significantly higher in the PS (195 minutes IQR 139-239) and VE groups (213 minutes IQR 195-254) compared to the NPS groups, p=0.02. When comparing the VE and PS groups, there was no difference in cardiopulmonary bypass time, p=0.29. Milrinone was significantly higher at 24 hours in the VE group compared to the PS and NPS groups, p=0.02. At 48 hours, the VE group had a significantly higher median Epinephrine (13.5 ml/hr IQR 0-30) compared to the PS group (0 ml/hr IQR 0-6) and Median Milrinone (10 ml/hr IQR 4-12) vs 0 ml/hr (IQR 0-6.5). There was no significant difference amongst the three groups with respect to 30 Day mortality, ICU length of stay, ventilation time or overall hospital length of stay. From our data, we can conclude that the VE group had a higher vasopressor requirement than the NPS and PS groups at 48 Hours. Irrespective of these differences, there did not appear to be any difference in ICU length of stay and overall hospital length of stay amongst the three groups.

193 Vasopressor Requirement in Patients Undergoing Ventricular Assist Device Explant and Heart Transplant

193 Vasopressor Requirement in Patients Undergoing Ventricular Assist Device Explant and Heart Transplant

Mortality, Morbidity, and Costs After Implementation of a Vasopressin Guideline in Medical Intensive Care Patients With Septic Shock: An Interrupted Time Series Analysis.

Background: Vasopressin decreases vasopressor requirements in patients with septic shock. However, the optimal norepinephrine dose for initiation or cessation of vasopressin is unclear. Objective: Analyze monthly intensive care unit (ICU) mortality rates 1 year preimplementation and postimplementation of a guideline suggesting a norepinephrine dose of 50 µg/min or more for initiation of vasopressin and early cessation of vasopressin. Methods: This retrospective quasi-experimental study included adult patients with septic shock admitted to the medical ICU of a tertiary care medical center over 2 years. Time periods were evaluated with interrupted time series analysis. Results: A total of 1148 patients were included: 573 patients preguideline and 575 patients postguideline. Group characteristics were well balanced at baseline, except patients postguideline had higher sequential organ failure assessment scores. Postguideline, fewer patients were initiated on vasopressin (305 [53.2%] vs 217 [37.7%], absolute difference -15.5% [95% CI -21.2% to -9.8%]), and the norepinephrine dose at vasopressin initiation was higher (median 25 [interquartile range 18, 40] µg/min vs 40 [22, 52] µg/min; median difference 15 [95% CI 11 to 19] µg/min; P < 0.01). After guideline implementation, there was no evidence for a difference in ICU mortality rate slope (slope change 0.07% [95% CI -0.8% to 1.0%] per month; P 0.87), but the vasoactive cost level decreased by US$183 (95% CI -US$327 to -US$39) per patient immediately after implementation. Conclusion and Relevance: Implementation of a guideline suggesting a high norepinephrine dose threshold for vasopressin initiation and early vasopressin cessation in patients with septic shock appears to be safe and may decrease vasoactive costs.

Evaluation of Perfusion Index as a Predictor of Vasopressor Requirement in Patients with Severe Sepsis.

We evaluated the ability of perfusion index (PI) to predict vasopressor requirement during early resuscitation in patients with severe sepsis. All consecutive patients with clinically suspected severe sepsis as defined by the criteria of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference were included. Perfusion variables included PI, arterial lactate level, central venous oxygen saturation, and the difference between central venous carbon dioxide and arterial carbon dioxide pressures, and were recorded before resuscitation and 6 h thereafter. We enrolled 36 patients with severe sepsis. Twenty-one patients required vasopressors, whereas 15 did not. The cut-off of the PI value for predicting vasopressor requirement was ≤0.3. This cut-off value had a sensitivity of 100% and a specificity of 93%; the area under the curve was 0.96 (95% confidence interval 0.8-0.99, P < 0.0001). The cut-off of the arterial lactate level for predicting vasopressor requirement was ≥1.8 mg dL. This cut-off value had a sensitivity of 82% and a specificity of 80%; the area under the curve was 0.84 (95% confidence interval 0.68-0.94, P < 0.0001). Other perfusion variables failed to predict vasopressor requirement in patients with severe sepsis. We concluded that PI and arterial lactate level are good predictors of vasopressor requirement during early resuscitation in patients with severe sepsis. Further studies are warranted to investigate whether monitoring PI during resuscitation improves the outcome of patients with septic shock.

Plasma adrenomedullin is associated with short-term mortality and vasopressor requirement in patients admitted with sepsis

IntroductionThe incidence of death among patients admitted for severe sepsis or septic shock is high. Adrenomedullin (ADM) plays a central role in initiating the hyperdynamic response during the early stages of sepsis. Pilot studies indicate an association of plasma ADM with the severity of the disease. In the present study we utilized a novel sandwich immunoassay of bioactive plasma ADM in patients hospitalized with sepsis in order to assess the clinical utility.MethodsWe enrolled 101 consecutive patients admitted to the emergency department with suspected sepsis in this study. Sepsis was defined by fulfillment of at least two systemic inflammatory response syndrome (SIRS) criteria plus clinical suspicion of infection. Plasma samples for ADM measurement were obtained on admission and for the next four days. The 28-day mortality rate was recorded.ResultsADM at admission was associated with severity of disease (correlation with Acute Physiology and Chronic Health Evaluation II (APACHE II) score: r = 0.46; P <0.0001). ADM was also associated with 28-day mortality (ADM median (IQR): survivors: 50 (31 to 77) pg/mL; non-survivors: 84 (48 to 232) pg/mL; P <0.001) and was independent from and additive to APACHE II (P = 0.02). Cox regression analysis revealed an additive value of serial measurement of ADM over baseline assessment for prediction of 28-day mortality (P < 0.01). ADM was negatively correlated with mean arterial pressure (r = -0.39; P <0.0001), and it strongly discriminated those patients requiring vasopressor therapy from the others (ADM median (IQR): no vasopressors 48 (32 to 75) pg/mL; with vasopressors 129 (83 to 264) pg/mL, P <0.0001).ConclusionsIn patients admitted with sepsis, severe sepsis or septic shock plasma ADM is strongly associated with severity of disease, vasopressor requirement and 28-day mortality.

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Introduction: Etomidate inhibits the conversion of deoxycortisol to cortisol, which may suppress cortisol production for up to 24 hours after administration of a single dose and could exacerbate the vasodilatory state seen in the early post-operative period after cardiac surgery with cardiopulmonary bypass (CPB). Hypothesis: The objective of the study was to compare post-operative vasopressor requirements in cardiac surgery patients receiving etomidate (group E) to patients not receiving etomidate (group N) for induction of anesthesia. Methods: This prospective, single-center observational study evaluated adult patients undergoing cardiac surgery with CPB who required vasopressors post-operatively. Use of vasopressors was defined as a continuous infusion of any of the following: norepinephrine, dopamine, phenylephrine, epinephrine or vasopressin. Time on vasopressors was defined as the time from admission to the Cardiovascular ICU until the last vasopressors was discontinued for 24 consecutive hours. The Clinical Severity Score (CSS), a validated tool used to assess post-cardiac surgery morbidity and mortality based on admission data, was used to compare the groups at baseline. Results: Groups were similar when comparing age, gender, race, renal function, ejection fraction (EF), past medical history and pre-operative medication use. Group E had a significantly higher CSS compared to group N (5 vs. 3, respectively; p =.02). There was no significant difference in time spent on vasopressors between group E and group N (48 hours and 46 hours, respectively; p=0.16). The proportion of patients who required vasopressors for greater than 24 hours was also similar between the two groups (67% in group E vs. 49% in group N, p = 0.10). Conclusions: The results of this investigation in cardiac surgery patients demonstrate that the use of etomidate for induction does not appear to have an effect on vasopressor requirements after surgery. However, a larger, randomized trial evaluating the use of etomidate in cardiac surgery patients is needed to fully understand the effect of etomidate on vasopressor requirements in this patient population.

Does Etomidate Increase Vasopressor Requirements in Patients Needing Mechanical Ventilation?

Single-dose etomidate is used as an induction agent for rapid-sequence intubation and is associated with transient adrenal insufficiency. There is ongoing debate as to the clinical consequences of this transient adrenal insufficiency for critically ill patients. To determine if the use of etomidate is associated with higher requirements for a vasopressor, relative to other induction agents, at a single time point (24 h after administration of the induction agent) in patients needing mechanical ventilation. In this retrospective observational study utilizing electronic health records, a convenience sample of 50 patients who had undergone intubation in the emergency department with etomidate were matched (1:1) with patients who had received other induction agents. Matching was based on primary admitting diagnosis relating to the cause of shock, APACHE II (Acute Physiology and Chronic Health Evaluation II) score, age, and sex. All patients were subsequently admitted to critical care areas for management. As a surrogate marker of hemodynamic instability, the vasopressor dose was recorded 24 h after intubation. Vasopressor doses were converted to norepinephrine equivalents for comparison. The mean dose of vasopressors, in norepinephrine equivalents, was 4 μg/min(-1) for patients receiving etomidate and 3 μg/min(-1) for the control group (mean difference 0.7 μg min(-1), 95% confidence interval [CI] -1.9 to 3.2 μg min(-1), p = 0.61). Twelve of the patients in the etomidate group and 16 of those in the control group required the use of vasopressors at 24 h following intubation (odds ratio 2.3, 95% CI 0.53 to 13.99, p = 0.34). Single-dose etomidate does not adversely affect hemodynamic stability, as measured by the dose of vasopressors required at 24 h after administration.

The Effect of Antihypertensive Class on Intraoperative Pressor Requirements During Carotid Endarterectomy

Certain classes of antihypertensive drugs have been associated with intraoperative hypotension, and frequently, patients are receiving multiple classes of antihypertensive medications. We sought to determine whether one class of antihypertensive medication either alone, or in combination with other classes of antihypertensive medications, increased the probability of intraoperative hypotension, determined by the amount of vasopressor required during carotid endarterectomy (CEA) performed under general anesthesia with specific arterial blood pressure management. This is a post hoc analysis of 252 patients scheduled for elective CEA under general anesthesia, all of whom participated in a prospective evaluation of cognitive dysfunction. Patients were characterized by class and number of preoperative antihypertensive medications taken. A predetermined anesthetic regimen was administered to all patients, with a phenylephrine infusion titrated to maintain mean arterial blood pressure at baseline before clamping the carotid artery, and approximately 20% above baseline during clamping. Computerized anesthesia records were used to record hemodynamics and to quantify medication administered intraoperatively. Patients taking diuretics as part of their antihypertensive regimen required significantly more (1.6 times) total intraoperative phenylephrine than those not taking diuretics, independently of the number of other antihypertensive medications. This difference in the phenylephrine requirement occurs only during the preclamp period, i.e., from induction to application of carotid artery clamping for the maintenance of preoperative blood pressure. However, in contrast to this result, there is no difference in pressor requirement comparing classes of antihypertensive medications to increase the mean arterial blood pressure 20% above baseline during the period when the carotid artery is clamped. Diuretics are associated with increased vasopressor requirements in patients having a CEA under general anesthesia in the preclamp period, which is likely true for any patient having a general anesthetic.

Preoperative characteristics and intraoperative transfusion and vasopressor requirements in patients with low vs. high MELD scores

Recent changes in organ allocation based on the model for end-stage liver disease (MELD) prioritize the most ill patients on the waiting list for liver transplantation. While patients undergoing liver transplantation in the MELD era are more acutely ill, the impact of the policy changes on perioperative management has not been completely assessed. We retrospectively reviewed the records of 124 primary adult liver transplant patients. Patients were divided into low (< or = 30) and high MELD (>30) score groups. Preoperative characteristics and intraoperative management were compared between the 2 groups. Patients with high MELD scores had lower baseline hematocrit and fibrinogen levels and were more likely to require ventilatory and vasopressor support before transplantation. Intraoperative transfusion requirements and use of vasopressors were also significantly increased in patients with high MELD scores compared to patients with low MELD scores. In conclusion, these data suggest that pretransplant MELD scores provide important information for perioperative management of patients undergoing liver transplantation.