One-year mortality of hematopoietic stem cell recipients admitted to an intensive care unit in a dedicated Brazilian cancer center: a retrospective cohort study

ABSTRACT BACKGROUND: Hematopoietic stem cell transplantation (HSCT) recipients requiring intensive care unit (ICU) admission early after transplantation have a poor prognosis. However, many studies have only focused on allogeneic HSCT recipients. OBJECTIVES: To describe the characteristics of HSCT recipients admitted to the ICU shortly after transplantation and assess differences in 1-year mortality between autologous and allogeneic HSCT recipients. DESIGN AND SETTING: A single-center retrospective cohort study in a cancer center in Brazil. METHODS: We included all consecutive patients who underwent HSCT less than a year before ICU admission between 2009 and 2018. We collected clinical and demographic data and assessed the 1-year mortality of all patients. The effect of allogeneic HSCT compared with autologous HSCT on 1-year mortality risk was evaluated in an unadjusted model and an adjusted Cox proportional hazard model for age and Sequential Organ Failure Assessment (SOFA) at admission. RESULTS: Of the 942 patients who underwent HSCT during the study period, 83 (8.8%) were included in the study (autologous HSCT = 57 [68.7%], allogeneic HSCT = 26 [31.3%]). At 1 year after ICU admission, 21 (36.8%) and 18 (69.2%) patients who underwent autologous and allogeneic HSCT, respectively, had died. Allogeneic HSCT was associated with increased 1-year mortality (unadjusted hazard ratio, HR = 2.79 [confidence interval, CI, 95%, 1.48-5.26]; adjusted HR = 2.62 [CI 95%, 1.29-5.31]). CONCLUSION: Allogeneic HSCT recipients admitted to the ICU had higher short- and long-term mortality rates than autologous HSCT recipients, even after adjusting for age and severity at ICU admission.

Trends of vasopressor use in intensive care units in Colombia / Tendencias de consumo de vasopresores en unidades de cuidados intensivos de Colombia

Abstract Introduction Vasopressors are essential in the management of various types of shock. Objective To establish the trend of vasopressors use in the intensive care units (ICU) in a population of patients affiliated with the Colombian Health System, 2010-2017. Methods Observational trial using a population database of patients hospitalized in eleven ICUs in various cities in Colombia. The drugs dispensed to hospitalized patients over 18 years old, from January 2010 until December 2017 were considered. A review and analysis of the vasopressors dispensed per month was conducted, taking into account sociodemographic and pharmacological variables (vasopressor used and daily doses defined per 100/beds/day (DBD). Results 81,348 dispensations of vasopressors, equivalent to 26,414 treatments in 19,186 patients receiving care in 11 hospitals from 7 cities were reviewed. The mean age of patients was 66.3±18.1 years and 52.6 % were males. Of the total number of treatments recorded, 17,658 (66.8 %) were with just one vasopressor. Norepinephrine was the most frequently prescribed drug (75.9 % of the prescriptions dispensed; 60.5 DBD), followed by adrenaline (26.6 %; 41.6 DBD), dopamine (19.4%), dobutamine (16.0 %), vasopressin (8.5 %) and phenylephrine (0.9 %). The use of norepinephrine increased from 2010 to 2017 (+6.19 DBD), whilst the use of other drugs decreased, particularly the use of adrenaline (-60.6 DBD) and dopamine (-10.8 DBD). Conclusions Norepinephrine is the most widely used vasopressor showing a growing trend in terms of its use during the study period, which is supported by evidence in favor of its effectiveness and safety in patients with shock.

Resumen Introducción Los fármacos vasopresores son fundamentales en el manejo de los diferentes tipos de choque. Objetivo Determinar la tendencia de utilización de fármacos vasopresores en unidades de cuidados intensivos (UCI) en una población de pacientes afiliados al Sistema de Salud de Colombia, 2010-2017. Métodos Estudio observacional, a partir de una base de datos poblacional con pacientes hospitalizados en once UCI de diferentes ciudades de Colombia. Se obtuvieron las dispensaciones de pacientes mayores de 18 años hospitalizados desde enero de 2010 hasta diciembre de 2017. Se hizo revisión y análisis de la dispensación mensual de vasopresores. Se consideraron variables sociodemográficas y farmacológicas (medicamento vasopresor usado y dosis diarias definidas por 100 camas/día [DCD]). Resultados Se revisaron 81.348 dispensaciones de vasopresores, equivalentes a 26.414 terapias en 19.186 pacientes atendidos en 11 hospitales de 7 ciudades, cuya edad promedio fue 66,3±18,1 años y el 52,6 % eran hombres. Del total de terapias registradas, 17.658 (66,8 %) fueron con un solo vasopresor. La norepinefrina fue el más comúnmente prescrito (75,9 % de las dispensaciones; 60,5 DCD), seguido por adrenalina (26,6 %; 41,6 DCD), dopamina (19,4 %), dobutamina (16,0 %), vasopresina (8,5 %) y fenilefrina (0,9 %). El uso de norepinefrina se incrementó de 2010 a 2017 (+6,19 DCD), mientras que el de otros fármacos disminuyó, especialmente adrenalina (-60,6 DCD) y dopamina (-10,8 DCD). Conclusiones La norepinefrina es el fármaco vasopresor más utilizado y el que ha demostrado una tendencia de uso incremental durante el periodo de estudio, lo cual está respaldado por evidencia a favor de su efectividad y seguridad en pacientes con choque.

Tres casos consecutivos de gangrena seca en invierno / Three consecutive cases of dry gangrene in winter

Se presentan tres casos de gangrena seca ocurridos en el invierno austral del 2018. El primero corresponde a un varón de 37 años, portador de vasculitis por crioglobulinemia y enfermedad celiaca silente, que desarrolla gangrena seca en manos y pies. El segundo es una mujer de 40 años que consulta por gangrena seca de manos y pies, sin etiología demostrable. El tercero es un varón de 38 años que ingresa por choque séptico de origen neumónico que requiere tratamiento con vasopresores desarrollando gangrena seca de manos y pies. A pesar que los tres casos tienen etiología diferente, coincidieron con temperaturas muy frías (media 6° C), inusuales para el clima tropical del Paraguay.

We present three cases of dry gangrene occurred in the southern winter of 2018. The first corresponds to a 37-year-old man, carrier of vasculitis due to cryoglobulinemia and silent celiac disease, which develops dry gangrene in hands and feet. The second is a 40-year-old woman who consults for dry gangrene of hands and feet, without demonstrable etiology. The third is a 38-year-old male admitted for septic shock of pulmonary origin that requires treatment with vasopressors developing dry gangrene of the hands and feet. Although the three cases have a different etiology, they coincided with very cold temperatures (average 6 °C), unusual for the tropical climate of Paraguay.

Central venous pressure value can assist in adjusting norepinephrine dosage after the initial resuscitation of septic shock / 中华医学杂志(英文版)

Background:@#New definitions for sepsis and septic shock (Sepsis-3) were published, but the strategy to adjust vasopressors after the initial guidelines is still unclear. We conducted a retrospective observational study to explore dosing strategy of norepinephrine (NE).@*Methods:@#A retrospective observational study in the 15-bed mixed intensive care unit of a tertiary care university hospital. The study was performed on septic shock patients after 30 mL/kg fluid resuscitation and mean arterial pressure (MAP) levels reached >65 mmHg requiring NE. We divided patients into NE dosage increase and decrease groups, and collected hemodynamic and tissue perfusion parameters before (T1) and after (T2) adjusting NE dosage.@*Results:@#In both NE increase and decrease groups, central venous pressure (CVP) and pressure difference between usual MAP and MAP (dMAP) at the T1 time point were associated with lactate clearance. In groups LC HM (CVP <10 mmHg, dMAP > 0 mmHg) and HC HM (CVP ≥ 10 mmHg, dMAP > 0 mmHg), decrease in NE dosage decreased lactate level, while in group HC LM (CVP ≥ 10 mmHg, dMAP≤0 mmHg), both increase and decrease in NE dosage led to increase lactate level.@*Conclusions:@#After patients with septic shock (Sepsis-3) resuscitated to reach the initial recovery target goals, combination of CVP and MAP refer to usual levels can help doctors make the next decision to make the correct choice of increase NE dosage or decrease NE dosage.

Puntaje LVIS como predictor de mortalidad en choque séptico / LVIS as mortality predictor in septic shock / Pontuação LVIS como preditor de mortalidade em choque séptico

Resumen: Introducción: El uso de vasopresores en choque séptico es parte fundamental del tratamiento. El uso de un puntaje que integre los múltiples vasopresores e inotrópicos como LVIS (levosimendan vasopressor inotropic score), puede ser de utilidad para el seguimiento y pronóstico de estos pacientes. Se ha estudiado en población pediátrica y no ha sido validada en población adulta. Material y métodos: Estudio retrospectivo, longitudinal, retrolectivo en pacientes adultos admitidos a UCI con diagnóstico de choque séptico con el fin de investigar si el puntaje LVIS es capaz de predecir mortalidad y lesión renal aguda. Seguimiento a 30 días. Resultados: Incluimos 77 pacientes, 24 (21.2%) pacientes murieron y 41 (53.23%) presentaron lesión renal aguda. Se observó un AUC (área bajo la curva) para LVIS 0.89 con un punto de corte de 21.3 (sensibilidad 50% y especificidad de 82%). El puntaje LVIS > 21.3 con RR 2.09 (IC95% 1.15-3.7, p = 0.003) y un HR de 3.8 (IC95% 1.5-9.3, p = 0.003), LR+ 2.81 y LR- 0.61 para mortalidad. LVIS no fue significativo para predecir LRA (lesión renal aguda). Conclusiones: LVIS es útil para predecir mortalidad en choque séptico, con un punto de corte 21.3. Es necesario continuar estudios para validarlo en población adulta con otras formas de choque.

Abstract: Introduction: Vasopressors have a fundamental roll in the treatment of septic shock. LVIS (levosimendan vasopressor inotropic score) as a score that integrates the main vasopressors and inotropic drugs may be useful for monitoring and prognosis. It's been studied in pediatric population, but not validated in adult patients so far. Material and methods: Retrospective, longitudinal, retrolective study in adults admitted in ICU with septic shock. We looked to investigate if LVIS score is useful to predict mortality and acute kidney injury in ICU, with a follow-up of 30 days. Results: We included 77 patients, 24 (21.2%) patients died and 41 (53.23%) developed acute kidney injury. LVIS had an AUC of 0.89 with a cut-off of 21.3 (50% sensitivity and 82% of specificity). LVIS score above the cut-off 21.3, had RR 2.09 (CI95% 1.15-3.7, p = 0.003), HR de 3.8 (CI 1.5-9.3, p = 0.003), LR+ 2.81 and LR- 0.61 for mortality. LVIS could not predict AKI (acute kidney). Conclusions: LVIS score is useful to predict mortality in patients with septic shock, with a cut-off of 21.3. More research is left to be done to validate this score in other forms of shock in adult population.

Resumo: Introdução: O uso de vasopressores no choque séptico é uma parte fundamental do tratamento. O uso de um escore que integra múltiplos vasopressores e drogas inotrópicas como o LVIS (Levosimendan Vasopressor Inotropic Score), pode ser útil para o acompanhamento e prognóstico desses pacientes. Foi estudado na população pediátrica e não foi validado na população adulta. Material e métodos: Estudo retrospectivo, longitudinal, retrolectivo em pacientes adultos admitidos na UTI com o diagnóstico de choque séptico para investigar se o escore LVIS é capaz de predizer a mortalidade e a lesão renal aguda em um acompanhamento de 30 dias. Resultados: Foram incluídos 77 pacientes, 24 (21.2%) pacientes morreram e 41 (53.23%) apresentaram lesão renal aguda. Uma AUC (área sob a curva) foi observada para LVIS 0.89 com um ponto de corte de 21.3 (sensibilidade 50% e especificidade 82%). O escore LVIS > 21.3 com RR 2.09 (IC95% 1.15-3.7, p = 0.003) e uma HR de 3.8 (IC95% 1.5-9.3, p = 0.003), LR + 2.81 e LR -0.61 para mortalidade. O LVIS não foi significativa na predição da LRA (lesão renal aguda). Conclusões: O LVIS é útil para prever a mortalidade no choque séptico, com um ponto de corte de 21.3. É necessário continuar os estudos para validá-lo na população adulta com outras formas de choque.

Vasopresores e inotrópicos: uso en pediatría / Vasopressors and inotropes: use in paediatrics

Resumen: El sistema cardiovascular es un sistema dinámico cuya función es asegurar un adecuado suministro de oxígeno, nutrientes y hormonas a los tejidos, necesarios para el metabolismo celular, además sintetiza y modifican los componentes vasoactivos los cuales regulan el tono vascular y la función miocárdica. Estos componentes vasoactivos son fundamentales en el manejo del paciente pediátrico en estado crítico con falla cardiaca y choque en los cuales se ha comprobado sus efectos benéficos, sin embargo, su uso y abuso trae consigo efectos nocivos, tales como mayor riesgo de arritmias, aumento el consumo miocárdico de oxígeno lo cual podría favorecer la presencia de isquemia. Por lo tanto, es preciso conocer el mecanismo de acción de los distintos tipos de agentes vasoactivos, así como las indicaciones de dichos fármacos para minimizar dichos efectos. El propósito de esta revisión es describir la farmacología y las aplicaciones clínicas de los agentes inotrópicos y Vasopresores en el paciente pediátrico en estado crítico. © 2017 Instituto Nacional de Cardiolog´ıa Ignacio Cha´vez. Publicado por Masson Doyma Me´xico S.A. Este es un art´ıculo Open Access bajo la licencia CC BY-NC-ND (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Abstract: The cardiovascular system is a dynamic system, which is required to ensure adequate delivery of oxygen, nutrients, and hormones to the tissues that are necessary for cell metabolism. It also synthesises and modifies the vasoactive components that regulate vascular tone and myocardial function. These vasoactive components have demonstrated their beneficial effects in the management of paediatric patients in a critical condition with heart failure and shock. However, their use and abuse brings harmful effects, increases mortality, and is associated with arrhythmias. An increase in myocardial oxygen consumption favours the presence of ischaemia, therefore it is necessary to know the mechanism of action and indications of these drugs to minimise their harmful effects. The purpose of this review is to describe the pharmacology and clinical applications of inotropic and vasopressor agents in the paediatric patient in acritical condition. © 2017 Instituto Nacional de Cardiologìa Ignacio Chàvez. Published by Masson Doyma Mèxico S.A. This is an open access article under the CC BY-NC-ND license (http://creativecommons. org/licenses/by-nc-nd/4.0/).

Whether catecholamines have beneficial effects on splanchnic perfusion / 中国小儿急救医学

The majority of vasoactive agents in clinical use are catecholamines,which are major vas-opressors and/or inotropes in shock.While the primary goal in treating shock is to maintain tissue perfusion and oxygenation.The question of the ideal vasoactive agent in a shock patient remains controversial and unan-swered. This article focused on whether catecholamines,such as norepinephrine,dopamine,dobutamine, epinephrine,norepinephrinecombined withdobutamine or epinephrine,have beneficial effects on splanchnic perfusion.

Selection and receptor distribution characteristics of vasoactive/inotropic agents / 中国小儿急救医学

Vasoactive medications in clinical use exert their cardiovascular effects by interacting with adrenergic receptors and non-adrenergic receptors,including vasopressors,inotropes and vasodilators.A classi-fication of vasoactive drugs based on their direct effects on the heart(presence or absence of positive inotropic effects) and on vascular tone(vasoconstriction or vasodilation) include inodilators(dobutamine and milri-none),inoconstrictors(norepinephrine,epinephrine,and dopamine),pure vasoconstrictors(phenylephrine and vasopressin) and pure vasodilators(sodium nitroprusside).Selection of vasoactive medications based on de-sired pharmacologic effects that are matched to the patient′s underlying pathophysiology situation may opti-mize hemodynamics while reducing the potential of adverse effects.

Norepinefrina vs etilefrina como prevención de hipotensión materna en cesárea bajo anestesia raquídea / Norepinephrine and Etilefrin as prevention of maternal hypotension in cesarean section under spinal anesthesia

INTRODUCCIÓN: En Bolivia existe dificultad en la disponibilidad del medicamento como es la fenilefrina, surge la inmediata necesidad de evaluar otro medicamento con características farmacológicas que son útiles para este fin. OBJETIVOS: Comparar el uso de norepinefrina versus etilefrina como prevención de hipotensión materna posterior a anestesia raquídea en cesárea electiva. MÉTODOS: Se realizó un ensayo clínico randomizado, doble ciego, en 126 pacientes sometidas a cesárea bajo anestesia raquídea divididas en tres grupos de 42 pacientes. Grupo E recibió Etilefrina bolo 2mg, grupo Norepinefrina Bolo (NB) 5µg y grupo Norepinefrina en Infusión (NI) 0,01µg/kg/min para controlar la hipotensión, se realizó control de presión arterial media, frecuencia cardiaca, análisis de costo del medicamento y puntuaciones de APGAR. El análisis estadístico se realizó en SPSS 22 y Microsoft Exce® 2010. RESULTADOS: La presión arterial media fueron similares hasta antes del nacimiento, posterior es mejor controlado con la infusión de norepinefrina (p 0,000). La frecuencia cardiaca más estable en el grupo de NB (p 0,000). No presentó efectos adversos maternos y en el recién nacido. Se evidencia un costo más elevado a usar Etilefrina en bolo 42,5 ± 8,36 (bolivianos) que usar norepinefrina en infusión 0,50 ± 0,15 (bolivianos) y norepinefrina en bolo 0,45 ± 0,14 (bolivianos) existe una diferencia estadísticamente significativa (p 0,000). CONCLUSIONES: Es eficaz la utilización de norepinefrina en infusión en comparación a etilefrina debido a que se controló mejor las variables hemodinámicas con un costo muy bajo para el manejo de la hipotensión materna posterior a anestesia raquídea.

INTRODUCTION: In Bolivia there is the difficulty on availability of the drug such as phenylephrine, there is the immediate need to evaluate another drug with pharmacological characteristics that are useful for this purpose OBJETIVE: To compare the use of norepinephrine versus etilefrine as prevention of maternal hypotension after spinal anesthesia in elective cesarean section. METHODS: Was conducted a randomized double-blind clinical trial in 126 patients undergoing Cesarean section under spinal anesthesia divided into three groups of 42 patients. Group E received Etilefrine bolus 2 mg, group NB norepinephrine bolus 5 µg and group NI norepinephrine infusion 0,01µg /kg/min to control hypotension control of mean arterial pressure, heart rate, were performed an analysis of drug cost and scores of APGAR. Was performed the statistical analysis in SPSS 22 and Microsoft Excel 2010. RESULTS: Mean arterial blood pressure was similar until before birth, later it is better controlled with norepinephrine infusion (p 0,000). The most stable heart rate in the NB group (p 0,000). There were maternal adverse effects and in the newborn. There is a higher cost to use bolus ethylephrine 42.5 ± 8.36 (bolivianos) than to use norepinephrine in infusion 0.50 ± 0.15 (bolivianos) and bolus norepinephrine 0.45 ± 0.14 (bolivianos) there is a statistically significant difference (p 0,000). CONCLUSIONS: The use of norepinephrine in infusion compared to etilefrine is effective because the hemodynamic variables were better controlled at a very low cost for the management of maternal hypotension after spinal anesthesia.

Nutrición enteral en el paciente hemodinámicamente inestable. ¿Qué nos dice la evidencia actual? / Enteral nutrition in the patient hemodynamically unstable What the evidence tells us current?

Los beneficios de la nutrición enteral, especialmente de la nutrición enteral precoz, están documentados. Sin embargo, aún existen controversias al momento de decidir el inicio del soporte nutricional por esta vía en pacientes críticos hemodinámicamente inestables, que están recibiendo agentes vasopresores o inotrópicos. La experiencia clínica en seres humanos sugiere que la provisión de nutrición enteral después de un período de hipotensión puede reducir la lesión o el grado de isquemia del intestino delgado. Sobre la base de la evidencia, el inicio cauteloso de la nutrición enteral con sustancias vasoactivas es posible y seguro. No obstante, se necesitan más estudios para poder profundizar en los aspectos relativos al inicio y la implementación del soporte nutricional.(AU)

Benefits of enteral nutrition, especially early enteral nutrition, have been well documented. However, there are still controversies when deciding the initiation of nutritional support by this route in critical hemodynamically unstable patients who are receiving vasopressor or inotropic drugs. Clinical experience in humans suggests that provision of enteral nutrition after a period of hypotension may reduce injury or the extent of small bowel ischemia. Based on the evidence, cautious onset of enteral nutrition with vasoactive substances is possible and safe. However, more studies are needed to know the aspects related to the initiation and implementation of nutritional support. (AU)

Microcirculation improvement after short-term infusion of vasopressin in septic shock is dependent on noradrenaline

OBJECTIVES: To assess the impact of vasopressin on the microcirculation and to develop a predictive model to estimate the probability of microcirculatory recruitment in patients with septic shock. METHODS: This prospective interventional study included patients with septic shock receiving noradrenaline for less than 48 hours. We infused vasopressin at 0.04 U/min for one hour. Hemodynamic measurements, including sidestream dark-field imaging, were obtained immediately before vasopressin infusion, 1 hour after vasopressin infusion and 1 hour after vasopressin withdrawal. We defined patients with more than a 10% increase in total vascular density and perfused vascular density as responders. ClinicalTrials.gov: NCT02053675. RESULTS: Eighteen patients were included, and nine (50%) showed improved microcirculation after infusion of vasopressin. The noradrenaline dose was significantly reduced after vasopressin (p=0.001) and was higher both at baseline and during vasopressin infusion in the responders than in the non-responders. The strongest predictor for a favorable microcirculatory response was the dose of noradrenaline at baseline (OR=4.5; 95% CI: 1.2-17.0; p=0.027). For patients using a noradrenaline dose higher than 0.38 mcg/kg/min, the probability that microcirculatory perfusion would be improved with vasopressin was 53% (sensitivity 78%, specificity 77%). CONCLUSIONS: In patients with septic shock for no longer than 48 h, administration of vasopressin is likely to result in an improvement in microcirculation when the baseline noradrenaline dose is higher than 0.38 mcg/kg/min.

Los mitos en torno de la relación entre presión sanguínea y flujo / Myths surrounding the relationship between blood pressure and flow

La hipotensión asociada con la vasodilatación inducida por el uso de agentes anestésicos es muy frecuente, un fenómeno que ha motivado la utilización casi generalizada de vasopresores, con la finalidad de restaurar la presión sanguínea a los niveles registrados antes de la anestesia. En Australia, entre todas las medicaciones que se usan en la anestesia, el costo de los vasopresores es un factor significativo en los costos de los sistemas de salud. La utilización de vasopresores debe basarse en los posibles beneficios y riesgos asociados. Desde hace tiempo se acepta que la presión arterial debe mantenerse con la finalidad de preservar la perfusión. Sin embargo, la evaluación detallada indica que este concepto podría surgir de la interpretación errónea de las leyes básicas de la física, como las leyes de Newton y de Ohm. En este trabajo se propone, en función de los principios de la física, que sólo las fuerzas pueden motivar el aceleramiento de los objetos. Para que la presión sea un conductor del flujo, debería ser una fuerza. Sin embargo, la presión es el resultado de fuerzas que actúan sobre una superficie determinada y, por ende, no representa en sí misma una fuerza y no puede ser un conductor de flujo. El flujo sanguíneo es resultado del equilibrio entre las fuerzas de propulsión y de resistencia; en este contexto se debe reconsiderar el supuesto beneficio de aumentar las fuerzas de resistencia, un fenómeno que, en realidad, motivará una reducción del flujo. En el estudio se cuestiona el uso de vasopresores, como también la relación básica, ampliamente aceptada, entre la presión sanguínea y el flujo sanguíneo.

Hypotension resulting from vasodilatation associated with administration of anaesthetic agents is very common. This has resulted in the almost ubiquitous use of vasopressors with a view to restoring blood pressure to pre-anaesthesia levels. In Australia, of all the medications used in anaesthesia, the cost of vasopressors is a significant factor in contributing to healthcare costs. The rationale for use of vasopressors warrants consideration with regard to their benefits as well as potential harm arising from their use. It has long been accepted that blood pressure needs to be maintained in order to maintain perfusion. However, on close scrutiny such thinking may simply be a misinterpretation of the basic laws of physics with respect to both Newton's laws and Ohm's law. This article develops the physics-based argument that only forces can cause objects to accelerate. For pressure to be a driver of flow it must therefore be a force. However, pressure is the result of forces acting over an area, and consequently is not a force in itself. Therefore, it cannot be a driver of flow. Blood flow is the result of the balance of propulsive and resistive forces, which raises the question as to the benefit of increasing resistive forces, which in fact will reduce flow. The use of vasopressors is challenged in this article as is the basic accepted relationship between blood pressure and blood flow.

Relación entre consumo crónico de betabloqueadores y mortalidad en sepsis y choque séptico / Relationship between chronic beta-blockers usage and mortality in sepsis and septic shock / A relação entre o consumo crônico de betabloqueadores e mortalidade em sepse e choque séptico

Resumen: Se ha considerado que los betabloqueadores pueden reducir la sobreestimulación adrenérgica en pacientes sépticos. Se diseñó este estudio retrospectivo de casos y controles para identificar la relación del consumo crónico de betabloqueadores en pacientes que desarrollaron sepsis y choque séptico tratados en UTI y la mortalidad a 30 días. Se incluyeron 104 pacientes dividiéndose en dos grupos: betabloqueadores (n = 16) y control (n = 88). Los pacientes del grupo de estudio no presentaron diferencia de mortalidad en relación con el control (p = 0.99); sin embargo, el SOFA cardiovascular fue mayor (p = 0.05), requirieron mayor dosis de vasopresores (p = 0.18) y mayor tiempo de estancia en UTI (p = 0.11). El consumo crónico de betabloqueadores no fue factor de protección para mortalidad en pacientes sépticos.

Abstract: It has been considered that beta-blockers are used to reduce adrenergic overstimulation in septic patients. Therefore, we designed a case-control study to identify if chronic use of beta-blockers is related to less 30-day mortality among septic patients. We review medical records of ICU admission. In total, we included 104 patients divided into two groups: beta-blockers (n = 16) and control (n = 88). Patients in the study group showed no difference in mortality relative to control (p = 0.99), however the cardiovascular SOFA was higher (p = 0.05), required higher dose of vasopressors (p = 0.18) and longer stay in UTI (p = 0.11). The chronic use of beta-blockers was not protective factor for mortality in septic patients.

Resumo: Considerou-se que os betabloqueadores podem reduzir a superestimulação adrenérgica em pacientes sépticos. Assim, desenhou-se um estudo retrospectivo de caso e controle para identificar a relação de consumo crônico de betabloqueadores em pacientes que desenvolveram septicemia e choque séptico tratados na UTI e mortalidade aos 30 dias. Foram incluídos 104 pacientes divididos em dois grupos: betabloqueadores (n = 16) e de controle (n = 88). Os pacientes no grupo do estudo não demonstraram diferença na mortalidade em relação ao grupo de controle (p = 0.99), no entanto o SOFA cardiovascular foi maior (p = 0.05), necessitaram uma dose mais elevada de vasopressores (p = 0.18) e maior tempo de UTI (p = 0.11). O consumo crónico de betabloqueadores não foi o fator de proteção para a mortalidade em pacientes sépticos.

Risk Factors for Acute Kidney Injury after Orthotopic Liver Transplantation: A Single-center Data Analysis / 华中科技大学学报（医学）（英德文版）

Acute kidney injury (AKI) is a common complication following orthotopic liver transplantation (OLT) and is associated with increased morbidity and mortality.The aim of the current study was to determine the risk factors for AKI in patients undergoing OLT.A total of 103 patients who received OLT between January 2015 and May 2016 in Tongji Hospital,China,were retrospectively analyzed.Their demographic characteristics and perioperative parameters were collected,and AKI was diagnosed using 2012 Kidney Disease:Improving Global Outcomes (KDIGO) staging criteria.It was found that the incidence of AKI was 40.8％ in this cohort and AKI was significantly associated with body mass index,urine volume,operation duration (especially ＞ 480 min),and the postoperative use of vasopressors.It was concluded that relative low urine output,long operation duration,and the postoperative use of vasopressors are risk factors for AKI following OLT.

Prognosis of patients with shock receiving vasopressors / 世界急诊医学杂志（英文）

BACKGROUND: Consensus guidelines suggested that both dopamine and norepinephrine may be used, but specific doses are not recommended. The aim of this study is to determine the predictive role of vasopressors in patients with shock in intensive care unit.METHODS: One hundred and twenty-two patients, who had received vasopressors for 1 hour or more in intensive care unit (ICU) between October 2008 and October 2011, were included.There were 85 men and 37 women, with a median age of 65 years (55-73 years). Their clinical data were retrospectively collected and analyzed.RESULTS: The median simplified acute physiological score 3 (SAPS 3) was 50 (42-55). Multivariate analysis showed that septic shock (P=0.018, relative risk: 4.094; 95% confi dential interval: 1.274-13.156), SAPS 3 score at ICU admission (P=0.028, relative risk: 1.079; 95% confidential interval: 1.008-1.155), and norepinephrine administration (P<0.001, relative risk: 9.353; 95% confidential interval: 2.667-32.807) were independent predictors of ICU death. Receiver operating characteristic curve analysis demonstrated that administration of norepinephrine ≥0.7 μg/kg per minute resulted in a sensitivity of 75.9% and a specifi city of 90.3% for the likelihood of ICU death. In patients who received norepinephrine ≥0.7 μg/kg per minute there was more ICU death (71.4% vs. 44.8%) and in-hospital death (76.2% vs. 48.3%) than in those who received norepinephrine <0.7 μg/kg per minute. These patients had also a decreased 510-day survival rate compared with those who received norepinephrine <0.7 μg/kg per minute (19.2% vs. 64.2%).CONCLUSION: Septic shock, SAPS 3 score at ICU admission, and norepinephrine administration were independent predictors of ICU death for patients with shock. Patients who received norepinephrine ≥0.7 μg/kg per minute had an increased ICU mortality, an increased in-hospital mortality, and a decreased 510-day survival rate.

Clinical Review: Management of weaning from cardiopulmonary bypass after cardiac surgery.

A sizable number of cardiac surgical patients are difficult to wean off cardiopulmonary bypass (CPB) as a result of structural or functional cardiac abnormalities, vasoplegic syndrome, or ventricular dysfunction. In these cases, therapeutic decisions have to be taken quickly for successful separation from CPB. Various crisis management scenarios can be anticipated which emphasizes the importance of basic knowledge in applied cardiovascular physiology, knowledge of pathophysiology of the surgical lesions as well as leadership, and communication between multiple team members in a high-stakes environment. Since the mid-90s, transoesophageal echocardiography has provided an opportunity to assess the completeness of surgery, to identify abnormal circulatory conditions, and to guide specific medical and surgical interventions. However, because of the lack of evidence-based guidelines, there is a large variability regarding the use of cardiovascular drugs and mechanical circulatory support at the time of weaning from the CPB. This review presents key features for risk stratification and risk modulation as well as a standardized physiological approach to achieve successful weaning from CPB.

Drogas vasopressoras nos estados choque: qual é a melhor opção? / Vasopressors drugs in the shock state: which is the best option?

JUSTIFICATIVA E OBJETIVOS: Apesar da terapia com fármacos vasopressores ser usada há décadas, poucos ensaios clínicos comparam os diferentes tipos utilizados nos diferentes tipos de choque. O objetivo deste estudo foi rever os principais estudos publicados, nas ultimas décadas, para orientação quanto à escolha da melhor droga vasopressora nos diferentes estados de choque. CONTEÚDO: Foram selecionados artigos na base de dados MedLine (1950-2008), por meio das palavras-chave: drogas vasoativas, drogas vasopressoras e choque. Adicionalmente, referências desses artigos, capítulos de livros e artigos históricos foram avaliados para esta revisão. Foram identificados e revisados 160 artigos. Foram considerados ensaios clínicos da língua inglesa, estudos retrospectivos e artigos de revisão. Os artigos foram avaliados por análise de método e determinação de limitações de desenho. Por não se tratar de uma metanálise, mas sim de uma revisão descritiva, serão apresentadas as conclusões mais relevantes dos principais estudos e metanálises encontrados nessa revisão, sem a interferência direta da análise pessoal dos autores deste estudo. CONCLUSÕES: O uso de drogas vasopressoras nos estados de choque permanece controverso. A escolha de uma droga específica para determinado tipo de choque permanece aberta. Existem várias drogas vasopressoras que podem ser utilizadas, inclusive em combinação na terapêutica dos pacientes em estado de choque. Estudos clínicos aleatórios têm sido realizados na tentativa de aperfeiçoar a evidência do uso de drogas vasoativas. Esta permanece ainda uma questão sem sólidas e robustas respostas baseadas em evidências. Descritores: drogas vasopressoras, estado de choque.(AU)

BACKGROUND AND OBJECTIVES: Despite treatment with drugs vasopressors are used for decades, few clinical trials comparing the different types and drugs used in different types of shock. This study aimed at reviewing the major articles published, in recent decades, for guidance on choosing the best vasopressor drugs in different state of shock. CONTENTS: Were selected articles in the database Med- Line (1950-2008), using the keywords: vasoactive drugs, drugs vasopressors and shock. Additionally, references of these articles, chapters of books and historical articles were evaluated for this review. Were identified and reviewed 160 articles. We considered clinical trials of English, retrospective studies and reviews. The articles were evaluated by analysis of method and determination of limitations of design. It is not a meta-analysis, but a descriptive review, will be presenting the findings most relevant of the major studies and meta from this review, without the interference of direct personal analysis of the authors of this study. CONCLUSION: The use of drugs vasopressors in the states of shock remains controversial. The choice of a drug specifically for a particular type of shock remains open. There are several drugs vasopressors that can be used, even in combination in therapeutic for patients in shock. Randomized clinical trials have been conducted in an attempt to optimize the evidence of the use of vasoactive drugs. This still remains an issue without solid and robust response based on evidence.(AU)

Efeitos hemodinâmicos e metabólicos da infusão de vasopressina em crianças com choque: [revisão] / Hemodynamic and metabolic effects of vasopressin infusion in children with shock: [review]

OBJETIVO: A vasopressina é um hormônio neuropeptídico utilizado clinicamente há mais de 50 anos, com papel importante na homeostase circulatória e na regulação da osmolalidade sérica. Seu papel no tratamento do choque vem recebendo ênfase recentemente. Foram revisadas a fisiologia deste neuro-hormônio e as evidências disponíveis para sua utilização no contexto de choque com vasodilatação na criança. FONTES DOS DADOS: MEDLINE, usando os termos vasopressin, vasodilation, shock, septic shock, e sinônimos e termos relacionados, além de publicações clássicas referentes ao tema, sendo escolhidas as mais representativas. SÍNTESE DOS DADOS: A vasopressina é sintetizada na neuro-hipófise e liberada em resposta à diminuição da volemia ou ao aumento da osmolalidade plasmática. A ação da vasopressina dá-se pela ativação de vários receptores acoplados à proteína G, os quais são classificados, de acordo com sua localização e rotas de transmissão intracelular, em receptores V1 (ou V1b), V2 e V3 (ou V1b) e por receptores de ocitocina. A função central da vasopressina é causar vasoconstrição, embora, em determinados órgãos, possa promover vasodilatação seletiva. Diversos estudos clínicos em adultos e crianças apontam efeitos benéficos e seguros da vasopressina no tratamento do choque com vasodilatação por diversas causas. CONCLUSÃO: As evidências são restritas, os estudos na maioria são retrospectivos e com número reduzido de pacientes, mas já há uma experiência bastante significativa no que diz respeito a seu uso em pediatria. A vasopressina possui um efeito clinico benéfico na criança e pode ser indicada no tratamento do choque refratário com vasodilatação, depois de adequada reposição volêmica e quando altas doses de outros vasopressores não foram eficazes.

OBJECTIVE:Vasopressin is a neuropeptide hormone which has been used clinically for more than 50 years and plays a major role in circulatory homeostasis and in the regulation of serum osmolality. Recent work has emphasized its role in the treatment of septic shock. This paper reviews the physiology of this neurohormone and the available evidence in favor of its use as a vasodilator for children in shock. SOURCES: MEDLINE, using the terms vasopressin, vasodilation, shock and septic shock, plus synonyms and related terms. Classic publications on the topic were also reviewed and selected depending on their relevance to the study objectives. SUMMARY OF THE FINDINGS: Vasopressin is synthesized in the neurohypophysis and released in response to a decrease in plasma volume or an increase in serum osmolality. The action of vasopressin is mediated by the activation of oxytocin receptors and of several G protein-coupled receptors, which are classified according to their location and intracellular transmission routes as V1 receptors (or V1b), V2 and V3 receptors (or V1b). The main role of vasopressin is to induce vasoconstriction. However, in certain organs, it can also induce selective vasodilation. Several clinical studies in adults and children have reported that the effects of vasopressin for the treatment of vasodilatory septic shock, due to a variety of causes, are both beneficial and safe. CONCLUSIONS: The evidence is restricted. Most studies are retrospective and include a small number of patients. Nevertheless, there is significant experience concerning the use of vasopressin in Pediatrics. Vasopressin has a beneficial clinical effect in children and can be indicated in the treatment of refractory vasodilatory shock, after adequate volume resuscitation and when high doses of other vasopressors are not effective.