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BACKGROUND: Children hospitalized with acute decompensated heart failure (ADHF) frequently require intravenous vasoactive (IVV) support drugs and are at risk for adverse cardiovascular (ACV) outcomes. We wished to assess whether serial changes in B-type natriuretic peptide (BNP) levels are associated with successful weaning off IVV support and/or prespecified ACV outcomes in children hospitalized with ADHF. METHODS AND RESULTS: Children hospitalized with ADHF from 2005 to 2021 at our institution were assessed for serial changes in BNP, weaning off of IVV support, and ACV outcomes. Changes in BNP level were evaluated using linear mixed-effects modeling. Bonferroni correction was used to adjust for multiple hypothesis testing. In 131 hospitalizations of children with ADHF, the median age was 4.8 years, with 74% receiving IVV support. ACV outcomes occurred in 62 children. IVV support was associated with lower admission left ventricular ejection fraction (26.7% versus 32%, P=0.002), more severe left ventricular dilation (left ventricular internal diastolic dimension Z score 5.9 versus 3.1, P=0.021) moderate or more mitral regurgitation (41.3% versus 20.6%, P=0.038), and qualitative right ventricular systolic dysfunction (in 45.4% versus 11.8%, P<0.001). Decline in BNP levels was more rapid in patients who were successfully weaned from IVV support (-0.20 versus -0.03 2log pg/mL per day, P<0.001) and in the non-ACV group (-0.17 versus -0.03 2log pg/mL per day, P<0.001). Right ventricular systolic dysfunction was an independent risk factor for ACV (odds ratio, 2.49; P=0.045). CONCLUSIONS: The declining rate of serial BNP levels was associated with weaning from IVV support and no ACV outcomes in children hospitalized with ADHF. Right ventricular systolic dysfunction was associated with ACV outcomes.

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Background: Septic shock is associated with systemic inflammatory response, hemodynamic instability, impaired sympathetic control, and the development of multiorgan dysfunction that requires vasopressor or inotropic support. The regulation of immune function in sepsis is complex and varies over time. However, activating Beta-2 receptors and blocking Beta-1 receptors reduces the proinflammatory response by influencing cytokine production. Evidence that supports the concomitant use of ultra short beta-blockers with inotropes and vasopressors in patients with septic shock is still limited. This study aimed to evaluate the use of ultra short beta-blockers and its impact on the ICU related outcomes such as mortality, length of stay, heart rate control, shock resolution, and vasopressors/inotropes requirements. Methods: A systematic review and meta-analysis of randomized controlled trials including critically ill patients with septic shock who received inotropes and vasopressors. Patients who received either epinephrine or norepinephrine without beta-blockers "control group" were compared to patients who received ultra short beta-blockers concomitantly with either epinephrine or norepinephrine "Intervention group". MEDLINE and Embase databases were utilized to systematically search for studies investigating the use of ultra short beta-blockers in critically ill patients on either epinephrine or norepinephrine from inception to October 10, 2023. The primary outcome was the 28-day mortality. While, length of stay, heart rate control, and inotropes/ vasopressors requirements were considered secondary outcomes. Results: Among 47 potentially relevant studies, nine were included in the analysis. The 28-day mortality risk was lower in patients with septic shock who used ultra short beta-blockers concomitantly with either epinephrine or norepinephrine compared with the control group (RR (95%CI): 0.69 (0.53, 0.89), I2=26%; P=0.24). In addition, heart rate was statistically significantly lower with a standardized mean difference (SMD) of -22.39 (95% CI: -24.71, -20.06) among the beta-blockers group than the control group. The SMD for hospital length of stay and the inotropes requirement were not statistically different between the two groups (SMD (95%CI): -0.57 (-2.77, 1.64), and SMD (95%CI): 0.08 (-0.02, 0.19), respectively). Conclusion: The use of ultra short beta-blockers concomitantly with either epinephrine or norepinephrine in critically ill patients with septic shock was associated with better heart rate control and survival benefits without increment in the inotropes and vasopressors requirement.

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Shock is a life-threatening circulatory failure that results in inadequate tissue perfusion and oxygenation. Vasopressors and inotropes are vasoactive medications that are vital in increasing systemic vascular resistance and cardiac contractility, respectively, in patients presenting with shock. To be well versed in using these agents is an important skill to have in the critical care setting where patients can frequently exhibit symptoms of shock. In this review, we will discuss the pathophysiological mechanisms of shock and evaluate the current evidence behind the management of shock with an emphasis on vasopressors and inotropes.

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Anti-hypotensive treatment, which includes dopamine, dobutamine, epinephrine, norepinephrine, milrinone, vasopressin, terlipressin, levosimendan, and glucocorticoids, is a long-established intervention in neonates with arterial hypotension (AH). However, there are still gaps in knowledge and issues that need clarification. The main questions and challenges that neonatologists face relate to the reference ranges of arterial blood pressure in presumably healthy neonates in relation to gestational and postnatal age; the arterial blood pressure level that potentially affects perfusion of critical organs; the incorporation of targeted echocardiography and near-infrared spectroscopy for assessing heart function and cerebral perfusion in clinical practice; the indication, timing, and choice of medication for each individual patient; the limited randomized clinical trials in neonates with sometimes conflicting results; and the sparse data regarding the potential effect of early hypotension or anti-hypotensive medications on long-term neurodevelopment. In this review, after a short review of AH definitions used in neonates and existing data on pathophysiology of AH, we discuss currently available data on pharmacokinetic and hemodynamic effects, as well as the effectiveness and safety of anti-hypotensive medications in neonates. In addition, data on the comparisons between anti-hypotensive medications and current suggestions for the main indications of each medication are discussed.

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Systolic anterior motion of the mitral valve and left ventricular outflow tract obstruction are complications following transcatheter aortic valve implantation and can lead to hemodynamic collapse. Medical management for those complications is usually centered on a reduction in left ventricular contractility with negative inotropes. An 88-year-old woman underwent transcatheter aortic valve implantation for severe aortic stenosis. Hemodynamic collapse and exacerbation of mitral regurgitation occurred immediately after valve implantation. For suspected left ventricular outflow tract obstruction, medical management centered on negative inotropes was performed. Hemodynamics and left ventricular outflow tract obstruction improved over time; however, the oxygen supply-demand imbalance progressed. On postoperative day 5, the patient suddenly went into pulseless electrical activity. Cardiopulmonary resuscitation was performed for three minutes, resulting in the return of spontaneous circulation. Subsequent refractory hypotension and oxygen supply-demand imbalance improved with continuous infusion of adrenaline, dobutamine, and phenylephrine. Her hemodynamics remained stable after she was weaned off the pressor infusions, and negative inotropes were not required again. In summary, the cause of cardiac arrest was possibly due to excessive negative inotropic effects even though the effects contributed to improvement of left ventricular outflow tract obstruction. Anesthesiologists and intensivists should recognize the risk of cardiac arrest induced by negative inotropic effects and use negative inotropes with rigorous hemodynamic monitoring, even when left ventricular outflow tract obstruction is treated effectively.

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Hemodynamic derangements are defining features of cardiogenic shock. Randomized clinical trials have examined the efficacy of various therapeutic interventions, from percutaneous coronary intervention to inotropes and mechanical circulatory support (MCS). However, hemodynamic management in cardiogenic shock has not been well-studied. This State-of-the-Art review will provide a framework for hemodynamic management in cardiogenic shock, including a description of the 4 therapeutic phases from initial 'Rescue' to 'Optimization', 'Stabilization' and 'de-Escalation or Exit therapy' (R-O-S-E), phenotyping and phenotype-guided tailoring of pharmacological and MCS support, to achieve hemodynamic and therapeutic goals. Finally, the premises that form the basis for clinical management and the hypotheses for randomized controlled trials will be discussed, with a view to the future direction of cardiogenic shock.

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Cardiogenic shock is a primary cardiac disorder that results in both clinical and biochemical evidence of tissue hypoperfusion and can lead to multi-organ failure and death depending on its severity. Inadequate cardiac contractility or cardiac power secondary to acute myocardial infarction remains the most frequent cause of cardiogenic shock, although its contribution has declined over the past two decades, compared with other causes. Despite some advances in cardiogenic shock management, this clinical syndrome is still burdened by an extremely high mortality. Its management is based on immediate stabilization of haemodynamic parameters so that further treatment, including mechanical circulatory support and transfer to specialized tertiary care centres, can be accomplished. With these aims, medical therapy, consisting mainly of inotropic drugs and vasopressors, still has a major role. The purpose of this article is to review current evidence on the use of these medications in patients with cardiogenic shock and discuss specific clinical settings with indications to their use.

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Hyperbaric Oxygen Therapy (HBOT) has garnered significant attention as a therapeutic principle with potential benefits across a variety spectrum of medical conditions, ranging from wound healing and ischemic conditions to neurologic disorders and radiation-induced tissue damage. HBOT involves the administration of 100% oxygen at higher atmospheric pressures, leading to increased oxygen dissolved in bodily fluids and tissues. The elevated oxygen levels are proposed to facilitate tissue repair, reduce inflammation, and promote angiogenesis. This case report presents a compelling instance of the usefulness of HBOT in promoting skin perfusion and healing following peripheral tissue injury resulting from the administration of inotropic and vasopressor agents in septic shock patients.

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This review provides a comprehensive summary of the current understanding of pulmonary hypertension (PH) in congenital diaphragmatic hernia, outlining the underlying pathophysiologic mechanisms, methods for assessing PH severity, optimal management strategies, and prognostic implications.

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Background: Transcatheter edge-to-edge mitral valve repair (TEER) has emerged as a viable approach to addressing substantial secondary mitral regurgitation. In the contemporary landscape where ultimate heart failure-specific therapies, such as cardiac replacement modalities, are available, prognosticating a high-risk cohort susceptible to early cardiac mortality post-TEER is pivotal for formulating an effective therapeutic regimen. Methods: Our study encompassed individuals with secondary mitral regurgitation and chronic heart failure enlisted in the multi-center (Optimized CathEter vAlvular iNtervention (OCEAN)-Mitral registry. We conducted an assessment of baseline variables associated with cardiac death within one year following TEER. Results: Amongst the 1517 patients (median age: 78 years, 899 males), 101 experienced cardiac mortality during the 1-year observation period after undergoing TEER. Notably, a history of heart failure-related admissions within the preceding year, utilization of intravenous inotropes, and elevated plasma B-type natriuretic peptide levels emerged as independent prognosticators for the primary outcome (p < 0.05 for all). Subsequently, we devised a novel risk-scoring system encompassing these variables, which significantly stratified the cumulative incidence of the 1-year primary outcome (16%, 8%, and 4%, p < 0.001). Conclusions: Our study culminated in the development of a new risk-scoring system aimed at predicting 1-year cardiac mortality post-TEER.

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Traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH) are critical neurological conditions that necessitate specialized care in the Intensive Care Unit (ICU). Managing cerebral perfusion pressure (CPP) and mean arterial pressure (MAP) is of primary importance in these patients. To maintain targeted MAP and CPP, vasopressors and/or inotropes are commonly used. However, their effects on cerebral oxygenation are not fully understood. The aim of this review is to provide an up-to date review regarding the current uses and pathophysiological issues related to the use of vasopressors and inotropes in TBI and SAH patients. According to our findings, despite achieving similar hemodynamic parameters and CPP, the effects of various vasopressors and inotropes on cerebral oxygenation, local CBF and metabolism are heterogeneous. Therefore, a more accurate understanding of the cerebral activity of these medications is crucial for optimizing patient management in the ICU setting.

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Cardiogenic shock (CS) is a complex clinical syndrome with a high risk of mortality. The recent, rapid development of temporary mechanical circulatory support (tMCS) has altered CS treatment. While catecholamines remain the cornerstone of CS therapy, tMCS usage has increased. According to shock severity, different treatment strategies including catecholamines alone, catecholamines and tMCS, or multiple tMCS might be used. State-of-the-art implantation techniques are necessary to avoid complications linked to the invasive nature of tMCS. In particular, bleeding and access-site complications might counteract the potential haemodynamic benefit of a percutaneous ventricular assist device. In this review, we describe the role of catecholamines in CS treatment and present the different tMCS devices with an explanation on how to use them according to CS aetiology and severity. Finally, an overview of the best practice for device implantation is provided.

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Introduction: Pharmacological support has become the mainstay therapy in patients with cardiogenic shock (CS). Unfortunately, the clinical benefits of such potent drugs remain unclear, therefore, the present study aims to elucidate the safety and efficacy of vasoactive agents in CS patients. Methods: Medical Information Mart for Intensive Care (MIMIC) IV databases were used for this retrospective study. The primary outcome of this study was 30-day all-cause mortality. The subgroup analysis of was the relationship between the combined use of vasopressors and inotropes and 30-day all-cause mortality. Results: A total of 2,216 patients diagnosed with CS were enrolled in this study. The non-survivors group was more likely to be older, presented with chronic kidney disease, have a lower systolic blood pressure, lower heart rate, and higher respiratory rate (all p < 0.05). In the multivariate Cox regression analysis, only dopamine [HR (95%CI): 1.219 (1.003-1.482)], norepinephrine [HR (95%CI): 2.528 (1.829-3.493)], and milrinone [HR (95%CI): 0.664 (0.512-0.861)] remained an independent predictor for 30-day all-cause mortality. Furthermore, a subgroup analysis was performed and found that no statistically significant difference between no vasopressor/inotrope use and 1 vasopressor/inotrope use (p = 0.107). Meanwhile, a substantial deterioration of cumulative survival was observed when a combination of 2 or more vasopressors/inotropes was used in CS patients in comparison with no vasopressor/inotrope or only 1 vasopressor/inotrope use (all p < 0.05). Conclusions: Using vasopressors/inotropes agents was associated with a higher risk of 30-day all-cause mortality in CS patients. In addition, only milrinone was associated with a better prognosis among the available vasoactive agents.

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The role of the beta-adrenergic signaling pathway in heart failure (HF) is pivotal. Early blockade of this pathway with beta-blocker (BB) therapy is recommended as the first-line medication for patients with HF and reduced ejection fraction (HFrEF). Conversely, in patients with severe acute HF (AHF), including those with resolved cardiogenic shock (CS), BB initiation can be hazardous. There are very few data on the management of BB in these situations. The present expert consensus aims to review all published data on the use of BB in patients with severe decompensated AHF, with or without hemodynamic compromise, and proposes an expert-recommended practical algorithm for the prescription and monitoring of BB therapy in critical settings.

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Background The WHO protocol for the management of shock in children with severe acute malnutrition (SAM) is not supported by physiological evidence. In this study, we aimed to assess the effectiveness of the WHO treatment protocol in the management of shock in children with SAM. Methodology This cohort study included children aged 2-60 months with WHO-defined SAM and fulfilling the WHO criteria for identification of shock. The exclusion criteria included severe anemia (hemoglobin <4 g/dL), congenital anomalies, congenital heart defects, and chronic diseases. The WHO treatment protocol for the management of shock was used, and features of resolution of shock were assessed at eight and 24 hours. Oliguria was recorded at eight and 24 hours along with in-hospital mortality. Multiple logistic regression was used to determine predictors of mortality. Results Of 53 children, 40 (75.4%) were discharged and 13 (24.5%) expired. We observed significant resolution of features of shock at 24 hours compared to eight hours (35 (71.4%) vs. 10 (18.8%), p < 0.0001). Further analysis revealed a significant resolution of features of shock (p = 0.03) at 24 hours in both fluid-responsive (24 vs. 10) and fluid-refractory children (11 vs. 27) compared to eight hours. Multivariate analysis revealed that mechanical ventilation was positively related to death (odds ratio (OR) = 85, 95% confidence interval (CI) = 8.49, 860, p < 0.0001), and inotrope scores <20 (OR = 0.053, 95% CI = 0.004, 0.64, p = 0.021) and blood transfusion (OR = 0.025, 95% CI = 0.001, 0.61, p = 0.024) had favorable outcomes. Conclusions The WHO protocol for the management of shock in children with SAM is effective in fluid-responsive shock whereas evidence was inconclusive in fluid-refractory shock.

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While a congestive heart failure patient will ultimately need an assist device or even a replacement heart as the disease progresses, not every patient is qualified for such advanced therapy. Such patients awaiting better circulatory support benefit from positive inotropes in the meantime as palliative care. These agents are often prescribed in patients with acute decompensated heart failure, with reduced left ventricular ejection fraction and symptoms of organ dysfunction. Although positive inotropes, for example, digoxin, dobutamine, milrinone, levosimendan, etc., are successfully marketed and in use, a lot of their adverse effects, like arrhythmias, hypotension, and even sudden cardiac death, are rather encouraging further research on the development of novel positive inotropes. This review has investigated the molecular mechanisms of some of these adverse effects in terms of the proteins they target, followed by research on newer targets. Studies from 2013-2023 that have reported new small molecules with positive inotropic effects have been revisited in order to determine the progress made so far in drug discovery.

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Hypereosinophilic syndrome (HES) is a myeloproliferative disorder characterized by persistent hypereosinophilia that is associated with multi-organ damage. Eosinophilic endocarditis is a serious complication of HES. The exact prevalence of the disease is unknown, and it is characterized by a persistently elevated eosinophil count, resulting in multi-organ involvement due to eosinophilic infiltration. We present a case of a 65-year-old Caucasian male patient who presented with one-week symptoms of feeling unwell and intermittent pleuritic chest pain. His medical history was significant for the idiopathic hypereosinophilic syndrome, eosinophilic myocarditis, hypertension (HTN), type 2 diabetes mellitus (T2DM), and chronic obstructive pulmonary disease (COPD). Inflammatory markers were raised, including eosinophil count, and a transthoracic echocardiogram (TTE) showed a mass attached to the mitral valve (MV) leaflets, suggesting vegetation or thrombus. The patient was commenced on intravenous antibiotics, inotropes for septic shock, and low molecular weight heparin (LMWH) for a possible thrombus. He showed mild biochemical improvement initially without any clinical improvement before further deterioration secondary to aspiration pneumonia. He was seen by the palliative care team and mental health team for confusion and agitation and was put on the palliative care pathway. All active medical treatment was stopped, and the patient succumbed to his illness three weeks into his admission.