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OBJECTIVE: To evaluate the safety and necessity of vasopressor infusion through midline catheter. METHODS: A convenient sampling method was used for a controlled study. A total of 88 adult patients who used vasopressors admitted to respiratory intensive care unit (RICU) of Fenyang Hospital in Shanxi Province from June 2022 to June 2023 were enrolled as the research subjects. A total of 44 patients who were infused with vasopressors through peripherally inserted central venous catheter (PICC) from June to December 2022 were enrolled as the PICC group, and 44 patients who were infused with vasopressors through midline catheter from January to June 2023 were enrolled as the midline catheter group. Both groups of patients used the modified Sedinger technique under the guidance of B-ultrasound for puncture and catheter placement. The middle 1/3 site between the cubital fossa and the axilla was selected. The catheters were 5 Fr double lumen. After catheter placement, the patients were followed until catheter removal, death, or 30 days (whichever came first). Based on the Infusion therapy standards of practice revised by American Infusion Nurses Society (INS), and combined with the results of previous preliminary tests, the safety evaluation was conducted on incomplete catheter obstruction, catheter-related bloodstream infection (CRBSI), phlebitis, thrombus within the catheter during extubation, redness of the puncture site (but no infection), and exudation of the puncture site in the two groups of patients. RESULTS: There were no statistical differences in gender, age, catheter indwelling time, and primary disease between the two groups, indicating that the baseline data of the two groups were balanced and comparable. No CRBSI or phlebitis occurred in both groups during the observation period after catheterization. One patient in both groups had exudation at the puncture site [both were 2.27% (1/44)]. Compared with the PICC group, the incidence of incomplete catheter obstruction, thrombus within the catheter during extubation, redness of the puncture site (but no infection) in the midline catheter group were lowered [incomplete catheter obstruction: 4.55% (2/44) vs. 6.82% (3/44), thrombus within the catheter during extubation: 0% (0/44) vs. 2.27% (1/44), redness of the puncture site (but no infection): 0% (0/44) vs. 4.55% (2/44)], the overall incidence was significantly decreased [6.82% (3/44) vs. 15.91% (7/44), P < 0.01]. CONCLUSIONS: Administering vasopressor through a midline catheter can reduce the incidence of catheter-related complications, decrease the rate of central venous catheterization, and reduce the financial burden on patients.
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Cateterismo Periférico , Vasoconstrictores , Humanos , Vasoconstrictores/administración & dosificación , Vasoconstrictores/uso terapéutico , Cateterismo Periférico/métodos , Cateterismo Periférico/efectos adversos , Unidades de Cuidados Intensivos , Cateterismo Venoso Central/métodos , Cateterismo Venoso Central/efectos adversos , Femenino , Masculino , Persona de Mediana Edad , AdultoRESUMEN
OBJECTIVE: This study aims to clarify the uncertain association between vasopressor administration and the development of intensive care unit-acquired weakness (ICUAW) in critically ill adult patients. METHODS: We conducted a comprehensive search of PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials up to October 10, 2023. Titles and abstracts were independently screened by two authors, who then reviewed full texts and extracted relevant data from the studies that met the inclusion criteria. This review included prospective and retrospective cohort studies that explored the relationship between vasopressor use and ICUAW utilizing univariate or multivariate analysis in adult ICU patients. RESULTS: A total of 15 studies were included in our review, collectively indicating a statistically significant association between the use of vasopressors and the occurrence of ICUAW (odds ratio [OR], 3.43; 95% confidence intervals [CI], 1.95-6.04), including studies utilizing multivariate analysis (OR, 3.43; 95% CI, 1.76-6.70). Specifically, the use of noradrenaline was significantly associated with ICUAW (OR, 4.42; 95% CI, 1.69-11.56). Subgroup and sensitivity analyses further underscored the significant relationship between vasopressor use and ICUAW, particularly in studies focusing on patients with clinical weakness, varying study designs, different sample sizes, and relatively low risk of bias. However, this association was not observed in studies limited to patients with abnormal electrophysiology. CONCLUSIONS: Our review underscores a significant link between the use of vasopressors and the development of ICUAW in critically ill adult patients. This finding helps better identify patients at higher risk of ICUAW and suggests considering targeted therapies to mitigate this risk.
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Enfermedad Crítica , Unidades de Cuidados Intensivos , Debilidad Muscular , Vasoconstrictores , Humanos , Vasoconstrictores/efectos adversos , Vasoconstrictores/administración & dosificación , Unidades de Cuidados Intensivos/estadística & datos numéricos , Debilidad Muscular/inducido químicamenteRESUMEN
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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Insuficiencia Cardíaca , Péptido Natriurético Encefálico , Humanos , Péptido Natriurético Encefálico/sangre , Masculino , Insuficiencia Cardíaca/sangre , Insuficiencia Cardíaca/fisiopatología , Femenino , Preescolar , Niño , Lactante , Biomarcadores/sangre , Estudios Retrospectivos , Resultado del Tratamiento , Volumen Sistólico/fisiología , Función Ventricular Izquierda , Adolescente , Vasoconstrictores/uso terapéutico , HospitalizaciónRESUMEN
Fascia iliaca compartment block (FICB) reduces opioid consumption and pain scores after total hip arthroplasty (THA), and has recently been widely applied. We investigated whether FICB could also reduce postoperative bleeding. One hundred and fifteen consecutive patients who underwent elective THA under general anesthesia over 5 months were retrospectively analyzed. They were divided into 2 groups: the FICB group received an epinephrine-mixed FICB procedure and the control group did not receive any block. Using the hematocrit measured at 4 different time points (preoperative and 1, 24, and 48 hours after surgery), the estimated blood loss (EBL) was calculated for 3 different time periods (0-1, 1-24, 24-48 hours after surgery). EBL at 1 to 24 hours (226 vs 398 mL, Pâ =â .008) was significantly lower in the FICB group than in the control group. Additionally, the number of packed red cell (PRC) units transfused per patient over 48 hours was 0.38 units in the FICB group, which was significantly lower than the 0.70 units used in the control group (Pâ =â .040). Epinephrine-mixed FICB in THA has the potential to reduce postoperative bleeding in the first 24 hours after surgery as well as reduce PRC transfusion requirements.
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Artroplastia de Reemplazo de Cadera , Epinefrina , Bloqueo Nervioso , Hemorragia Posoperatoria , Humanos , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Cadera/métodos , Epinefrina/administración & dosificación , Estudios Retrospectivos , Masculino , Femenino , Anciano , Hemorragia Posoperatoria/prevención & control , Hemorragia Posoperatoria/etiología , Persona de Mediana Edad , Bloqueo Nervioso/métodos , Fascia/inervación , Anestésicos Locales/administración & dosificación , Anestésicos Locales/uso terapéutico , Vasoconstrictores/uso terapéutico , Vasoconstrictores/administración & dosificación , Dolor Postoperatorio/prevención & control , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/etiologíaRESUMEN
INTRODUCTION: The dynamic arterial elastance (EaDyn), calculated as pulse pressure variation divided by stroke volume variation, has been studied as a predictor of vasopressor weaning. However, its potential as a haemodynamic tool for tapering off vasopressors in patients with sepsis remains unexplored. Therefore, our study aimed to assess whether using EaDyn for weaning vasopressor support could reduce the duration of vasopressor support in patients with sepsis. METHODS AND ANALYSIS: This pragmatic single-centre controlled clinical trial will take place at Fundación Santa Fe de Bogotá, Colombia. Adult patients diagnosed with septic shock according to the sepsis-3 criteria and a Sequential Organ Failure Assessment score ≥4 will be included. A total of 114 patients (57 per group) will undergo conventional critical care monitoring, and the weaning of vasopressor support will be initiated based on the EaDyn or mean arterial pressure (MAP), depending on the assigned group. EaDyn will be estimated based on the measurements obtained from a PiCCO device connected to a PulsioFlex Monitoring Platform (PULSION Medical Systems SE, Feldkirchen, Germany). Our primary outcome is the difference in vasopressor support duration between the EaDyn and MAP groups.Participants and statisticians performing the statistical analysis will be blinded to the group allocation. Dependent and independent variables will be analysed through univariate and multivariate statistical tests. Since we will perform three repeated measurements for analysis, we will implement a Bonferroni post hoc correction. Additionally, Cox regression and Kaplan-Meier analyses will be conducted to address objectives related to time. ETHICS AND DISSEMINATION: This study was approved by the Ethics Committee at Fundación Santa Fe de Bogotá (CCEI-16026-2024). Written informed consent will be obtained from all participants. The results will be disseminated through publication in peer-reviewed journals and presentations at national and international events. TRIAL REGISTRATION NUMBER: NCT06118775.
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Choque Séptico , Vasoconstrictores , Humanos , Choque Séptico/tratamiento farmacológico , Choque Séptico/fisiopatología , Vasoconstrictores/uso terapéutico , Ensayos Clínicos Controlados Aleatorios como Asunto , Volumen Sistólico , Masculino , Colombia , Femenino , Presión Arterial/efectos de los fármacos , Cuidados Críticos/métodos , AdultoRESUMEN
Bleeding events are feared complications in patients with advanced liver diseases and are associated with morbidity and mortality. In this context, gastrointestinal bleeding, particularly upper gastrointestinal bleeding, has a special clinical importance. In addition to endoscopic measures for hemostasis, reducing portal pressure in particular is a key component of treatment. Although the standard coagulation parameters are often altered in patients with liver diseases, optimizing coagulation plays a secondary role. Typically, a bundle of measures are employed in patients with portal hypertensive bleeding, which nowadays in most cases can halt the bleeding and stabilize the situation. The measures include endoscopy, antibiotic treatment, vasopressor treatment and, if necessary, shunt placement (transjugular intrahepatic portosystemic shunt).
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Hemorragia Gastrointestinal , Hipertensión Portal , Derivación Portosistémica Intrahepática Transyugular , Humanos , Hemorragia Gastrointestinal/terapia , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/diagnóstico , Hipertensión Portal/diagnóstico , Hipertensión Portal/terapia , Hipertensión Portal/etiología , Terapia Combinada , Hepatopatías/diagnóstico , Hepatopatías/terapia , Vasoconstrictores/uso terapéutico , Antibacterianos/uso terapéutico , Cirrosis Hepática/complicaciones , Cirrosis Hepática/diagnóstico , Várices Esofágicas y Gástricas/terapia , Várices Esofágicas y Gástricas/diagnósticoRESUMEN
Early diagnosis and prompt management are essential to enhance the outcomes of patients with sepsis and septic shock. Over the past two decades, evidence-based guidelines have guided appropriate treatment and recommended the implementation of a bundle strategy to deliver fundamental treatments within the initial hours of care. Shortly after its introduction, the implementation of a bundle strategy has led to a substantial decrease in mortality rates across various health care settings. The primary advantage of these bundles is their universality, making them applicable to all patients with sepsis. However, this same quality also represents their primary disadvantage as it fails to account for the significant heterogeneity within the septic patient population. Recently, the individualization of treatments included in the bundle has been suggested as a potential strategy for further improving the prognosis of patients with sepsis. New strategies for the early identification of microorganisms and their resistance patterns, advanced knowledge of antibiotic kinetics in critically ill patients, more conservative fluid therapy in specific patient populations, and early use of alternative vasopressors to catecholamines, as well as tailored source control based on patient conditions and site of infection, are potential approaches to personalize initial care for specific subgroups of patients. These innovative methodologies have the potential to improve the management of septic shock. However, their implementation in clinical practice should be guided by solid evidence. Therefore, it is imperative that future research evaluate the safety, efficacy, and cost-effectiveness of these strategies.
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Antibacterianos , Paquetes de Atención al Paciente , Sepsis , Humanos , Sepsis/terapia , Antibacterianos/uso terapéutico , Fluidoterapia/métodos , Medicina de Precisión/métodos , Diagnóstico Precoz , Enfermedad Crítica/terapia , Choque Séptico/terapia , Guías de Práctica Clínica como Asunto , Vasoconstrictores/uso terapéutico , Vasoconstrictores/administración & dosificaciónRESUMEN
INTRODUCTION: Angiotensin II (ATII) maintains blood pressure via RAAS with a beneficial adverse effect profile versus catecholamines and phenylephrine. Head-to-head data comparing ATII to phenylephrine are lacking regarding renal allograft function, hemodynamic efficacy, and safety within the perioperative period of kidney transplantation. METHODS: This single-center, retrospective study included adult kidney transplant recipients who received continuous infusions of ATII or phenylephrine within a 24-h perioperative period as a first-line vasopressor according to an institutional algorithm. The primary endpoint was allograft function. Secondary endpoints were hemodynamic efficacy and adverse effects. RESULTS: Among 105 patients, there was no significant difference in IGF (p = 0.545), SGF (p = 0.557), or DGF (p = 0.878) between patient cohorts. In the 34 patients with cold ischemia time (CIT) > 14-h, IGF was higher (p = 0.013) and DGF (p = 0.045) was lower in the ATII cohort versus phenylephrine. In all patients, ATII was associated with a decreased need for additional vasopressor agents (p < 0.001). Adverse effect profiles were similar between cohorts (p > 0.05). CONCLUSION: Among kidney transplant recipients, ATII may be a suitable first-line alternative compared with phenylephrine in the perioperative period for hypotension management with a reduced need for additional vasopressor support. Allograft benefits were observed in patients with prolonged CIT.
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Angiotensina II , Supervivencia de Injerto , Trasplante de Riñón , Fenilefrina , Vasoconstrictores , Humanos , Femenino , Masculino , Vasoconstrictores/administración & dosificación , Vasoconstrictores/uso terapéutico , Estudios Retrospectivos , Fenilefrina/administración & dosificación , Fenilefrina/uso terapéutico , Persona de Mediana Edad , Estudios de Seguimiento , Supervivencia de Injerto/efectos de los fármacos , Pronóstico , Adulto , Fallo Renal Crónico/cirugía , Tasa de Filtración Glomerular , Complicaciones Posoperatorias/tratamiento farmacológico , Pruebas de Función Renal , Atención Perioperativa , Rechazo de Injerto/prevención & control , Rechazo de Injerto/etiología , Rechazo de Injerto/tratamiento farmacológico , Factores de Riesgo , Infusiones IntravenosasRESUMEN
BACKGROUND: Spinal anaesthesia is a common anaesthetic method for caesarean sections but often results in hypotension, posing potential risks to maternal and neonatal health. Norepinephrine, as a vasopressor, may be effective in preventing and treating this hypotension. This systematic review and meta-analysis aims to systematically evaluate the efficacy and safety of prophylactic norepinephrine infusion for the treatment of hypotension following spinal anaesthesia in caesarean sections. METHODS: Literature searches were conducted in PubMed, Embase, Web of Science, Cochrane Library, CNKI, Wanfang, and VIP databases for relevant studies on prophylactic administration of norepinephrine for the treatment of hypotension after spinal anaesthesia in caesarean delivery. Reference lists of included articles were also searched. The latest search update was on March 20, 2024. Meta-analysis was conducted using R software. The methods recommended by the Cochrane Handbook, Begge's and Egger's tests were used for risk of bias evaluation of the included literature. RESULTS: Nine studies were finally included in this study. The results showed that prophylactic administration of norepinephrine was superior to the control group in four aspects of treating hypotension after spinal anaesthesia in caesarean delivery: the incidence of hypotension was reduced [RR = 0.34, 95%CI (0.27-0.43), P < 0.01]; the incidence of severe hypotension was reduced [RR = 0.32, 95%CI (0.21-0.51), P < 0.01]; and maternal blood pressure was more stable with MDPE [MD = -5.00, 95%CI (-7.80--2.21), P = 0.06] and MDAPE [MD = 4.11, 95%CI (1.38-6.85), P < 0.05], the incidence of nausea and vomiting was reduced [RR = 0.52, 95%CI (0.35-0.77), P < 0.01]. On the other hand, the incidence of reactive hypertension was higher than the control group [RR = 3.58, 95%CI (1.94-6.58), P < 0.01]. There was no difference between the two groups in one aspects: newborn Apgar scores [MD = -0.01, 95%CI (-0.10-0.09, P = 0.85)]. CONCLUSION: Prophylactic administration of norepinephrine is effective in treating hypotension after spinal anaesthesia in caesarean delivery patients; however, it does not provide improved safety and carries a risk of inducing reactive hypertension.
Hypotension, or low blood pressure, after spinal anaesthesia can threaten the health of both mothers and their babies during caesarean sections. Norepinephrine is a drug that affects heart rate less and does not easily cross the placental barrier, which may reduce its potential negative effects on the baby. However, there are not many studies on using norepinephrine as a preventive measure. Our study systematically evaluated the use of prophylactic norepinephrine infusion to prevent hypotension in caesarean section patients. We found that it is effective in preventing low blood pressure but does not show improved safety and carries some risk of causing high pressure as a reaction.
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Anestesia Obstétrica , Anestesia Raquidea , Cesárea , Hipotensión , Norepinefrina , Vasoconstrictores , Humanos , Cesárea/efectos adversos , Anestesia Raquidea/efectos adversos , Anestesia Raquidea/métodos , Femenino , Hipotensión/prevención & control , Hipotensión/etiología , Hipotensión/tratamiento farmacológico , Norepinefrina/administración & dosificación , Norepinefrina/uso terapéutico , Norepinefrina/efectos adversos , Embarazo , Anestesia Obstétrica/efectos adversos , Anestesia Obstétrica/métodos , Vasoconstrictores/administración & dosificación , Vasoconstrictores/uso terapéutico , AdultoRESUMEN
The relationship between VISmax and mortality in patients undergoing major abdominal surgery remains unclear. This study aims to evaluate the association between VISmax and both short-term and long-term all-cause mortality in patients undergoing major abdominal surgery, VISmax was calculated (VISmax = dopamine dose [µg/kg/min] + dobutamine dose [µg/kg/min] + 100 × epinephrine dose [µg/kg/min] + 10 × milrinone dose [µg/kg/min] + 10,000 × vasopressin dose [units/kg/min] + 100 × norepinephrine dose [µg/kg/min]) using the maximum dosing rates of vasoactives and inotropics within the first 24 h postoperative ICU admission. The study included 512 patients first admitted to the intensive care unit (ICU) who were administered vasoactive drugs after major abdominal surgery. The data was extracted from the medical information mart in intensive care-IV database. VISmax was stratified into five categories: 0-5, > 5-15, > 15-30, > 30-45, and > 45. Compared to patients with the lowest VISmax (≤ 5), those with the high VISmax (> 45) had an increased risk of 30-day mortality (hazard ratio [HR] 3.73, 95% CI 1.16-12.02; P = 0.03) and 1-year mortality (HR 2.76, 95% CI 1.09-6.95; P = 0.03) in fully adjusted Cox models. The ROC analysis for VISmax predicting 30-day and 1-year mortality yielded AUC values of 0.69 (95% CI 0.64-0.75) and 0.67 (95% CI 0.62-0.72), respectively. In conclusion, elevated VISmax within the first postoperative 24 h after ICU admission was associated with increased risks of both short-term and long-term mortality in patients undergoing major abdominal surgery.
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Abdomen , Vasoconstrictores , Humanos , Masculino , Femenino , Estudios Retrospectivos , Anciano , Persona de Mediana Edad , Abdomen/cirugía , Vasoconstrictores/administración & dosificación , Vasoconstrictores/uso terapéutico , Unidades de Cuidados Intensivos , Cardiotónicos/administración & dosificación , Norepinefrina , Epinefrina/administración & dosificación , Dobutamina/administración & dosificación , Dopamina , Vasopresinas , Milrinona/administración & dosificaciónRESUMEN
BACKGROUND: Previous studies have shown that a 0.05 µg/kg/min of norepinephrine infusion in combination with an initial bolus reduces the incidence of spinal hypotension during cesarean delivery. The initial norepinephrine bolus influences the incidence of spinal hypotension during continuous norepinephrine infusion; however, the ideal initial bolus dose for 0.05 µg/kg/min of continuous infusion remains unknown. METHODS: This randomized, controlled, dose-finding study randomly allocated 120 parturients scheduled for elective cesarean delivery to receive initial bolus doses of 0, 0.05, 0.10, and 0.15 µg/kg of norepinephrine, followed by continuous infusion at a rate of 0.05 µg/kg/min. The primary outcome was the dose-response relationship of the initial norepinephrine bolus in preventing the incidence of spinal hypotension. Spinal hypotension was defined as systolic blood pressure (SBP) decreased to <80% of the baseline value or to an absolute value of <90 mmHg from intrathecal injection to delivery, and severe spinal hypotension was defined as SBP decreased to <60% of the baseline value. The secondary outcomes included the incidence of nausea and/or vomiting, hypertension, and bradycardia, as well as the Apgar scores and results of the umbilical arterial blood gas analysis. The effective dose (ED) 90 and ED95 were estimated using probit regression. RESULTS: The per-protocol analysis included 117 patients. The incidence of spinal hypotension varied significantly among the groups: Group 0 (51.7%), Group 0.05 (44.8%), Group 0.10 (23.3%), and Group 0.15 (6.9%). The ED90 and ED95 values were 0.150 µg/kg (95% confidence interval [CI], 0.114-0.241 µg/kg) and 0.187 µg/kg (95% CI, 0.141-0.313 µg/kg), respectively. However, the ED95 value fell outside the dose range examined in this study. The incidence of severe spinal hypotension differed significantly (P = 0.02) among Groups 0 (17.2%), 0.05 (10.3%), 0.10 (3.3%), and 0.15 (0.0%); however, the incidence of hypertension and bradycardia did not. The incidence of nausea and/or vomiting decreased with an increase in the initial bolus dose (P = 0.03). The fetal outcomes were comparable among the groups. CONCLUSIONS: An initial bolus of 0.150 µg/kg of norepinephrine may be the optimal dose for preventing spinal hypotension during cesarean delivery with a continuous infusion rate of 0.05 µg/kg/min, and does not significantly increase the incidence of hypertension but substantially reduces the risk of nausea and/or vomiting.
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Presión Sanguínea , Cesárea , Relación Dosis-Respuesta a Droga , Hipotensión , Norepinefrina , Humanos , Femenino , Cesárea/efectos adversos , Embarazo , Hipotensión/prevención & control , Hipotensión/epidemiología , Hipotensión/etiología , Hipotensión/inducido químicamente , Adulto , Norepinefrina/administración & dosificación , Norepinefrina/efectos adversos , Infusiones Intravenosas , Presión Sanguínea/efectos de los fármacos , Vasoconstrictores/administración & dosificación , Vasoconstrictores/efectos adversos , Anestesia Obstétrica/efectos adversos , Anestesia Obstétrica/métodos , Anestesia Raquidea/efectos adversos , Anestesia Raquidea/métodos , Hipertensión/prevención & control , Hipertensión/epidemiología , Incidencia , Bradicardia/prevención & control , Bradicardia/epidemiología , Bradicardia/inducido químicamente , Puntaje de Apgar , Náusea y Vómito Posoperatorios/prevención & control , Náusea y Vómito Posoperatorios/epidemiología , Náusea y Vómito Posoperatorios/etiologíaRESUMEN
PURPOSE: After cardiac surgery, fluid bolus therapy (FBT) with 20% human albumin may facilitate less fluid and vasopressor administration than FBT with crystalloids. We aimed to determine whether, after cardiac surgery, FBT with 20% albumin reduces the duration of vasopressor therapy compared with crystalloid FBT. METHODS: We conducted a multicentre, parallel-group, open-label, randomised clinical trial in six intensive care units (ICUs) involving cardiac surgery patients deemed to require FBT. We randomised 240 patients to receive up to 400 mL of 20% albumin/day as FBT, followed by 4% albumin for any subsequent FBT on that day, or to crystalloid FBT for at least the first 1000 mL, with use of crystalloid or 4% albumin FBT thereafter. The primary outcome was the cumulative duration of vasopressor therapy. Secondary outcomes included fluid balance. RESULTS: Of 480 randomised patients, 466 provided consent and contributed to the primary outcome (mean age 65 years; median EuroSCORE II 1.4). The cumulative median duration of vasopressor therapy was 7 (interquartile range [IQR] 0-19.6) hours with 20% albumin and 10.8 (IQR 0-22.8) hours with crystalloids (difference - 3.8 h, 95% confidence interval [CI] - 8 to 0.4; P = 0.08). Day one fluid balance was less with 20% albumin FBT (mean difference - 701 mL, 95% CI - 872 to - 530). CONCLUSIONS: In patients after cardiac surgery, when compared to a crystalloid-based FBT, 20% albumin FBT was associated with a reduced positive fluid balance but did not significantly reduce the duration of vasopressor therapy.
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Albúminas , Procedimientos Quirúrgicos Cardíacos , Soluciones Cristaloides , Fluidoterapia , Vasoconstrictores , Humanos , Fluidoterapia/métodos , Fluidoterapia/normas , Fluidoterapia/estadística & datos numéricos , Femenino , Masculino , Procedimientos Quirúrgicos Cardíacos/métodos , Anciano , Persona de Mediana Edad , Vasoconstrictores/administración & dosificación , Vasoconstrictores/uso terapéutico , Soluciones Cristaloides/administración & dosificación , Soluciones Cristaloides/uso terapéutico , Albúminas/administración & dosificación , Albúminas/uso terapéutico , Unidades de Cuidados Intensivos/estadística & datos numéricos , Soluciones Isotónicas/administración & dosificación , Soluciones Isotónicas/uso terapéuticoRESUMEN
BACKGROUND: Norepinephrine (NE) is a cornerstone drug in the management of septic shock, with its dose being used clinically as a marker of disease severity and as mortality predictor. However, variations in NE dose reporting either as salt formulations or base molecule may lead to misinterpretation of mortality risks and hinder the process of care. METHODS: We conducted a retrospective analysis of the MIMIC-IV database to assess the impact of NE dose reporting heterogeneity on mortality prediction in a cohort of septic shock patients. NE doses were converted from the base molecule to equivalent salt doses, and their ability to predict 28-day mortality at common severity dose cut-offs was compared. RESULTS: 4086 eligible patients with septic shock were identified, with a median age of 68 [57-78] years, an admission SOFA score of 7 [6-10], and lactate at diagnosis of 3.2 [2.4-5.1] mmol/L. Median peak NE dose at day 1 was 0.24 [0.12-0.42] µg/kg/min, with a 28-day mortality of 39.3%. The NE dose showed significant heterogeneity in mortality prediction depending on which formulation was reported, with doses reported as bitartrate and tartrate presenting 65 (95% CI 79-43)% and 67 (95% CI 80-47)% lower ORs than base molecule, respectively. This divergence in prediction widened at increasing NE doses. When using a 1 µg/kg/min threshold, predicted mortality was 54 (95% CI 52-56)% and 83 (95% CI 80-87)% for tartrate formulation and base molecule, respectively. CONCLUSIONS: Heterogeneous reporting of NE doses significantly affects mortality prediction in septic shock. Standardizing NE dose reporting as base molecule could enhance risk stratification and improve processes of care. These findings underscore the importance of consistent NE dose reporting practices in critical care settings.
Asunto(s)
Norepinefrina , Choque Séptico , Humanos , Choque Séptico/tratamiento farmacológico , Choque Séptico/mortalidad , Anciano , Femenino , Masculino , Estudios Retrospectivos , Persona de Mediana Edad , Norepinefrina/uso terapéutico , Norepinefrina/administración & dosificación , Vasoconstrictores/uso terapéutico , Vasoconstrictores/administración & dosificación , Estudios de CohortesRESUMEN
BACKGROUND: Norepinephrine and phenylephrine are commonly used vasoactive drugs to treat hypotension during the perioperative period. The increased release of endogenous norepinephrine elicits prothrombotic changes, while parturients are generally in a hypercoagulable state. Therefore, this trial aims to investigate whether there is a disparity between equivalent doses of prophylactic norepinephrine infusion and phenylephrine infusion on prothrombotic response in patients undergoing cesarean section under spinal anesthesia. METHODS: Sixty-six eligible parturients will be recruited for this trial and randomly assigned to the norepinephrine or phenylephrine group. The "study drug" will be administered at a rate of 15 ml/h starting from the intrathecal injection. The primary outcome are plasma coagulation factor VIII activity (FVIII: C), fibrinogen, and D-dimer levels. The secondary outcomes include hemodynamic variables and umbilical artery blood pH value. DISCUSSION: Our study is the first trial comparing the effect of norepinephrine and phenylephrine on prothrombotic response in patients undergoing cesarean section under spinal anesthesia. Positive or negative results will all help us better understand the impact of vasoactive drugs on patients. If there are any differences, this trial will provide new evidence for maternal choice of vasoactive medications in the perioperative period. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2300077164. Registered on 1 November 2023. https://www.chictr.org.cn/ .
Asunto(s)
Anestesia Obstétrica , Anestesia Raquidea , Cesárea , Norepinefrina , Fenilefrina , Ensayos Clínicos Controlados Aleatorios como Asunto , Vasoconstrictores , Humanos , Cesárea/efectos adversos , Anestesia Raquidea/efectos adversos , Femenino , Norepinefrina/sangre , Método Doble Ciego , Embarazo , Fenilefrina/administración & dosificación , Vasoconstrictores/uso terapéutico , Anestesia Obstétrica/efectos adversos , Anestesia Obstétrica/métodos , Adulto , Productos de Degradación de Fibrina-Fibrinógeno/metabolismo , Productos de Degradación de Fibrina-Fibrinógeno/análisis , Factor VIII , Resultado del Tratamiento , Coagulación Sanguínea/efectos de los fármacos , Hemodinámica/efectos de los fármacosRESUMEN
Background: Vasopressors remain an important strategy for managing spinal anesthesia-induced hypotension in women with preeclampsia. The aim of this study was to investigate the ED90s and efficacy ratio of phenylephrine and norepinephrine in managing spinal anesthesia-induced hypotension in women with preeclampsia during cesarean delivery. Methods: 60 women with preeclampsia, who underwent cesarean delivery, were randomly assigned to receive either a continuous intravenous infusion of phenylephrine or norepinephrine following spinal anesthesia. The initial dosage of phenylephrine or norepinephrine for the first women was 0.5 or 0.05 µg/kg/min, respectively, and subsequent infusion dosages were adjusted based on their efficacy in preventing spinal anesthesia-induced hypotension (defined as a systolic blood pressure less than 80% of the baseline level). The incremental or decremental doses of phenylephrine or norepinephrine were set at 0.1 or 0.01 µg/kg/min. The primary outcomes were the ED90s and efficacy ratio of phenylephrine and norepinephrine infusions for preventing spinal anesthesia-induced hypotension prior to delivery. Results: The results obtained from isotonic regression analysis revealed that the ED90 values of the phenylephrine and norepinephrine group for preventing spinal anesthesia-induced hypotension were 0.597 (95% CI: 0.582-0.628) and 0.054 (95% CI: 0.053-0.056) µg/kg/min, respectively, with an efficacy ratio of 11.1:1. The results of Probit regression analysis revealed that the ED90 values were determined to be 0.665 (95% CI: 0.576-1.226) and 0.055 (95% CI: 0.047-0.109) µg/kg/min, respectively, with an efficacy ratio of 12.1:1. Conclusion: The administration of 0.6 µg/kg/min phenylephrine and 0.05 µg/kg/min norepinephrine has been found to effectively manage a 90% incidence of spinal anesthesia-induced hypotension in women with preeclampsia.
Asunto(s)
Anestesia Raquidea , Cesárea , Hipotensión , Norepinefrina , Fenilefrina , Preeclampsia , Humanos , Femenino , Embarazo , Fenilefrina/administración & dosificación , Preeclampsia/tratamiento farmacológico , Anestesia Raquidea/efectos adversos , Hipotensión/prevención & control , Hipotensión/inducido químicamente , Norepinefrina/administración & dosificación , Adulto , Infusiones Intravenosas , Relación Dosis-Respuesta a Droga , Vasoconstrictores/administración & dosificación , Presión Sanguínea/efectos de los fármacos , Adulto JovenRESUMEN
Objectives: To assess the knowledge and awareness of dental house officers regarding calculation of local anaesthesia dosage, and to evaluate differences in practices at various tertiary care facilities. METHODS: The cross-sectional study was conducted at three dental hospitals affiliated with Dow University of Health Sciences, Karachi from July to December 2022, and comprised house officers of either gender currently enrolled at the participating centres. Data was collected using a self-administered questionnaire to assess knowledge and awareness of local anaesthesia dosage calculation, administration methods, and common complications. Data was analysed using SPSS 26. RESULTS: Of the 200 subjects approached, 136(68%) responded, and 89(65.4%) of them were females. Knowledge regarding the meaning of 2% lidocaine solution was low 45(33%), and 68(50%) subjects were knowledgeable about the maximum dosage of lidocaine with epinephrine. In terms of practice, lidocaine was the most commonly administered local anaesthetic 115(85%), followed by bupivacaine 15(11%). The majority of subjects administered local anaesthesia with vasoconstrictor 127(94%), but only 36(27%) performed aspiration during administration. Syncope 71(52%) was the most commonly reported complication, followed by lip/cheek/tongue biting by 35(26%). CONCLUSIONS: House officers' knowledge level of local anaesthesia administration indicated the need for adequate training.