1
|
Abstract
Myocardial depression is a common yet reversible phenomenon that occurs in patients in septic shock. Initially, it was unclear whether this provided an adaptive survival benefit, as early studies showed decreased mortality in septic patients with myocardial depression. However, subsequent larger studies have debunked this myth. Given that no benefit exists, cardiac dysfunction in septic patients may be monitored via echocardiography and may be treated with inotropic agents. Beta-blockers provide a novel avenue of treatment as they aid in reducing adrenergic overstimulation and cytokine production, which may drive the pathogenesis of septic shock. This review chronicles how the understanding of myocardial depression in sepsis has evolved and how it should be clinically managed.
Collapse
|
2
|
Oda S, Aibiki M, Ikeda T, Imaizumi H, Endo S, Ochiai R, Kotani J, Shime N, Nishida O, Noguchi T, Matsuda N, Hirasawa H. The Japanese guidelines for the management of sepsis. J Intensive Care 2014; 2:55. [PMID: 25705413 PMCID: PMC4336273 DOI: 10.1186/s40560-014-0055-2] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 09/16/2014] [Indexed: 02/08/2023] Open
Abstract
This is a guideline for the management of sepsis, developed by the Sepsis Registry Committee of The Japanese Society of Intensive Care Medicine (JSICM) launched in March 2007. This guideline was developed on the basis of evidence-based medicine and focuses on unique treatments in Japan that have not been included in the Surviving Sepsis Campaign guidelines (SSCG), as well as treatments that are viewed differently in Japan and in Western countries. Although the methods in this guideline conform to the 2008 SSCG, the Japanese literature and the results of the Sepsis Registry Survey, which was performed twice by the Sepsis Registry Committee in intensive care units (ICUs) registered with JSICM, are also referred. This is the first and original guideline for sepsis in Japan and is expected to be properly used in daily clinical practice. This article is translated from Japanese, originally published as “The Japanese Guidelines for the Management of Sepsis” in the Journal of the Japanese Society of Intensive Care Medicine (J Jpn Soc Intensive Care Med), 2013; 20:124–73. The original work is at http://dx.doi.org/10.3918/jsicm.20.124.
Collapse
Affiliation(s)
- Shigeto Oda
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-Ku, Chiba 260-8677 Japan
| | - Mayuki Aibiki
- Department of Emergency Medicine, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime 791-0295 Japan
| | - Toshiaki Ikeda
- Division of Critical Care and Emergency Medicine, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo 193-0998 Japan
| | - Hitoshi Imaizumi
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, S1 W17, Chuo-ku, Sapporo, 060-8556 Japan
| | - Shigeatsu Endo
- Department of Emergency Medicine, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate 020-0023 Japan
| | - Ryoichi Ochiai
- First Department of Anesthesia, Toho University School of Medicine, 6-11-1 Omori-nishi, Ota-ku, Tokyo 143-8541 Japan
| | - Joji Kotani
- Department of Emergency, Disaster and Critical Care Medicine, Hyogo College of Medicine, 1-1 Mukogawacho, Nishinomiya, Hyogo 663-8131 Japan
| | - Nobuaki Shime
- Division of Intensive Care Unit, University Hospital, Kyoto Prefectural University of Medicine, Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566 Japan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192 Japan
| | - Takayuki Noguchi
- Department of Anesthesiology and Intensive Care Medicine, Oita University School of Medicine, 1-1 Idaigaoka, Hazamacho, Yufu, Oita 879-5593 Japan
| | - Naoyuki Matsuda
- Emergency and Critical Care Medicine, Graduate School of Medicine Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550 Japan
| | | | | |
Collapse
|
3
|
Senz A, Nunnink L. Review article: inotrope and vasopressor use in the emergency department. Emerg Med Australas 2008; 21:342-51. [PMID: 19694785 DOI: 10.1111/j.1742-6723.2009.01210.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Shock is a common presentation to the ED, with the incidence of septic shock increasing in Australasia over the last decade. The choice of inotropic agent is likely dependent on previous experience and local practices of the emergency and other critical care departments. The relatively short duration of stay in the ED before transfer leaves little room for evaluating the appropriateness of and response to the agent chosen. Delays in transfer to inpatient facilities means that patients receive advanced critical care within the ED for longer, requiring initiation and titration of vasoactive agents in the ED. This article discusses the general concepts of shock and the indicators for inotrope and vasopressor use, revises the various agents available and reviews the current evidence for their use.
Collapse
Affiliation(s)
- Ainslie Senz
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD 4006, Australia.
| | | |
Collapse
|
4
|
Liet JM, Jacqueline C, Orsonneau JL, Gras-Leguen C, Potel G, Rozé JC. The effects of milrinone on hemodynamics in an experimental septic shock model. Pediatr Crit Care Med 2005; 6:195-9. [PMID: 15730608 DOI: 10.1097/01.pcc.0000155636.53455.96] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the specific hemodynamic effects of the phosphodiesterase inhibitor milrinone in a rabbit model of septic shock in the absence of any other treatment. DESIGN A prospective, controlled, interventional study. Animal Model: Fourteen sedated New Zealand rabbits. SETTING Research laboratory of a health sciences university. INTERVENTIONS Rabbits were anesthetized and vascular catheters inserted in femoral artery and jugular vein. After a stabilization period and the recording of baseline measurements (H0), all animals received a 10-mL infusion of Pseudomonas aeruginosa. Two hours later (H2rabbits were randomly assigned to receive 5% dextrose (control group) or milrinone (milrinone group). MEASUREMENTS AND MAIN RESULTS Mean arterial blood pressure (MAP) was monitored continuously, and a cardiac index (CI) was determined every 30 mins by a transpulmonary thermodilution technique using an integrated monitoring device (PICCO). No differences were detected between the two groups after stabilization (H0) or before the treatment (H2) for either CI (mL/min(-1)/kg(-1)) or MAP (mm Hg). CI decreased progressively in the control group during the following 4 hrs, but not in the treated group (at H6: 122 +/- 4 vs. 207 +/- 16 mL/min(-1)/kg(-1); p < .05). No drop of MAP occurred after milrinone infusion. A comparison of the treated and control group reveals that milrinone improved tissue perfusion as evidenced by measurements of central venous saturation (at H4: 0.59 +/- 0.05 vs. 0.71 +/- 0.03, p = .04), lactacidemia (at H6: 10.3 +/- 2.4 vs. 3.9 +/- 0.9 mmol/L, p = .03), creatinemia (at H6: 95 +/- 11 vs. 60 +/- 5 micromol/L, p = .02) and survival (at H6: 5 vs. 7, not significant). CONCLUSION Milrinone improves cardiac output and tissue perfusion in a rabbit model involving severe septic shock.
Collapse
Affiliation(s)
- Jean-Michel Liet
- Pediatric Intensive Care Unit and the Department of Medical Biochemistry, University Hospital of Nantes, France
| | | | | | | | | | | |
Collapse
|
5
|
Hollenberg SM, Ahrens TS, Annane D, Astiz ME, Chalfin DB, Dasta JF, Heard SO, Martin C, Napolitano LM, Susla GM, Totaro R, Vincent JL, Zanotti-Cavazzoni S. Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update. Crit Care Med 2004; 32:1928-48. [PMID: 15343024 DOI: 10.1097/01.ccm.0000139761.05492.d6] [Citation(s) in RCA: 372] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To provide the American College of Critical Care Medicine with updated guidelines for hemodynamic support of adult patients with sepsis. DATA SOURCE Publications relevant to hemodynamic support of septic patients were obtained from the medical literature, supplemented by the expertise and experience of members of an international task force convened from the membership of the Society of Critical Care Medicine. STUDY SELECTION Both human studies and relevant animal studies were considered. DATA SYNTHESIS The experts articles reviewed the literature and classified the strength of evidence of human studies according to study design and scientific value. Recommendations were drafted and graded levels based on an evidence-based rating system described in the text. The recommendations were debated, and the task force chairman modified the document until <10% of the experts disagreed with the recommendations. CONCLUSIONS An organized approach to the hemodynamic support of sepsis was formulated. The fundamental principle is that clinicians using hemodynamic therapies should define specific goals and end points, titrate therapies to those end points, and evaluate the results of their interventions on an ongoing basis by monitoring a combination of variables of global and regional perfusion. Using this approach, specific recommendations for fluid resuscitation, vasopressor therapy, and inotropic therapy of septic in adult patients were promulgated.
Collapse
|
6
|
Chatterjee K, De Marco T. Role of nonglycosidic inotropic agents: indications, ethics, and limitations. Med Clin North Am 2003; 87:391-418. [PMID: 12693731 DOI: 10.1016/s0025-7125(02)00185-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Nonglycosidic inotropic agents have been used for the short-term management of low output states and hypotension complicating acute myocardial infarction for several years. Without adequate reperfusion of the ischemic myocardium, inotropic agents are seldom effective in producing sustained hemodynamic responses. Furthermore, the potential exists for enhancement of ischemia and extension of myocardial necrosis. Thus, inotropic and vasopressors therapy should be regarded as temporary supportive treatment in patients with acute coronary syndrome and should be discontinued as soon as feasible. Parenteral sympathomimetic agents, usually dobutamine, and phosphodiesterase inhibitors, usually milrinone, are used for the management of exacerbations of chronic systolic heart failure. Although hemodynamics, and occasionally clinical status, improve, such therapy is associated with increased mortality and can potentially hasten a patient's demise. Nonparenteral sympathomimetics, such as ibopamine, phosphodiesterase-III inhibitors, such as milrinone and enoximone, calcium-sensitizing agents, such as pimobendan, and other novel inotropic agents, such as vesnarinone, all increase mortality of patients with chronic heart failure. Furthermore, newer noninotropic agents, such as B-natriuretic peptide, have been introduced for treatment of decompensated heart failure. New nonpharmacologic devices, such as biventricular pacing, are available for the treatment of advanced heart failure. Thus, indications for the use of presently available nonglycosidic inotropic agents are limited and should be considered only for short-term therapy or when no other treatment is available.
Collapse
Affiliation(s)
- Kanu Chatterjee
- Department of Medicine, University of California at San Francisco, Chatterjee Center for Cardiac Research, Moffit-Long Hospital, San Francisco, CA 94143, USA.
| | | |
Collapse
|
7
|
De Witt BJ, Ibrahim IN, Bayer E, Fields AM, Richards TA, Banister RE, Kaye AD. An analysis of responses to levosimendan in the pulmonary vascular bed of the cat. Anesth Analg 2002; 94:1427-33, table of contents. [PMID: 12032000 DOI: 10.1097/00000539-200206000-00009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Calcium-sensitizing drugs, such as levosimendan, are a novel class of drug therapy for heart failure. We investigated the hypothesis that levosimendan is a pulmonary vasodepressor mediated through inhibition of phosphodiesterase, adenosine triphosphate (ATP)-dependent potassium channels, or both. We investigated responses to the calcium sensitizer levosimendan in the pulmonary vascular bed of the cat under conditions of controlled pulmonary blood flow and constant left atrial pressure when lobar arterial pressure was increased to a high steady level with the thromboxane A(2) analog U-46619. Under increased-tone conditions, levosimendan caused dose-related decreases in lobar arterial pressure without altering systemic arterial and left atrial pressure. Responses to levosimendan were significantly attenuated, although not completely, after the administration of U-37883A, a vascular selective nonsulfonylurea ATP-sensitive K(+)-channel-blocking drug. Responses to levosimendan were not significantly different after the administration of the nitric oxide synthase inhibitor L-N(5)-(1-iminoethyl)-ornithine or the cyclooxygenase inhibitor sodium meclofenamate or when lung ventilation was interrupted. These data show that levosimendan has significant vasodilator activity in the pulmonary vascular bed of the cat. They also suggest that pulmonary vasodilator responses to levosimendan are partially dependent on activation of ATP-sensitive K(+) channels and independent of the synthesis of nitric oxide, activation of cyclooxygenase enzyme, or changes in bronchomotor tone in the pulmonary vascular bed of the cat. IMPLICATIONS Calcium-sensitizing drugs, such as levosimendan, are a novel class of drug therapy for heart-failure treatment. The lung circulation affects both right- and left-sided heart failure. Levosimendan decreased lobar arterial pressure via a partial K(+)(ATP) (potassium channel sensitive to intracellular adenosine triphosphate levels)-dependent mechanism. These data suggest that, in addition to calcium-sensitizing activity, levosimendan decreases pulmonary resistance, which may also aid in the treatment of heart failure.
Collapse
Affiliation(s)
- Bracken J De Witt
- Department of Anesthesiology, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX 79430, USA
| | | | | | | | | | | | | |
Collapse
|
8
|
De Witt BJ, Ibrahim IN, Bayer E, Fields AM, Richards TA, Banister RE, Kaye AD. An Analysis of Responses to Levosimendan in the Pulmonary Vascular Bed of the Cat. Anesth Analg 2002. [DOI: 10.1213/00000539-200206000-00009] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
9
|
Abstract
Septic shock presents a unique challenge in the pediatric patient. Sepsis stimulates the release of inflammatory mediators that can compromise cardiac function. Oxygen extraction abnormalities, diminished responses to adrenergic agonists, and impaired ventricular function often result. After fluid resuscitation and antibiotic therapy, careful cardiovascular assessment is needed to administer appropriate inotropic and vasoactive drugs.
Collapse
Affiliation(s)
- S Tabbutt
- Cardiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
| |
Collapse
|
10
|
Abstract
Sepsis and septic shock constitute an important cause of morbidity and mortality in critically ill children. Thus, the systemic response to infection and its management remains a major challenge in clinical medicine. Apart from antibiotic administration, the majority of available therapies are limited to supportive strategies, although considerable efforts are being undertaken to devise innovative approaches that modulate host inflammatory responses. In suspected sepsis, 2 or 3 days' empiric antibiotic therapy should begin immediately after cultures have been obtained without awaiting results. Antibiotics should be re-evaluated when the results of the cultures and susceptibility tests are available. The initial antibiotic (combination) is determined by the likely causative agent, susceptibility patterns within a specific institution, CNS penetration, toxicity, and the patient's hepatic and renal function. The likely offending micro-organism in turn depends primarily on the patient's age, coexistence of any premorbid condition leading to impaired immune response, and the presenting signs and symptoms. Close attention to cardiovascular, respiratory, fluid and electrolyte, haematological, renal and metabolic/nutritional support is essential to optimise outcome. Fluid resuscitation is of utmost importance to overcome hypovolaemia on the basis of a diffuse capillary leak. Monitoring and normalisation of the heart rate is essential. In case of nonresponse to fluid resuscitation, inotropic and vasoactive agents are commonly used to increase cardiac output, maintain adequate blood pressure and enhance oxygen delivery to the tissue. Because respiratory distress syndrome is seen in about 40% of critically ill children with septic shock, increased inspired oxygen is essential. To provide optimal relief from respiratory muscle fatigue and facilitate the provision of positive airway pressure, early intubation and mechanical ventilation should be considered. Renal support is essential to avoid prolonged renal shutdown in hypoperfusion states. Haematological support comprises replacement therapy of clotting factors to overcome disseminated intravascular coagulation. Metabolic support may include glucose support, extraction of ammonia from the body and recognition of liver dysfunction. Nutritional support may modify the inflammatory host response, and early enteral feeding can improve outcome in critical illness. To date, glucocorticoid and non-glucocorticoid anti-inflammatory agents have not shown significant benefit in septic patients.
Collapse
|
11
|
De Witt BJ, Marrone JR, Kadowitz PJ. Comparison of responses to siguazodan, rolipram, and zaprinast in the feline pulmonary vascular bed. Eur J Pharmacol 2000; 406:233-8. [PMID: 11020486 DOI: 10.1016/s0014-2999(00)00501-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The present study was undertaken to investigate and compare responses to the cyclic nucleotide phosphodiesterase inhibitors siguazodan (type III, guanosine 3',5'-cyclic monophosphate (cGMP)-inhibited adenosine 3',5'-cyclic monophosphate (cAMP)), rolipram (type IV, cAMP-specific), and zaprinast (type V, cGMP-specific) in the feline pulmonary vascular bed. When tone in the pulmonary vascular bed was raised to a high steady level with a constant infusion of the thromboxane mimic U46619 (9,11-dideoxy-11, alpha9alpha-epoxymethano prostaglandin F(2alpha)), intralobar injections of the three phosphodiesterase inhibitors caused dose-related decreases in lobar arterial pressure. In terms of relative vasodilator activity, rolipram was more potent at higher doses than siguazodan, which was more potent than zaprinast. The duration of the pulmonary vasodilator response to zaprinast was shorter than for siguazodan or rolipram. Furthermore, siguazodan and rolipram, but not zaprinast, decreased systemic arterial pressure when injected into the perfused lobar artery in the range of doses studied. The present data demonstrate that the three phosphodiesterase inhibitors have potent, long-lasting vasodilator activity in the pulmonary vascular bed of the cat. These data suggest that there is rapid turnover of cAMP and cGMP in the pulmonary circulation and indicate that phosphodiesterase enzyme types III, IV, and V may play an important role in the regulation of vasomotor tone in the feline lung.
Collapse
Affiliation(s)
- B J De Witt
- Department of Pharmacology SL83, Tulane University School of Medicine, 1430 Tulane Avenue, 70112, New Orleans, LA, USA
| | | | | |
Collapse
|
12
|
|
13
|
Abstract
The optimal therapy for the treatment of sepsis and septic shock remains controversial. Many protocols are followed, using different strategies for initial resuscitation, cardiovascular monitoring, hemodynamic intervention, and eradication of infection. Overall, an aggressive approach to the management of cardiovascular dysfunction in septic shock is warranted. Initially, large volume fluid resuscitation is instituted. Our first choice of resuscitation fluid is 0.9% normal saline. Invasive hemodynamic monitoring using a flotation pulmonary artery catheter as well as invasive arterial blood pressure monitoring is a necessity in the hemodynamic management of septic shock. If the patient remains hypotensive (mean arterial pressure < 65 mm Hg) after adequate volume resuscitation has been established (pulmonary capillary wedge pressure 12 to 15 mm Hg), then vasopressor agents must be instituted. Our first choice is usually dopamine. In patients who remain hypotensive after maximal doses of dopamine are reached, norepinephrine is added. If these agents generate excessive tachycardia or if tachyarrhythmias develop, phenylephrine can be substituted or added. Inotropic agents are useful if the patient demonstrates hypotension with a low cardiac output state. Dobutamine is the agent of choice. We initiate broad-spectrum empiric antibiotics at presentation, modifying the exact regimen based on 1) site of infection; 2) prevailing organisms and antibiotic resistance patterns in the patient's environment; and 3) other specific risk factors (immunosuppression, chronic disease, exposure and vaccination history, invasive medical devices). When appropriate, aggressive surgical debridement is pursued. Currently, there are no clinical data to support the use of antagonists for sepsis mediators, although various clinical trials remain underway. Steroids are contraindicated except for adrenal replacement therapy.
Collapse
|
14
|
Schmidt W, Tinelli M, Secchi A, Gebhard MM, Martin E, Schmidt H. Milrinone improves intestinal villus blood flow during endotoxemia. Can J Anaesth 2000; 47:673-9. [PMID: 10930208 DOI: 10.1007/bf03019001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To determine whether the compromised intestinal villus blood flow in a rat model of endotoxemia could be improved by continuous infusion of the phosphodiesterase (PDE) inhibitor milrinone. METHODS Twenty-four anesthetized and ventilated rats were laparotomized and an ileal portion was exteriorized and opened by an antimesenteric incision. The ileal segment was fixed with the mucosal surface upward. Microcirculatory parameters were assessed by intravital videomicroscopy. The animals were randomly assigned to receive one of three treatments: infusion of Escherichia coli lipopolysaccharides without phosphodiesterase inhibitor pretreatment (=LPS group); or infusion of LPS with milrinone pretreatment (= milrinone group), or without infusion of LPS or milrinone (=control group). Macrohemodynamic parameters (MAP, HR) and microhemodynamic parameters of ileal mucosa (mean diameter of central arterioles = D(A) and mean erythrocyte velocity within the arterioles= V(E)) were measured 30 min before and at 0, 60, and 120 min after induction of endotoxemia. Mucosal villus blood flow was calculated from D(A) and V(E). RESULTS In the milrinone group MAP decreased 60 min after induction of endotoxemia whereas it remained stable in the control and the LPS group. In both groups given endotoxin V(E) decreased after start of LPS infusion. In contrast, D(A) decreased in the LPS group, but increased in the milrinone group after 120 min of endotoxemia. Thus, the endotoxin-induced decrease of intestinal villus blood flow was diminished but not fully restored by milrinone infusion. CONCLUSION Our results indicate that milrinone has some beneficial microcirculatory effects during endotoxemia. Although it contributed to systemic hypotension, it attenuated intestinal mucosal hypoperfusion.
Collapse
Affiliation(s)
- W Schmidt
- Department of Anesthesiology, University of Heidelberg, Germany.
| | | | | | | | | | | |
Collapse
|
15
|
|